Journal of Nursing Education

Guest Editorial Free

Orthodoxy and Innovation: Next Practices for Nursing Education

Teri A. Murray, PhD, APHN-BC, RN, FAAN

The author has disclosed no potential conflicts of interest, financial or otherwise.

The real act of discovery consists not in finding new lands, but in seeing with new eyes.

It has been nearly 3 years since the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine (IOM), recommended the need for profound and sweeping innovative changes in nursing education (IOM, 2010). Since the unveiling of that landmark report, most of the innovative advances in nursing education have been modest, primarily focusing on simulation technology (high-fidelity manikins and virtual technologies such as Second Life® multi-user virtual environment), strategic partnerships (academic-service, interprofessional, interinstitutional, and intrainstitutional), and pedagogical approaches in the classroom or clinical setting (clickers, flipped classrooms, dedicated education units, clinical immersion) (IOM, 2010; Murray, 2013). In as much as these innovations were needed and are laudable, they have not yet sparked substantial disruption or a seismic shift in the prevailing academic model of nursing education.

Disruptive innovations transform ways of life or current practices (Dyer, Gregersen, & Christensen, 2011). Consider how banking practices changed after the advent of the ATM or how the coin-operated telephone booth became obsolete with the introduction of the cell phone. Mobile technology (the Internet, e-mail, text messages, and social media platforms) shrunk the world like nothing else since the beginning of time and transformed modes of communication. Nursing education has not experienced disruptive innovations of this magnitude, despite numerous calls for transformation and reformation. With the exception of accelerated nursing education, which began more than 40 years ago, little has changed in the pedagogy of nursing education. The limited progress toward new and innovative approaches supports the notion that nursing, along with higher education in general, tends to strangle innovation and reform (Kirschner, 2012). The U.S. Department of Education (2006) confirmed that when compared with a business model, academia is a mature enterprise that is increasingly risk averse, at times self-satisfied, and unduly expensive.

Classroom activity remains the traditional academic model for prelicensure nursing education, followed by the school-based faculty supervision of a small group of six to 10 students in the clinical setting. This time-honored approach is still the gold standard for clinical teaching, in spite of the lack of agreement on the number of clinical hours necessary to produce a safe and competent entry-level practitioner. The clinical hour requirement among nursing education programs differs and can range from 500 to 1,300 hours (National Council of State Boards of Nursing [NCSBN], 2013). Even with this huge variation in clinical hours, nurse administrators question whether any amount of clinical hours actually produce the learning necessary for students to effectively transition to practice, given that 40% of new graduates report making medication errors and 50% lack confidence in recognizing life-threatening complications (The Advisory Board, 2008; IOM, 2010; NCSBN, 2013). Nonetheless, the nursing academic community has not relinquished its unabashed commitment to its predominant model of education, despite the documented reality and transitional stressors associated with new graduate nurse entry into practice (Hoffart, Waddell, & Young, 2011). Notwithstanding, the current education model remains labor intensive and impacts staff nurse productivity at a time when high levels of productivity and vigilance are needed to avoid the costs associated with hospital readmissions and the uncertainties related to third-party payment reimbursement.

The demand for nursing remains at an all-time high, with thousands of students enrolling in nursing education programs each year. There has been considerable expansion of existing programs, along with the proliferation of new programs. This growth has occurred in spite of the known faculty and clinical site capacity limitations and can be compared with a sand pile. The sand pile is created by the continued addition of sand when no one knows the capacity within the pile, the internal workings of the pile, or when the pile might reach or exceed its threshold. Most importantly, no one knows if or when an avalanche will occur and the pile will collapse. On the other hand, “the American automobile industry was an extremely well-functioning highly complex set of organizations aligned perfectly to get the results it got as it crashed headlong into adaptive pressures about which it had been warned for decades” (Heifetz, Grashow, & Linksy, 2009, pp. 18–19). To avoid such scenarios, it is critical for academic nursing to plan for and envision what the future might look like, identify the opportunities or challenges that might arise, and build capabilities to capitalize on them (Prahalad, 2010).

