Journal of Nursing Education

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Editorial 

Changing Nursing Education: Creating Our Tipping Point

Janis P. Bellack, PhD, RN, FAAN

Abstract

Nursing education and nurse educators are facing unprecedented challenges and working hard to address the looming nursing work force shortage. New programs are coming on line, literally and figuratively, and enrollments in existing programs are expanding, in response to growing demands for entry to the profession. At the same time, we are facing a critical faculty shortage and reported shortages of, or growing competition for, clinical learning sites. Yet, our traditional teaching-learning models are not serving us well in facing these challenges.

There is little evidence that nurse educators have done much to challenge the long-standing structure and processes of undergraduate nursing education in order to achieve greater efficiency and, more important, to improve the learning outcomes and readiness of our graduates for the world of nursing practice. In addition, changed expectations and norms regarding what it means to be a nurse educator have, in some ways, unintentionally contributed to the faculty shortages. During the past decade, we have spoken much about the need for new models of partnership and collaboration in nursing education, but little of real benefit or impact has taken hold to date.

To stimulate dialogue and exploration to move us collectively toward new ways of being and doing nursing education, I offer several innovations below, some of which are not new but bear repeating because they have not yet become widespread practices. None alone is sufficient to change our system of undergraduate nursing education, but together they offer the possibility of achieving dramatic improvements in the ways we organize and teach our programs and the ways our students learn and are socialized into the profession.

Schools of nursing can create reciprocal partnerships with clinical sites, rather than simply negotiating for clinical staff to assist with supervising or precepting students in addition to their already busy workloads. Schools should be prepared to buy out or negotiate a fair trade for a portion of clinical staff time; grant clinical faculty appointments; and provide opportunities for staff to participate as full partners and faculty members, including learning the role and responsibilities of nurse educators, contributing to curriculum design and evaluation, and being involved in student life to the extent to which they are able or desire. In turn, the clinical agency can pay or trade for a portion of the school’s full-time faculty to assist with staff development, research or clinical specialist consultation, or clinical practice.

Schools can co-fund a selected number of faculty positions with clinical partners. For example, the salary for a single full-time faculty position could be split four ways and used to hire four master’s prepared clinicians for quarter-time positions. Each clinician could be assigned four undergraduate students for weekly clinical learning experiences, thus increasing the effect of a single position two-fold (assuming a 1:8 faculty-to-student ratio for 2 days per week). Or a full-time position could be equally shared and funded by both the school and the clinical partner, with the position holder responsible for a full clinical teaching workload (8 students, 2 days per week), thus increasing the school’s capacity to cover twice the number of clinical learning experiences with funding for a single, full-time equivalent position.

Academic-year appointments can be converted to calendar-year appointments, and clinical courses can be offered during summers as well as the academic year, thus achieving more efficient and effective year-round use of clinical settings. The additional revenue from summer courses, which even public institutions are usually permitted to retain to cover costs, can be used to cover the additional salary and benefits costs. In addition, by ensuring year-round employment higher salaries (and benefits), academic nursing may become…

Nursing education and nurse educators are facing unprecedented challenges and working hard to address the looming nursing work force shortage. New programs are coming on line, literally and figuratively, and enrollments in existing programs are expanding, in response to growing demands for entry to the profession. At the same time, we are facing a critical faculty shortage and reported shortages of, or growing competition for, clinical learning sites. Yet, our traditional teaching-learning models are not serving us well in facing these challenges.

There is little evidence that nurse educators have done much to challenge the long-standing structure and processes of undergraduate nursing education in order to achieve greater efficiency and, more important, to improve the learning outcomes and readiness of our graduates for the world of nursing practice. In addition, changed expectations and norms regarding what it means to be a nurse educator have, in some ways, unintentionally contributed to the faculty shortages. During the past decade, we have spoken much about the need for new models of partnership and collaboration in nursing education, but little of real benefit or impact has taken hold to date.

To stimulate dialogue and exploration to move us collectively toward new ways of being and doing nursing education, I offer several innovations below, some of which are not new but bear repeating because they have not yet become widespread practices. None alone is sufficient to change our system of undergraduate nursing education, but together they offer the possibility of achieving dramatic improvements in the ways we organize and teach our programs and the ways our students learn and are socialized into the profession.

Innovations to Change Nursing Education

Partner with Clinical Sites

Schools of nursing can create reciprocal partnerships with clinical sites, rather than simply negotiating for clinical staff to assist with supervising or precepting students in addition to their already busy workloads. Schools should be prepared to buy out or negotiate a fair trade for a portion of clinical staff time; grant clinical faculty appointments; and provide opportunities for staff to participate as full partners and faculty members, including learning the role and responsibilities of nurse educators, contributing to curriculum design and evaluation, and being involved in student life to the extent to which they are able or desire. In turn, the clinical agency can pay or trade for a portion of the school’s full-time faculty to assist with staff development, research or clinical specialist consultation, or clinical practice.

Co-Fund Faculty Positions

Schools can co-fund a selected number of faculty positions with clinical partners. For example, the salary for a single full-time faculty position could be split four ways and used to hire four master’s prepared clinicians for quarter-time positions. Each clinician could be assigned four undergraduate students for weekly clinical learning experiences, thus increasing the effect of a single position two-fold (assuming a 1:8 faculty-to-student ratio for 2 days per week). Or a full-time position could be equally shared and funded by both the school and the clinical partner, with the position holder responsible for a full clinical teaching workload (8 students, 2 days per week), thus increasing the school’s capacity to cover twice the number of clinical learning experiences with funding for a single, full-time equivalent position.

