Nursing comprises the largest workforce in health care, and in the shadow of a predicted nursing workforce shortfall in Australia (Buchan, Duffield, & Jordan, 2015; Health Workforce Australia, 2012) the ability for health services to recruit and retain nurse educators becomes even more important. Nurse educators are integral to the health care system by supporting clinical practice through developing a skilled and competent hospital-based nursing workforce (Sayers, DiGiacomo, & Davidson, 2011). Failure to consider the recruitment and retention of appropriately skilled nurses into nurse educator roles may result in limited work-based professional development of hospital nurses. This, in turn, will negatively affect the quality of nursing care and patient outcomes (Aiken et al., 2011; American Nurses Credentialing Center, 2014).
This article reports the findings from a phenomenological study highlighting the importance of the nurse educator role, the inherent factors that comprise the role, and the influence this has on nurse educator practice. The purpose of this article is to highlight the challenges for nurse educators transitioning into these roles, as well as some suggestions on strategies to recruit and retain nurse educators into the future.
The term nurse educator is not a homogenous term used to define nurses who have an education role. Within nursing literature, the terms nurse educator (Laurencelle, Scanlan, & Brett, 2016), nurse teacher (Australian Nurse Teachers' Society, 2010; Guy, Taylor, Roden, & Blundell, 2011), clinical nurse educator (Fairbrother, Rafferty, Woods, Tyler, & Howell 2015), and nurse lecturer (Smith, Gentleman, Loads, & Pullin, 2014) are used interchangeably when referring to an array of nursing education roles, whether within a higher education institution or hospital. For the purpose of this article, the term nurse educator is used to denote nurses whose primary role is nurse education within a hospital. Despite the lexicon that is used across varied national and international jurisdictions when referring to nurse educators, the majority of published literature concerning nurse educators has focused on the roles and functions of nurse educators in higher education institutions (Campbell & Daley, 2013; Gardner, 2014; Williams, 2012). Nurse educators in higher education institutions are primarily responsible for the formal education of undergraduate and postgraduate nursing students, whereas nurse educators within the hospital setting are responsible for the provision of continuing professional development for hospital-based nurses.
The increasing focus of nursing as an evidence-based (Friedman & Levin, 2013) knowledge profession (Williams, 2013) has culminated in the use of increasingly advanced technological approaches by which to enhance nurses' knowledge acquisition and critical thinking abilities (Lapkin & Levett-Jones, 2011). The American Nurses Association (2012) identified that the “half-life of knowledge in the health care field is three–four years” (p. 1). The ongoing education of hospital-based nurses within the work environment is of no less significance than formal education undertaken within the higher education sector. This necessitates the positioning of nurse educators within the hospital environment to assist hospital-based nurses to engage in continuing professional development and ongoing work-based education or else risk potential erosion of their knowledge base and negatively affect patient outcomes (Aiken et al., 2011; American Nurses Credentialing Center, 2014; Price & Reichart, 2017).
A paucity of literature focusing on hospital-based nurse educators' understanding of their role and how those understandings are translated into their practice was identified using a computerized search of PubMed®, CINAHL® via EBSCOhost, and ERIC™ via ProQuest® databases.
The methodology used in this research was hermeneutic phenomenology based on the work of Max van Manen (1990, 1997) to answer the question: How do hospital-based nurse educators understand their role and translate that understanding into practice? Phenomenology values the lived experience and reflects on the essential themes that characterize the phenomenon. The phenomenon that is at the heart of this study is the lived experience of hospital-based nurse educators.
Population and Sample
The study sites were four acute care major metropolitan hospitals within South Australia, Australia. A purposeful selection method was chosen to engage with participants who were information rich (van Manen, 1997). Study participants included 11 RNs who had primary responsibility for provision of ongoing professional development for hospital-based nurses. Individuals were identified by the colloquial term nurse educator. Selection of participants was not influenced by length of employment.
A structured open-ended interview, enabling collection of narratives of participant's lived experiences, was chosen because it enabled participants to share their stories in their own words. Interviews were conducted by the researcher and digitally recorded with the participant's permission (Table). Interviews were transcribed verbatim by a third party. Each participant was offered a copy of his or her transcribed interview at a subsequent interview where clarification was sought on statements not understood by the researcher. Clarified interviews were electronically offered to respective participants.
Semi-Structured Open-Ended Questions
Data collection was undertaken by the author as part of a doctoral thesis. The author was the principle researcher who conceived the research question, selected the methodological approach, and conducted the data analysis. The researcher had previously utilized a hermeneutic phenomenological approach to data analysis in a previous higher research degree.
Data analysis occurred via theme analysis through a process whereby keywords or phrases were highlighted (van Manen, 1990). A descriptor was then assigned to keywords or phrases. Interview content was then arranged per the descriptor assigned to the keyword or phrase.
