1. The Future of NursingEducation: A CollaborativePerspective Christine A. Tanner, RN, PhD Oregon Health & Science University School of Nursing

2. Calls for Reform • Reexamination of curricular structures & processes (The Curriculum Revolution) • Preparing a new kind of nurse

3. The Curriculum Revolution • New pedagogies • Preparing tomorrows leaders • Multicultural diversity • Caring Curriculum

4. Demands for a New Kind of Nurse Fueled by changes in the nursing practice environment: Increasing complexity and acuity Decreased length of stay Shift of care to home & community Exponential growth of knowledge Explosion of technologies Identification of the “Quality Chasm”

5. Demands for a New Kind of Nurse Fueled by changes in demographics: Aging population with increased prevalence of chronic illness Families increasingly engaged in care giving with little or no nursing support Increased attention to health-promotion

6. Central Competencies • Critical thinking

7. Critical thinking = Thinking Like a Nurse?

8. A Short History ofNursing ProcessClinical Problem SolvingClinical Decision MakingDiagnostic ReasoningCritical Thinkingin other words . . .Thinking Like a Nurse

9. Two decades of Research on CT • Critical thinking and clinical thinking (i.e., decision making, clinical judgment) are different constructs. • No relationship between education & critical thinking. • No relationship between critical thinking and patient outcomes

10. Central Competencies • Clinical Judgment: • Case based • Contextually bound • Interpretive reasoning

11. Central Competencies • Clinical Judgment requires deep background knowledge for: • Noticing • Considering plausible interpretations • Collecting reasonable evidence • Choosing the best course of action

12. Central Competencies • Clinical Judgment is always within • the context of a particular patient • A deep understanding the patient’s experience, values and preferences • Ethical standards of the discipline

13. Central Competencies • Understanding clinical judgment in this way • Renews interest in case-based approaches to instruction • Demand new approaches to clinical education • Provides guidance to use of simulation in nursing education

14. Central Competencies:Quality-Safety Initiative • Patient-centered care • Team-work and collaboration • Evidence-based practice • Quality improvement • Informatics

15. Preparing More Nurses

16. Preparing More Nurses • In the face of a profound faculty shortage

17. Preparing More Nurses • In the face of a profound faculty shortage • Limitation in the number, type and quality of sites for clinical education.

18. Current practices in clinicaleducation

19. A very short history of clinicaleducation

20. Challenges in Clinical Education • Traditional clinical learning driven by placement opportunities and challenges • Insufficient number of “placements” using total patient care model • High acuity, greater risk with neophyte students • Staff nurse burden for supervision of students in rapidly changing situations • Learning is dependent on… • Available patient population • Facility’s schedule availability • Availability of faculty with required expertise

21. Summary: Driving Forces for Reform • Demands for Reform in Nursing Education 1985-2005 • Study of Curricular processes • Evidence of poorly prepared graduates even for acute care • Quality-safety

22. Summary: Driving Forces for Reform • Demands for Reform in Nursing Education 1985-2005 • Need for a “new” nurse • Changes in the practice environment • Emerging health care needs • Practice in environment of severe shortage

23. Summary: Driving Forces for Reform • Demands for Reform in Nursing Education 1985-2005 • Need for a “new” nurse • Other pressures: • Content explosion • Advances in the science of learning • Outdated model of Clinical education

24. Part II: The Oregon Consortium for Nursing Education

25. OCNE • A collaboration among 8 community colleges and 5 campuses of OHSU to: • Deliver a standard competency based curriculum with an AAS exit and completion of Baccalaureate in nursing on “home” campus • Increase the number of nurses prepared with baccalaureate degree • Transform nursing education to more closely align with emerging health care needs

26. A very short history of OCNE • 2000: Study of nursing shortage in Oregon • 2001: Strategic plan developed by Oregon Nursing leaders • 2002: Education plan unveiled and political turmoil ensued • 2003: Launched OCNE with Project Director • 2004: Began curriculum development & Phase I of Faculty Development • 2005: Curriculum change approved by OSBN, NLNAC & CCNE • 2006: Phase I Clinical Education Project launched • 2006: First class of 255 students admitted on 6 campuses to nursing courses • 2007: Phase II Faculty Development • 2008: Preceptor Development • 2009: First Baccalaureate class graduates

27. OCNE as a response to these challenges • Committed to collaboration across programs enabling the best use of scarce resources • Standard, competency based curriculum focused on preparing the “new” nurse. • Teaching approaches that rest on the science of learning • Faculty development as an integral part of curriculum development • Reform of clinical education

28. Guiding Principles in Curriculum Design • Responsive to demands for reform • NCSBN – 2001 – lack of preparation of grads • JCAHO (2002) – continental divide between education and practice • IOM reports

29. Guiding Principles in Curriculum Design • Responsive to demands for reform • Emerging health care needs • Aging population • Increasing acuity • Increasing prevalence of chronic illnesses • Demands placed on caregiving families with inadequate nursing care support