Consider Academic-Year Versus Calendar-Year Appointments

Academic-year appointments can be converted to calendar-year appointments, and clinical courses can be offered during summers as well as the academic year, thus achieving more efficient and effective year-round use of clinical settings. The additional revenue from summer courses, which even public institutions are usually permitted to retain to cover costs, can be used to cover the additional salary and benefits costs. In addition, by ensuring year-round employment higher salaries (and benefits), academic nursing may become more competitive with the practice sector and, thus, attract more nurses to education careers.

Use Simulation Technology

Schools could increase the use of simulation technology. Admittedly, a substantial up-front investment is needed to equip an on-campus learning space with state-of-the-art simulation models and computer technology. However, once the investment is made, such a laboratory makes it possible for students to practice in a safe environment, without risk to patients, and acquire a level of knowledge and practice that readies them for the actual clinical environment. This can decrease the number of practice hours and the close supervision needed in the actual clinical setting, thus reducing the burden on clinical teaching staff. Funding for the technology can be sought through public and private grant sources, as well as through cost-sharing with clinical partners.

Place Students in a Single Health Care Institution

Typically, nursing students rotate through a variety of clinical settings during the course of their educations. But how much time is wasted orienting them to each new setting (e.g., its physical facility, unit personnel, documentation and medication systems)? Instead, students could be placed in a single health care institution for the majority of their clinical learning experiences. By assuring continuity within a given care delivery system, with its range of settings from acute to ambulatory to home care, learning time would be maximized and staff “wear and tear” would be dramatically reduced. Less time would be spent orienting new groups of students, leaving more time to focus on learning. In addition, clinical partners may be more willing to commit to having students work with them if they can devote more time to helping them learn to provide and coordinate care, rather than figuring out the documentation system and locating supplies.

Change the Traditional Clinical Rotation Model

On average, undergraduate students still spend 2 days per week in the clinical setting during each academic term. Why not adopt a clinical immersion model in which students spend 32 to 40 hours per week in the clinical setting for a shorter number of weeks during every quarter or semester, allowing them to experience clinical practice as they will as new graduates? While this model is common in the final term before graduation, its use throughout the curriculum is rare.

Rethink the Roles and Expectations of Nursing Faculty

It is necessary to rethink the traditional roles and expectations of nursing faculty, including whether the doctoral degree is “the appropriate and desired credential for a career as a nurse educator” (American Association of Colleges of Nursing, 1996, p. 3). Doctorally prepared nurse educators are certainly needed for our graduate education programs and to continue the great strides made in advancing nursing’s unique body of knowledge. However, most are not eager to spend a significant portion of their work week in a clinically intensive setting overseeing the learning experiences of undergraduate students. Isn’t it time we openly acknowledge this fact and aim for a more reasonable and realistic balance of master’s and doctorally prepared faculty in our schools?

In addition, we continue to cling to role expectations that require every faculty member to teach, conduct research (and, increasingly, find extramural funding to support it), participate in institutional service, advise students, and update curricula. However, in the service sector, all of these roles are rarely, if ever, expected of the same individual. And while we allow, even encourage, prolific nurse researchers to “buy out” of teaching time, we do not provide similar opportunities for our expert teachers, so they can devote their full-time efforts to teaching. Perhaps it is time to create differentiated faculty work models, with appropriate recognition and rewards for each. Boyer’s (1990) model of diverse scholarship supports this idea, but because there is little extramural funding to support the “scholarship of teaching,” the contributions of expert teachers go largely unrecognized and unrewarded.

Reduce Waste in the Nursing Education System

Are all of our committees, and their meetings, necessary? We need to streamline the collective non-teaching commitments of faculty to free time for the real work of teaching-learning, scholarship, and mentoring students. This can be achieved by using technology for information sharing (e.g., committee reports), saving meeting time for deliberation and decision making. Leadership for changing this entrenched model must come from the top (e.g., the dean or director) or from the collective push of faculty. Too many programs and faculty spend inordinate hours processing, planning, and deliberating, not to mention revisiting what has already been decided. We can begin by shaving 30 minutes off of every meeting or meeting fewer times per year; setting time limits for deliberating items; and considering which committees are necessary. What is needed is a commitment to reasonable consensus and a “let’s try it” attitude, rather than full agreement, before a decision is made. We need to decide when good is “good enough” to move forward.

Conclusion

What constraints—institutional, regulatory, professional, or self-imposed—make it so difficult to change the way we educate new nurses? Collectively, we need to “just do it” (as the Nike motto suggests). If Gladwell’s (2000) theory is correct, small changes, such as those offered above, can have a big impact, spreading like a virus throughout a system, and leading to a “tipping point”—“that one dramatic moment in an epidemic where everything can change all at once” (Gladwell, 2000, p. 9). We need to create, through innovation, our tipping point in nursing education.

Janis P. Bellack, PhD, RN, FAAN

Associate Editor

References

  • American Association of Colleges of Nursing. (1996). The essentials of master’s education for advanced practice nursing. Washington, DC: Author.
  • Boyer, E.L. (1990). Scholarship reconsidered: Priorities of the professoriate. Princeton, NJ: The Carnegie Foundation for the Advancement of Teaching.
  • Gladwell, M. (2000). The tipping point. Boston: Little, Brown & Company.

10.3928/01484834-20040801-04

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