Educating Nurses

A Call for Radical Transformation

Patricia Benner, Molly Sutphen, Victoria Leonard, Lisa Day

• Publisher: Jossey-Bass
• Year: 2009
• ISBN:
  9780470557150
• Edition: 1
• Topic: Medicine
• Subtopic: Medical Education

The authors outline a clear vision of what nursing education can and should be and provide practical exemplars of how we can achieve this vision. This is a call for us to work together as guardians of the discipline to assure that future nurses enter the health care system ready and able to meet the challenges ahead.
— P AMELA M. I RONSIDE, director, Center for Research in Nursing Education, Indiana University

The profession of nursing in the United States is at a significant moment. Since the last national nursing education study almost forty years ago, profound changes in science, technology, and the nature and settings of nursing practice have reshaped the field. Yet schools have lagged behind in adapting to these changes. Added to this, the profession faces a shortage of nurses and nursing faculty.

To meet these challenges, the authors assert that schools, service providers, and the profession must change. They recommend four controversial yet essential changes that are needed to transform nursing education.

A volume in The Carnegie Foundation for the Advancement of Teaching's ­Preparation for the Professions series, the book discusses key topics for the future of the field and offers revolutionary recommendations for change.

PART ONE

TRANSFORMATION, CRISIS, AND OPPORTUNITY

AT A TIME when nurses face new demands on their knowledge and responsibilities, the U.S. health care system is anticipating both a staggering shortage of nurses and a drop in the number of available faculty to educate new nurses. How, at this moment, can nursing education maximize its capacity and meet the needs of a transforming profession? How can teaching—and hence student learning—more effectively prepare students to enter a complex practice?

In the first of the four chapters in this part, we look at today’s nursing practice in the United States. We consider the tremendous change the profession has undergone in recent decades and the challenge that nurses and nurse educators cite as their most pressing and constant concern: keeping up with the knowledge and skills that their work demands. We describe our findings in light of this challenge and others that nurse educators face, including the unintegrated structures of U.S. nursing education, faculty shortage, work overload, low faculty salaries, and limited clinical placements. We then turn, in Chapters Two and Three, to specific findings from our study about the experience of teaching and learning in clinical settings and the classroom.

We close Part One with a recommendation for a new approach to nursing education, one that builds on the considerable strengths we found and emphasizes teaching for a complex practice.

1

A PROFESSION TRANSFORMED

WE EMBARKED ON this study aware of the sweeping social and technological changes that have altered the context and substance of nurses’ work since Lysaught’s 1970 national study of nursing education. As professionals with expanding responsibilities in an increasingly complex field, even seasoned expert nurses must continuously learn across domains of knowledge and skill (Benner, Tanner, & Chesla, 2009; Porter-O’Grady & Malloch, 2003, 2007). This is an ethical mandate of the profession, a fact of professional life. An introduction to general science concepts is no longer adequate for understanding—and responding to—the complex health, illness, and treatment phenomena that nurses encounter in practice.

Nurses and nurse educators alike acknowledge the enormous pressure of expanded expectations for today’s nursing practice. Continuing education for nurses is now mandated for relicensure, and state boards of nursing are giving attention to improving assessment of competency for continued licensure by state boards of nursing. At this point, nurses are left to their own self-assessment and selection of continuing education from a range of continuing education classes. Although most health care organizations have become centers of teaching and learning in their own right, they focus mainly on teaching new technologies and new regulations, both of which are necessary but do not offer the clinical knowledge and skilled know-how needed for a self-improving practice. Like staff nurses, nurse educators struggle to find continued education to keep up their clinical skills and ongoing faculty development for upgrading their pedagogical and curricular skills.

A Health Care System Transformed

Increasingly, the U.S. health care system has been concerned with profits, costs, and competition; health care is viewed as a commodity and even acutely ill patients are referred to as clients, customers, or even “product lines.” Hospital-based care has changed dramatically, and care for the less acutely ill has shifted to the home and community. Reimbursement strategies are shifting from volume-based to “pay-for-performance” systems, and these systems depend on nurses to ensure that hospitals meet certain measures for quality, efficiency, and patient satisfaction (Lutz & Root, 2007), thereby positioning nurses as revenue sources rather than just part of hospital cost overhead.