Protection of Human Participants
Ethical approval was obtained from the relevant university and employing agency of the volunteer participants. Participants were assigned a pseudonym.
All participants were female and had worked as an RN between 6 and 37 years and as a nurse educator between 1.5 and 34 years. Four themes arose from the theme analysis: Becoming an Educator, Capability Building, Panacea, and Tension. The four themes collectively comprised 15 subthemes, as identified within Figure 1.
Nurse educators' understanding of their role.
Becoming an Educator
This theme comprised three subthemes: the journey, education knowledge attainment, and always a nurse. The education journey was characterized by participants who on reaching the destination of being a nurse educator recognized they required more than their clinical acumen and experience. In response, nurse educators engaged in further education to inform and justify educational practices required to fulfill the role. The requirement for specific knowledge was supported by Fairbrother et al. (2015), who recognized that nurse educators “valued knowledge and expertise developed through formal completion of study in education” (p. 8), as exemplified by participant seven who stated: “It isn't the [nursing] knowledge; it is the ability and skill to deliver that knowledge.” Nurse educators, however, remained adamant they were nurses first and foremost; participant one stated, “I still see myself as a nurse with a focus on education.”
This theme comprised five subthemes: scaffolding, being a bridge, role modeling, being visible, and collaboration. Nurse educators used scaffolding techniques (Salinitri, Wilhelm, & Crabtree, 2015) comprising questioning, facilitation, problem solving, and formation of critical thinking skills to enable nurses to be active lifelong learners, as articulated by participant eight, who identified that they determine “where someone's [nurse] deficit is and then provide[s] them with the resources so they [nurse] can actually expand their [nurse] practice.”
Scaffolding contrasted with being a bridge in that being a bridge focused on nurse educators assisting nurses in their current practice with regard to clinical and non-clinical deficits. The nurse educator was a direct conduit to assist nurses to function in the clinical environment when deficits were identified or arose in relation to policy, procedure, skill, or knowledge. This role was not dissimilar to the professional activity of nurse educators identified by Fairbrother et al. (2015).
Role modeling was understood by nurse educators to set a standard of practice that was professionally representative of nursing, which is congruent to role-modeling practices used by nurse academics in the preparation of undergraduate nursing students (Baldwin, Mills, Birks, & Budden, 2017; Davis, 2013). The practice of role modeling by nurse educators resulted in them experiencing a degree of external pressure, as they understood their practice was being scrutinized by their clinical nurse colleagues. Role modeling required nurse educators to reflect evidence-based nursing practice at all times, as evidenced by participant seven, who stated:
I have an opportunity in an official capacity to…set… standards. It can be simple things like doing the proper complete shower…. Things have always got to be done so properly…. I might want to throw the towel across the room into the skip and you can't.
Being visible for nurse educators occurred through their presence within the clinical environment. Being visible was understood to provide nurse educators with credibility within the clinical setting, and, in turn, nurse educators felt respected and trusted to work in collaboration with nursing colleagues. Collaboration was understood by nurse educators to be an effective approach for the nurse educator to augment role modeling, which contributed to capability building of hospital-based nurses. Collaborating with peers and other health care agencies assisted nurse educators to reinforce and introduce appropriate practices to create competent nurses.
This theme comprised two subthemes: all things to all people, and driven by safety. Nurse educators understood they were viewed as a panacea—that is, as someone who will solve all problems. Being all things to all people was characterized by work demands that took them away from educating nurses, as explained by participant five:
The definite change I have noticed during the time I have been in education is [that] educators seem to [be] given all the stuff that no one else wants to do.
Nurse educators understood that a significant part of their role was focused on safety to prevent adverse patient outcomes. Nurse educators translated this understanding into their practice through up-skilling nurses to improve their competence and capability to minimize adverse patient outcomes. This is exemplified by participant seven, who identified that “if there were no hospital-based nurse educators, I think safety would be compromised because people [nurses] wouldn't be updated.” The importance of continuing professional development for nurses, a key component of effective practice environments, is recognized as integral to reducing adverse patient outcomes and patient mortality (Wong, 2015).
This theme comprised five subthemes: knowing thyself, role relevance requiring validation, resentment, educator or other, and how others see them. Knowing thyself evidenced the nurse educators need to know from those they were educating that they made a difference to the knowledge and skill acquisition of hospital-based nurses. This was demonstrated by participant five, who identified they “need to know that whatever [they] do has an effect on that person.”
Role relevance requiring validation arose from nurse educators' perception that their role was not considered relevant by hospital-based nurses. Nurse educators responded to this perception by increasing their presence within the clinical environment, as evidenced by participant one, who stated “I am happy to write time off on clinical stuff.”
