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Course Correction: Better Preparing Today’s Nurses For 21st Century Health Care Service

June 20th, 2014

Nursing has always been considered a highly established profession with solid job security for many, even in the midst of troubling economic conditions. In fact, a recent US News and World Report’s list of the Best 100 Jobs shows both nurse and nurse practitioner in the Top 10.  And it’s a respected profession as well: A 2013 Gallup poll showed 82 percent of Americans rate the ethical and honesty standards of nurses as “high or very high,” the highest of all professions.

Yet despite talk of an impending nursing shortage over the next few years, some believe there is an even bigger crisis looming, one that stems from the very heart of the career — education.  Quite simply, nursing students are not as prepared as they should be for the “real world” of nursing and patient care.

This skills deficit is all-encompassing. There is a lack of the basic technical skills, such as physical assessment and emergency response. But the equal lack of “soft skills,” such as critical thinking, problem recognition, prioritization and recognition of urgency, and communication with physicians, is just as alarming.

Perhaps the most unfortunate part is these serious gaps aren’t being caught early on in the nurse’s education. As a result, we’re seeing many young professionals get far enough down the nursing education path that when they reach the clinical phase of their education, it is too late to catch up and too onerous for supervising nurses to help them.

A Lack of Education

This lack of education isn’t just affecting entry-level nurses. In fact, many nurses are not learning the in-demand skills that can help them take their career to the next level. For example, there is an increased demand for nursing administrators in hospitals, labs, and other health care settings. These nurses get competitive salaries and also receive a number of other benefits. Yet a study published in The Joint Commission Journal on Quality and Patient Safety, well before the implementation of the Affordable Care Act showed many new nurses entering the profession felt “poorly” or “very poorly” prepared by their nursing education programs to implement quality improvement measures; these are duties demanded of nurse administrators and ones that will be in higher demand as ACA takes full effect.

Of course it’s not as though these issues have arisen independent of the dramatic changes in the overall health care and nursing landscape. To be sure, today, the complexity of patient care is exponentially greater than it was five years ago, due to technological advances in care, decreased length of patient stay, and rapidity of change. This has undoubtedly changed the way nurses should—and need to be—learning. And what they should be learning is how to provide quality patient-centered care, where doctors, nurses, and other hospital personnel work together as an integrated team to make sure the patient has the best outcome and experience possible.

One of the barriers to achieving this level of care is that although there is far more complexity to the state of nursing today and more educational material to be covered in the same amount of time, clinical education is still being conducted as it was in the 1960s. Then, nursing education consisted of all of the familiar courses, such as anatomy and physiology, pharmacology, and medical-surgical nursing. The difference was that typically after six months of school the students were actually in charge of nursing divisions, which allowed them to be immersed in the clinical arena rather quickly.

By contrast, today many nursing school faculty simply don’t have the clinical skills that are being demanded of their students following graduation. Instead, they have concentrated on nursing theory rather than the practical aspects of actually dealing with doctors and patients, which doesn’t help their students post-graduation. And, as is the criticism with the education system overall in this country, many feel that nursing schools are simply gearing their programs to teach students to take tests—in this case NCLEX (National Council Licensure Examination).

Improvements in Nursing Education and Skills

With millions of previously uninsured Americans ready to join the patient population in the next two years, it is more critical than ever to ensure our nurses are in the position to provide the best possible service.

Here is how we might accomplish this goal:

Establish nursing residency programs. It’s a model that works extremely well for physicians, so why not for nurses? In fact, the Institute of Medicine’s recent report, “Future of Nursing: Leading Change, Advancing Health,” recommends residency programs to aid the transition from education to practice.  Given the increasing role many nurses are playing in health care, it would appear to be a logical next step.

Increase clinical competence. Nursing schools will benefit from a curriculum that focuses on real-life applications rather than just abstract classroom learning, as well as increasing interdisciplinary education and the skill set to work as a team. This would entail hiring faculty with a solid mix of clinical and academic skills and experience. The idea is to bring in the best of both worlds—instructors who can speak from personal experience about the conditions or situations they are teaching.