30. Guiding Principles in Curriculum Design • Responsive to demands for reform • Emerging health care needs • Graduates would be practicing in an environment of chronic, severe RN shortages • More efficient & effective with dwindling supply of nursing faculty • Competencies of the “new” nurse would require at least 4 years, but there would need to be AD exit

31. Overview of the Curriculum • First year: Prerequisites • Second year & first two quarters of the third year: • Required non-nursing courses • Standard nursing courses on all campuses • Third quarter of the third year: • Complete Precepted Scope of Practice Practicum, graduate with AAS and be eligible to sit for NCLEX OR • Continue directly into 400 level nursing courses for 4 remaining quarters, complete 15 credits of upper division arts & science, and graduate with BS

32. Transformation of the Nursing Curriculum:Some Features • Courses organized around foci of care: • Health Promotion • Chronic Illness Management • Acute Care • End-of-Life Care

33. Transformation of the Nursing Curriculum: Some Features • Last 4 clinical nursing courses toward Bachelors degree, students may select a population for focus in: • Public health and population-based care • Leadership and outcomes management • Clinical immersion or integrative practicum for twenty weeks

34. Transformation of the Nursing Curriculum: Some Features • Redefines nursing fundamentals to: • Clinical Judgment • Evidence-based Practice • Patient-centered care • Leadership

35. Transformation of the Nursing Curriculum: ApplyingThe New Pedagogy • Draws on tremendous advances in the science of learning from a variety of disciplines (cognitive science, psychology, higher education)

36. The New Pedagogy • Emphasizes deep understanding of the discipline’s most central concepts --- • Purposeful REDUCTION in content • Selection of content based on: • Prevalence of condition • Useful to teach integration across competencies • (e.g. ethical comportment, clinical judgment, evidence-based practice, health systems issues & leadership,

37. The New Pedagogy • Emphasizes deep understanding of the discipline’s most central concepts • Active learning through case-based instruction, integration among theory, clinical and simulation.

38. The New Pedagogy • Emphasizes deep understanding of the discipline’s most central concepts • Active learning through case-based instruction, integration among theory, clinical and simulation. • Authentic performance assessment & promotion of self-directed learning

39. Process for Consensus Building during Curriculum Development • Institutional representatives • Leadership model • Faculty development combined with curriculum development • Frequent Review & Counsel by groups with expertise & vested interests: • Faculty on each of the 12 campuses • Specialty task forces

40. Challenges in Clinical Education • Traditional clinical learning driven by placement opportunities and challenges • Insufficient number of “placements” using total patient care model • High acuity, greater risk with neophyte students • Staff nurse burden for supervision of students in rapidly changing situations • Learning is dependent on… • Available patient population • Facility’s schedule availability • Availability of faculty with required expertise

41. Desired Features of New Clinical Education Model • Relationship-centered care keeping the patient and family at the center • Science of learning and findings of the Carnegie study • (i.e. integration across apprenticeships, retain prep, coaching and debriefing and other best practices)

42. Desired Features of New Clinical Education Model • Relies on Clinical learning activities that: • Are designed to support attainment of Competencies • Include, but not dominated by “Total Patient Care” • Developmentally appropriate for level of student • Vary faculty–student ratios & nursing staff roles by level of student, acuity of patient, nature of learning activity • Culminate in one or more Immersion experiences.

43. Types of Clinical Learning Experiences • Focused direct care experiences • Patient-centered care • Therapeutic relationship • Individualized care

44. Types of Clinical Learning Experiences • Focused direct care experiences • Concept-based experiences: focus on learning concepts (e.g. oxygenation) through seeing many patients who exemplify the concept

45. Types of Clinical Learning Experiences • Focused direct care experiences • Concept-based experiences • Case-based experiences: focused on learning clinical judgment through working through clinical problems presented in text-based through fully simulated scenarios.

46. Types of Clinical Learning Experiences • Focused direct care experiences • Concept-based experiences • Case-based experiences • Skill-based experiences: focused on learning basic skills through repetitive practice, includes psychomotor skills, such as interviewing.

47. Types of Clinical Learning Experiences • Focused direct care experiences • Concept-based experiences • Case-based experiences • Skill-based experiences • Integrative experiences: opportunity to integrate prior learning and linking learning activities to RN role in clinical agency.

48. Types of Clinical Learning Experiences: Differentiated by: Type of learning and appropriate pedagogy Degree of accountability for patient care

49. Transformation of Clinical Education • Phase I & II: consensus building on need for change • Phase III: 8 pilot projects, evaluating innovative clinical learning activities that when combined may lead to a new model • Phase IV: development of and consensus building on new model • Phase V: statewide demonstration of new model through 3 years of OCNE nursing curriculum

50. 6 Major Components ofConsortium Development • Developmental Processes & Infrastructure • Faculty Development • Simulation Capacity • Curriculum Development • Clinical Education Capacity • Comprehensive evaluation