Resentment was experienced by nurse educators who felt that being removed from the bedside threatened their identity as a nurse. Participant 11 described that in being moved from a clinical role to an education role “I felt troubled…. More importantly, I was not a bedside nurse.” Resentment was also experienced by nurse educators when they had to undertake administrative functions, which was acknowledged by participant one, who identified, “you don't need to be nurse to do that.”
Educator or other manifested when nurse educators were required to fulfill management functions, which included performance management of clinically situated nursing staff. This occurred despite clinically situated nurses direct line reporting to a clinical manager. Participant seven indicated that the nurse educator role functioned more as a “performance manager and counsellor than education. I do have pockets of education but overall…I would say I worked as a manager.”
The perception of how others saw their role created tension for nurse educators as they understood their non-educator nursing colleagues had little regard for the educational expertise required of such a position, while they themselves understood they required a distinct body of educational knowledge to execute their role, as evidenced by participant seven, who stated:
One of the frustrating things is that people believe that you do not need any kind of experience to do this job…. They don't believe you need any experience or any knowledge.
The participants' narratives highlighted that the nurse educator role is not a simple homogenous activity. Interpretation of the four themes highlighted two distinct understandings of the nurse educator role: it was under-valued (Fairbrother et al., 2015; Sayers, 2011, 2013), while at the same time it adds value. Being undervalued and value adding are translated into nurse educator practice as resilience, being educationally literate, investing (in the workforce), and having a presence, as portrayed in Figure 2. This discussion explores these practices and acknowledges nurse educator experiences and how they have adapted, the challenges they face, and their integral role in the provision of relevant and meaningful continuing professional development opportunities for hospital-based nurses.
A coherent picture of how nurse educators understand their role and translate that understanding into practice.
Nurse educators perceived that their role was undervalued by their non-nurse educator colleagues (Fairbrother et al., 2015; Sayers, 2011, 2013). This was evident where work planned by the nurse educator was pushed aside to address issues deemed more important by either management or clinically based nursing colleagues. Nurse educators internalized their experiences of being undervalued and responded by building resilience and educational literacy, thus enabling nurse educators to more effectively contribute to the capability development of the nursing work-force.
Nurse educators, in perceiving that their role and work was undervalued and considered unequal in comparison to clinically based nurses, responded through building their resilience. Resilience is the capacity to withstand stress (Webb, 2013). Resilience was enacted through nurse educators' formation of positive relationships with each other and with clinical leaders. Nurse educators also sustained a strong belief that although their role might be misunderstood, they valued their contribution to the provision of high-quality patient care, through the provision of continuing professional development of hospital-based nurses.
Nurse educators underpinned their role with sound educational theories and practices, demonstrating educational literacy. Nurse educators were aware that their role was perceived by their clinical nurse colleagues to be relatively easy in comparison to clinically situated nursing work. This perception implied that nurse educator work was not real work and nurse educators were not real nurses (Howett & Evans, 2011).
Nurse educators understood they required educational literacy to develop, design, and deliver quality educational opportunities. Nurse educators also understood that their clinical nurse colleagues may not have been aware of the fundamental components of their role. Nurse educators are not only required to be grounded in nursing practice and knowledge but also in educational literacy to adequately address the educational component of the role. Nurse educators' educational literacy was developed through their attainment of education-related qualifications. The application of this knowledge informed their educational practices and strategies, such as a facilitative approach to teaching and learning and utilization of scaffolding techniques (Salinitri et al., 2015). The practice of educational literacy served to ensure nurse educators effectively contributed to the capability development of the nursing workforce (SA Health, 2014) through professional development opportunities (Price & Reichart, 2017).
The value adding component of their role occurred when nurse educators understood that their contribution to ongoing professional development with their clinical nurse colleagues ultimately contributed to reducing patient mortality (Aiken et al., 2011). The up-skilling of nursing staff leading to a more educated workforce was achieved by nurse educators having a presence in the clinical environment and seeking connections with nurses within that same environment.
The nurse educators invested in building a more capable and responsive nursing workforce to provide consistently safe patient care. Investment was undertaken by addressing both the immediate technical knowledge or skill deficit and the ability of the hospital-based nurse to be a self-directed lifelong learner. Immediate investment in the nursing workforce occurred through the provision of opportunistic education sessions that assisted nurses to attain technical capability, enabling them to fulfill their role. Investing in the nursing workforce through the provision of professional development and training of nurses is identified as a key factor in nurse retention (Dawson, Stasa, Roche, Homer, & Duffield, 2014) and leads to increased career satisfaction (Price & Reichart, 2017) and potential reduction in nurse turnover. The average cost of nurse turnover per full-time equivalent in Australia has been calculated at $49,255 Australian dollars (Roche, Duffield, Homer, Buchan, & Dimitrelis, 2015, p. 355).