Create better academic/clinical synergies. We must remember that our nursing students will in fact one day be interacting with real-life patients. Therefore, classroom content needs to be tied seamlessly to clinical content and the focus has to shift from technical skills to sound clinical judgment  — and in the words of former professor emerita Patricia Benner (Department of Social and Behavioral Sciences at the University of California, San Francisco), “shift to thinking in action” and then finally to application.  Interestingly, nursing graduates also crave better academic/clinical synergies.  Across the board, nurses who graduated from undergrad programs not only requested more clinical time for students but also suggested that clinical assignments be more realistic.  For example having students watch over six to seven patients at a time rather than one or two.

Establish partnerships. Nursing schools and health care organizations should consider collaborative partnerships to create dedicated education units that can provide a more realistic immersion into the clinical environment. This could involve hybrid partnerships, where the clinical faculty members are actually the clinical nurses working at the bedside. It could also include specialty-specific fellowships where students are enculturated in the clinical setting.

The decline in nursing skills didn’t happen overnight, and it will take some time to fix. A collaborative effort focusing on a combination of academic instruction and real-life applications – and a focus on both the technical as well as “soft” skills – will be crucial to getting our nurses back on track and ready to properly serve the patients and families that so trust and respect them.

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4 Responses to “Course Correction: Better Preparing Today’s Nurses For 21st Century Health Care Service”

  1. Leslie Neal-Boylan Says:

    I have conducted surveys of both new graduates and practicing nurses and much of what Kelly has written is also reflected in their comments. However, I think it is a mistake to think that we have too much theory in nursing programs. We risk sacrificing status and recognition as professionals when we shift our focus from theory and research to an emphasis on skills. The public will continue to see us as technicians rather than as respected professionals if we don’t emphasize the underpinnings of theory and research in all that we do. Yes, our students must be prepared to enter the workforce with the knowledge of basic and advanced nursing skills. However, we should not and cannot sacrifice a broad liberal arts education, emphasis on writing and speaking well,and knowledge of theory and research and how to apply them to practice.
    I also agree with Susan that many of these issues have been ongoing since nursing declared itself a profession early in the 20th century.

  2. Susan Kastris, Rn BSN Says:

    It makes me sad to see this same conversation that was occurring when I graduated from nursing school in 1971. Not much progress has been made it seems. I’ve been working at hospitals mostly since then. i felt my clinical experience was very lacking in my BSN program (and it was) and it made it so hard to have any confidence in my skills on my first job. I didn’t have an understanding of how the floors worked, the roles of all, the pros and cons of nursing as a career. I felt minimally qualified for my first job and struggled as other new graduates quit and left. I think hospitals need to go back to having “candystripers” to give those interested a chance to see how the floors work and what the medical world is all about and it would provide very needed help to the floor RN’s who don’t have adequate support staff. This would be a good beginning. I am working with some great new grads who have been hired and delight in showing them things and enjoy their attitude and they are going through the same struggles that I went through with very little structured support. ANd it is so much harder now. Susan-RN for 35 years

  3. Richard Says:

    I think residency programs sound great. Part of the problem is that schools are pumping out new grads at a high rate due to the “nursing shortage.” Enrollments are high and schools are competing for clinical rotations. Sometimes it is difficult for the schools to get good clinical experiences for the students. I’m sure the schools (both public and private) love all the students their nursing programs attract because it means more money for the institution. I just completed an accelerated nursing program and thankfully landed a good job at a magnet facility. Do I wish I had had more clinical experience? Yes! I will be working with a preceptor for 8 weeks. Is that enough? Probably not.

  4. Barbara Hillock Says:

    Very perceptive acknowledgement of some of the issues with nursing education/clinical experience. My recent experience entails nurses in the ED not having the clinical competency to hang blood, lack of understanding of the reasons behind each medication administered as they pertain to the patient. They understand the mechanics of BCMA, don’t know quality measures exist, they have become robots with no thinking or evaluation behind the tasks they perform.

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