Since the Lysaught Report was published, employment-based health care insurance has eroded and now only partially compensates highly technical care by public insurance programs. This change causes grave inequities in U.S. health care. At this writing, according to the U.S. Census Bureau’s Current Population Survey, forty-seven million people in the United States are without health insurance. As it stands now, such an unwieldy system presents few incentives for preventive care for the uninsured, though for the past ten years managed care has sought to address prevention for insured patient populations (Institute of Medicine [IOM], 2008). Medical care itself tends to focus on acute episodic care because that is what most medical education programs emphasize. Moreover, U.S. society is ethnically and linguistically diverse, which increases the challenge of communication and understanding on the part of both health care workers and patients and their families. Another challenge is an aging population, and hospital patients reflect this fact, evidenced by recent increases in Medicare’s Case Mix Index for inpatients (Lutz & Root, 2007), creating strain on care demands and economic resources of hospitals.

The revolution in information technology, the mushrooming of medical and nursing literature and technologies for accessing it, and the press to adopt electronic medical records while also protecting patient privacy have also changed the landscape of nurses’ work. As sharing of expertise is facilitated by technology, care is now delivered by phone, computer, and across state lines and other geographic boundaries; further development along these lines will most certainly continue. Moreover, hospitals now care primarily for highly physiologically unstable patients and those whose ongoing therapies require careful monitoring, and often immediate adjustment of medications and therapies on the basis of the patient’s responses to those therapies. As Marilyn Chow, vice president of patient care services at Kaiser Permanente, describes it, today’s medical-surgical patient is the ICU patient of the 1970s (Robert Wood Johnson Foundation [RWJF], 2007). Today’s nurses must work effectively in highly technical arenas within complex health care delivery systems, managing and titrating all the major medical therapies delivered in the acute care hospital, as well as in ambulatory care facilities and the home.

New Responsibilities

A tremendous shift of responsibility from physicians to nurses in all health care settings has occurred over the past sixty years. Physicians in many specialties now function primarily as diagnosticians and prescribers of treatment regimes. Nurses, patients, and family members administer these treatment regimens, usually under distant medical supervision. This requires a high degree of skill and knowledge. For example, to prepare medications nurses must understand multiple techniques of drug reconstitution, along with complex rules for drug compatibilities and incompatibilities. On the basis of the patient’s response, the nurse must also adjust and titrate most therapies. Nurses are expected to perform complex, precise, and diverse technological interventions, keeping track of many machines and other devices. We noted in the staff break room of one pediatric unit that there are twenty intravenous (IV) infusion sets for children, all with distinct uses, many of which cannot be used interchangeably.

Given the nature of the interventions, the nurse’s astute and early identification of changes in patients’ physical condition in acute and long-term care facilities is critical to the safety and well-being of patients. The requirements of attentiveness and good clinical judgment multiply with the increasing acuity levels of hospitalized patients and with the many and diverse chronic illnesses now common in a rapidly aging population.

At the same time that this increase in the needs of hospitalized patients has come about, there has been a decline in the percentage of registered nurses (RNs) working in hospitals. The proportion of the nurse workforce employed in hospitals peaked in 1984 at 68.1 percent and has declined steadily to its current low of 56.2 percent employed registered nurses (HRSA/BHP, 2006), with more nursing care delivered in ambulatory care settings, the community, and in the home.

New Challenges

Despite these significant changes in the nature of health care work, including the need for physician nurse collaborations, health care settings remain hierarchical (Freidson, 1970), making communication across disciplines and the design of safe health care systems more complex. However, as “doctor’s orders” change from specific directions to guidelines and parameters for nurses to judiciously adjust therapies according to the patient’s responses, clear communication and coordination between nursing and medicine becomes imperative. Studies have shown improved patient outcomes when the communication channels between nurses and physicians work well (Carroll, 2007; Arford, 2005; Baggs et al., 1999; Baggs, 1989), and a number of studies have demonstrated that poor nurse-physician communication is linked to medication errors (Kohn, Corrigan, & Donaldson, 2000; Leape, 1994), patient injuries (Page, 2004), and patient deaths (Tammelleo, 2001, 2002).