The longer term investment in hospital-based nurses came about when nurse educators focused on the development of hospital based nurses' skills that would assist and enable them to take responsibility for identifying their own learning needs over the duration of their professional career. Longer term investment occurred through the fostering of a learning culture and the deliberate use of a facilitation model of education (Salinitri et al., 2015) as distinct to a transmission model (Hornsby & Osman, 2014). The nurse educators aimed to strengthen hospital-based nurses' capability and capacity to be a self-directed learner who utilized reflection and critical thinking skills within their everyday practice.
Having a Presence
The value-adding practice of investing in the hospital-based nursing workforce was augmented by nurse educators having a presence in the clinical practice environment. Having a presence in the clinical environment had the aim of increasing nurse educators' exposure to hospital-based nurses and making them more accessible and, in turn, relevant to nurses in that environment. It acted as a conduit to assist in building the capability of the hospital-based nursing workforce.
Nurse educators recognized that being situated away from the clinical environment negatively affected the perception that hospital-based nurses had of them; it made them invisible and diminished their capacity to be seen as relevant to the nursing profession. It also denied hospital-based nurses quick and ready access to the nurse educator. To redress these perceptions, nurse educators sought to raise their accessibility and visibility, a form of personal marketing (Avila et al., 2013, p. 102), to strengthen their relationships with hospital-based nurses. Nurse educators actively engaged in a range of activities that enabled and justified them having a presence in the clinical environment and reinforced their position as a nurse. These included the provision of information sessions at ward level on new practices, procedures, or policies, engaging in delivery of direct patient care, and attending meetings with clinically situated nurses.
Recognizing how nurse educators add value is an important factor in recognizing the work of nurse educators. In undertaking the nurse educator role, employers should allow nurse educators to balance the pedagogical demands of being a nurse educator with the opportunity to connect with clinicians through having a presence in the clinical area.
Enhancing Perceptions of the Nurse Educator
Strategies to enhance the perception of nurse educators include focusing on promoting the nurse educator role as a specialization and how it adds value to the nursing profession through retention of nursing staff (Price & Reichart, 2017) and improved patient outcomes (Aiken et al., 2011). Promoting how the nurse educator adds value to the profession can be achieved through celebration of education innovation, acknowledging the breadth of work undertaken by nurse educators, ensuring nurse educators are appropriately supported to work to their full scope of practice as educational experts and are actively deferred to as education experts within the organizations in which they work. These strategies would be enhanced by employing organizations that encourage and support nurse educators to undertake postgraduate nurse education studies. Nurse educators in maintaining active links with clinical areas should not be a substitute clinical workforce, as identified occurred by Fairbrother et al., (2015); to do so denigrates the value of the nurse educator role.
Thematic analysis identified the nurse educator role is understood as comprising four overarching themes: Becoming an Educator, Capability Building, Panacea, and Tension. Combined, these four themes comprised 15 subthemes. Further analysis revealed two disparate views in relation to the perceived value of the nurse educator role with each affecting nurse educator practice. The role is understood to be undervalued, yet it adds value to the capability of the hospital-based nurse.
Findings from this research project have implications for nurse educator practice. The production and sustainability of a competent professional hospital-based nursing workforce is underpinned by nurse educators who facilitate and provide delivery of continuous professional development to nurses in the workplace (Price & Reichart, 2017). Nurse educators are the key conduit for hospital-based professional nurse education at a time when knowledge, technologies, and practices are rapidly changing. The nurse educator is therefore critical to the sustainability and efficacy of a capable nursing workforce in the high-stakes and high-cost environment of hospital care.
Without nurse educators, hospitals risk the cessation of real-time responsive pedagogically informed ongoing professional development of their workforce and, in turn, the quality of nursing care and thus patient outcomes (Aiken et al., 2011). The ability to recruit and retain nurse educators in the shadow of a health system faced with looming workforce shortages (Buchan, Duffield, & Jordan, 2015; Health Workforce Australia, 2012), advancing technological innovation, increasing patient complexity, and rising health care costs challenge hospital administrators to consider the role nurse educators play with respect to the ongoing capability development of the nursing workforce. More importantly, nurse leaders should consider what they can do to ameliorate the perceptions that exist within the clinical nursing community that nurse educators are not real nurses.
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Semi-Structured Open-Ended Questions
|How did you become a nurse educator?|
|How do you understand the role of the educator within a hospital setting?|
|Tell me what defines your work as a nurse educator.|
|What does being a nurse educator mean to you?|
|What does education mean for you in your role as a nurse educator?|
|What do you see as the benefits of having hospital-based nurse educators?|
|How has the work context or hospital influenced the nature of your work?|