Many unknown variables on the horizon will ultimately affect nursing education, the educational process, and the economics of nursing education. In complex environments where unpredictability and flux have become the norm, one model of education may not be easily maintained, and there is considerable danger in relying on too much certainty (Snowden & Boone, 2007).

Significant changes have occurred in the funding mechanisms for higher education. It is unclear how the federal budget sequester will affect nursing education, but it is presumed it will further erode funding for nursing education programs. Thus, it is highly anticipated there will be fewer nurses, nursing students, faculty, and educational opportunities as a result of sequestration and at a time when more people will seek health care services as a result of the Affordable Care Act (American Association of Colleges of Nursing, 2013). These unknowns represent an adaptive challenge for nursing education.

Adaptive challenges are created in response to new environments and provide an opportunity to reexamine value, purpose, and process by building on the past, along with discovering next practices to thrive anew (Heifetz et al., 2009; Prahalad, 2010). Adaptive challenges require an integration of leadership, adaptation, systems, and change theories (Heifetz et al., 2009). According to Prahalad (2010), Peter Drucker once said that the best opportunities are “visible, but not seen” (p. 32), and organizations or professions often benefit from tackling adaptive challenges when the problems of one approach are widely recognized, affect other organizations, the industry’s economics are impacted, and tackling the problem could create big opportunities for the profession. Thinking differently is the only real and sustainable bridge from our current state to a preferred future (Maher, 2004). When asked, “What is the sum of 5 plus 5?” there is only one correct response, but when the question is framed, “What two numbers add up to 10?” there are a number of options not readily apparent with the first question (Seelig, 2013). Dyer et al. (2011) outlined five skills that can foster disruptive innovation and could be used to frame the discovery of next practices in nursing education:

  • Associating involves drawing connections or ideas from unrelated fields. Innovative ideas often emerge from combining existing ideas into something new. Is there a cross-pollination of ideas or perspectives from other areas or professions that can provide new insights for nursing education? Innovators excel at linking together ideas that are not obviously related.
  • Questioning involves asking provocative questions that challenge the prevailing practice and push boundaries and assumptions that prevail in nursing education. Are you willing to ask questions such as “Why?” “Why not?” and “What if?”
  • Observing involves watching to see what works and what does not. It can include questioning students, clinical partners, and other stakeholders to identify new ways of doing things. Could doing so create more relevance in nursing education? According to the NCSBN (2013), approximately 25% of new nurses leave a position within 1 year of practice. The transition from student to new nurse remains difficult despite best efforts by academic nursing to prepare safe entry-level nurses and nursing service efforts to orient and mentor the new graduate for effective transition into practice.
  • Experimenting involves developing interactive experiences, prototypes, and unorthodox approaches to determine what insights might emerge. How can the profession move beyond practices based on historical precedence and regulation to make relevant the clinical and business case for innovation in nursing education? How can we foster and benefit from pilot educational models, prototypes, and innovation incubators?
  • Networking involves mixing with diverse groups of individuals to access different ideas and perspectives.

 It is imperative for academic leaders to prepare the profession for what lies ahead (Hoque, 2013). This challenge will require the type of leadership needed when the basic belief and model of how nurses are educated is threatened or challenged (Heifetz et al., 2009). Academic nursing must remain open to new insights and master the ability to question the existing worldview and subsequently develop next practices (Prahalad, 2010). Are we ready for the challenge?

Doublestein (2010) said:

Leadership is about taking people to a place that they would not go on their own. It is about disrupting the core and upsetting the status quo. It is about possessing and utilizing the proper skills to envision a preferred future; having the ability and commitment to persistently scan the horizon for trends that would either negatively or positively impact that future; creating strategies that lead toward and enforce the preferred future; designing and promoting an environment of creativity in order to develop strategies to avoid obstacles to the preferred future; supporting and encouraging the development of disruptive innovations that foster, rather than impede the future; leading the diffusion of those innovations into the general population; integrating change-theory strategies that move people forward in a unified manner; and mentoring others in the profession along the way to keep them focused on the ends. (pp. 18-19)

Teri A. Murray, PhD, APHN-BC, RN, FAAN

Dean and Associate Professor

School of Nursing

Saint Louis University

3525 Caroline Mall, Suite 225

St. Louis, MO 63104


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