The futurists have been warning us for decades that 21st century nursing would look very different than 20th century nursing. Fm beginning to believe them. In a provocative op-ed published last summer, Tim Porter-O'Grady (2001) declared that:
nursing practice in its current configurations and forms is dying as the demands of the health system are changing both substance and service.... The role of the clinical executive is to end the practice of nursing as we have known it.... Time-based nursing care with the activities of bathing, treating, changing, feeding, intervening, drugging and discharging are quickly becoming historic references to an age of practice that no longer exists (p. 183).
The evidence of this profound change is all around us. In Oregon, the average length of hospital stay is now less than 4 days, and only 55% of nurses currently practice in institutional settings, compared to 80% a little more than a decade ago (Tanner, 2001). Practicing nurses in all settings are reeling from the increased intensity of their work- more patients, rapid turnover, high acuity, and the overwhelming sense that they can no longer practice nursing nor provide the quality of care they would like. The nursing shortage both fuels and is fueled by these dramatic changes in nursing practice.
As nurse educators, we continue to struggle with our time-honored approaches to clinical teaching. Except in the most innovative nursing programs, we continue to use, in Porter-O'Grady's terms, "resident, bed-based nursing care fundamentals as the foundation for basic nursing education" (2001, p. 185). From fundamentals on, students are placed in a clinical setting where they can be assigned to a patient, develop a plan of care applying what they have learned in their theory courses, and then provide total patient care based on that care plan. The role of clinical faculty is to find good placements, develop relationships with nurses in the clinical setting so they will be welcoming and helpful to students, make patient assignments for their students, and then supervise the students as they provide care. The learning is derived from students acting like nurses, learning from providing care to one or more patients each week, and absorbing whatever other learning presents itself while in the clinical setting.
The "clinical placement" model is beginning to unravel in the whirling dervish of nursing practice change. Increasing acuity in most settings terrifies beginning students and raises the specter of unaffordable student-faculty ratios to assure safe levels of supervision. The rapid turnover of patients is awesome. Patients often are discharged before students are able to implement the plan of care they developed so carefully the night before. In addition, the competition for clinical placements in metropolitan areas is fierce. With the increasing nursing shortage, qualified preceptors are becoming difficult to find. And somehow, amid this chaos, nurse educators must rise to the challenge of educating more nurses if we are to avert the greatest shortage of nurses in our history.
Revolutionizing clinical education is no longer an option- we must. The nursing care fundamentals of the 20th century simply are not relevant in the 21st century. Technology, accessibility of information, the emerging impact of genomics, and the move toward "early engagement health services" should alter dramatically both what and how we teach. Moreover, new understandings of how human beings learn from their experiences also should shape our processes of clinical instruction.
Fast forward to 2010. What would the new model of clinical education look like? Here are some of its characteristics:
* Faculty roles will change from acting as deliverers of content and supervisors of clinical education to being facilitators of learning and active designers of clinical learning experiences.
* Faculty will develop a range of learning experiences from which students may choose to help them achieve required competencies for practice. The emphasis will be on development of flexible skill sets that can be used across settings.
* Faculty will help students progress in their development, with experiences designed to encourage them to, first, think like nurses, then care like nurses, act like nurses, and finally, be nurses. For students to learn how to think like nurses, they need a sense of what they are aiming for. They may shadow nurses in any setting who can think aloud with them, pointing the way to the decisions they make, how they make them, what information they access, and how they draw on the expertise of other disciplines.
Students need practice thinking like nurses in situations that are not threatening to patient safety. They may be presented with virtual simulations that require the application of knowledge and the exercise of judgment. Students need help learning to make the qualitative distinctions so essential for good judgment. A clinical expert may spend a few hours with a small group of students guiding them through the assessment of patients and families with common chronic conditions, pointing out features salient for care planning.
Students also will need experiences to help them care like nurses. Faculty may develop learning activities that help students understand patients' and families' experiences in coping with an illness, learning health behaviors, or deciding to undergo genetic testing.
Finally, students need experiences in acting like nurses-experiences in which students are immersed in a clinical setting, with enough time to discover the pace and rhythm of the setting, where and how to access information, and that they practice as a member of the health care team, as well as with an opportunity to pull it all together.
This issue of the Journal of Nursing Education brings together a collection of articles on clinical learning. Taken together, they should stimulate and provoke discussion about how we help our students become nurses who can practice competently in the new environment. We look forward to a continuing dialogue about advances in clinical learning.
- Porter-O'Grady, T. (2001). Profound change: 21st century nursing. Nursing Outlook, 49(4), 182-186.
- Tanner, C. (2001). Oregon's nursing shortage: A public health crisis in the making. Portland, OR: Northwest Health Foundation.