At cross-purposes to this new need for clear and precise communication within an interprofessional health care team is education for the various members of the team. Nursing, medicine, physical therapy, and other health care professions educate their students in academic silos, isolated from one another and hence largely ignorant of the expertise of those with whom they will need to work closely and seamlessly. Julie Gerberding, former director of the Centers for Disease Control and Prevention, has called for changing how doctors, nurses, and other health care providers are educated: “I believe that what we really need in this country are schools of health. . . . If we are seriously thinking about building a health care system, then we need to be training professionals in a collegial and collaborative manner” (Fox, 2007). However, both the Carnegie Foundation’s study of medical education and this study of nursing education found that even though there is agreement that more collaborative medical and nursing education is needed, this coordination is practically absent in curriculum plans, and informal collaboration is infrequent, even in clinical settings where nurses and doctors are both in training.

New Opportunities

Over the past two decades in particular, nursing has made important academic strides through growth in programs in nursing research housed in graduate nursing schools and the availability of federal funds to support the research programs. The National Center for Nursing Research was established in 1986 by the Health Research Extension Act of 1985 (Public Law 99-158; see Kjervrik, 2006), and in 1993 the center became a full-fledged institute within the National Institutes of Health (NIH), the National Institute of Nursing Research (NINR).

These developments fostered important increases in the quantity, and quality, of research done by nurses. Exciting research is shedding new light on such issues as the psychosocial aspects of coping with illness, patient education, and physiological and behavioral aspects of health promotion and chronic illness management. There is a growing body of nursing research on symptom management, end-of-life care, care of the aged and chronically ill, genomics, and more.

The NINR research agenda continues to be directed primarily toward basic and applied research related to patient care; promotion of health and prevention of illness; reducing health disparities; understanding individual, family, and community responses to acute and chronic illness and disability; and end-of-life care. Patient care research also addresses ethical and public policy concerns that affect delivery of patient care. This research sponsorship by NIH moved nursing education and research into a new era. The impact of research-intensive nursing schools on nursing science has been extensive, and these schools led a shift in the primary focus of nursing research from nursing education to patient care. The shift was much needed, but it went too far; researchers can no longer continue to focus on one at the expense of the other. Hence one purpose of this book is to revitalize research programs in nursing education and increase efforts and resources for better faculty preparation in graduate school and ongoing faculty development and research and development of nursing education.

Integrating Nursing Science and Caring Practices

In 1970, Lysaught complained of overemphasis on the expressive, emotional, nurturing side of nursing, which at the time was usually dismissed as a feminine trait instead of being understood as facets of deep knowledge and complex skills. Lysaught worried that underemphasis of the technical and instrumental work of nurses, exemplified by such therapies as the high-impact work of starting closed-chest resuscitation, or titration of potent intravenous medications, would lead to undervaluing of the knowledge and skill required for nursing practice.

Lysaught was concerned about nurses representing themselves and being understood as having exceptional relational skills, which obscured their scientific and technical capacities. He read caregiving practices as noninstrumental “niceties” that somehow did not really count as knowledge and skill at all compared to medicine’s therapeutic and curative enterprise. He offered an oversimplified choice: nurses had to represent themselves either as highly effective interventionists who were knowledgeable and skillful in science and technology or as nonskilled nurturers—two mutually exclusive options, neither of which accurately represents the complexity of nursing care. A decade later, second-wave feminists in the 1980s sought to correct the marginalization of caring practices, arguing that caring practices and relational work, which foster growth, empowerment, and liberation, are indeed knowledge-based and complex (Benjamin, 1988; Benner & Wrubel, 1989; Ruddick, 1989; Whitbeck, 1983). This setting of instrumental, technical-scientific work in opposition to relational work is still perpetuated when nurses present their practice as primarily instrumental, or relational and nurturing work (Nelson, 2006). They ignore the fact that interpersonal relational and technical-scientific knowledge are intricately intertwined in nursing and medical instrumental work. Typically in professional fields, as the technical and instrumental nature of the knowledge and skilled know-how increase, so does the need for effective communication and relational skills.

Lysaught correctly read his current culture, but he could not predict how much technology and economics would change health care, the extent to which nurses’ shift to high-stakes technical therapies also increased the need for higher levels of skill necessary to communicate with patients and families, and how crucial relational work would be for effective highly technical patient care (Benner, 1984; Benner, 2000; Benner, Tanner, & Chesla, 2009). He could not have anticipated the deep and complex education that nurses would need—the array of knowledge from the nursing sciences, natural sciences, social sciences, and humanities; skills of practice; and ethical comportment—to function as professionals. He did not confront the problem of splitting off the instrumental and the emotional skills in thinking or in any complex practice (Damasio, 1994).

This study considers the nature of nursing practice in ways that Lysaught perhaps could not recognize at the time he was writing. It joins the other Carnegie Preparation for the Professions studies to examine the deep and complex education that professionals need. All of these studies use the metaphor of “apprenticeship” to capture the experiential learning that requires interaction with a community of practice, situated coaching by teachers, and demonstration of aspects of a complex practice that are not easily translated. For example, a student cannot read about bundling premature infants as a procedure in a book and then be expected to bundle a premature infant without some professional guidance for how to avoid damaging the underdeveloped muscles of a fragile premature infant who is easily overstimulated and injured. In a professional practice, one does not easily translate what one learns from textbooks and research articles into skilled know-how and the ability to engage in clinical reasoning across changes over time. Nor is it easy to gain a sense of salience, which is when a practitioner can discern what is more or less important in a clinical situation.

To explain how students learn during their professional education, we suggest three broad and inclusive apprenticeships that refer to the whole domain of professional knowledge and practice: (1) an apprenticeship to learn nursing knowledge and science, (2) a practical apprenticeship to learn skilled know-how and clinical reasoning, and (3) an apprenticeship of ethical comportment and formation. We use the word apprenticeship with some caveats. They are “high-end” apprenticeships, and by this we do not mean slavish imitation of master teachers or coaches; instead creative and critical thinking, questioning, and innovation are central to learning a professional practice. Nor do we mean on-the-job training. We also do not mean apprenticing to one master teacher or institution. High-end apprenticeships should not be confused with Bloom’s taxonomy (1968), which uses teaching concepts that involve cognitive, affective, and motor pathways to teach or learn a concept or skill at the daily level of teaching specific content. Bloom points to acquiring new skills or knowledge through sight, emotion, and action pathways as a central principle of learning anything new. Indeed we agree with his integrative point about using all perceptual pathways for more effective learning. Finally we acknowledge that the term apprenticeship learning is particularly controversial in nursing. We thought long and hard about the advantages and disadvantages of using it. Our use of the term is not a reference to the historical apprenticeship model of learning most common in diploma schools of nursing until the early 1970s, when nursing moved into the academy. In the older model of apprenticeship of hospital training programs, students furnished the major portion of care to patients and were seen not as engaged in a program of education. In the service-driven diploma programs of forty years ago, classroom instruction and planned, tutored clinical experiences were subordinated to hospital demands for an inexpensive, and relatively unskilled, labor pool to care for patients.

Even though we want to avoid the connotations of abuse, domination, and control often associated with apprenticeship learning, we still hold on to the notion of learning by doing, observing, and participating in a community of practice. Instead, by apprenticeship we mean a range of integrative learning required for any professional that includes (1) instantiating, articulating, and making visible and accessible key aspects of competent and expert performance; (2) giving learners a chance for supervised practice; (3) coaching in the supervised practice to help students understand, reflect on, and articulate their practice, particularly the nature of particular clinical situations; (4) helping novice students recognize the priorities and demands embe...