A time to reform nursing education?

[nyteshade]

After reading some very interesting posts around here lately in regards to "fluff" being taught in nursing school, I wonder if it is time to reform nursing education.

I feel we could do without the nursing diagnosis. I understand they can help a student group and rank interventions for a disease process (dare I say that?), but there are better ways to help a student understand this concept. I am not against throwing out holistic nursing practices, but we really could do without the fluff. Why is it that many new grads can't "put it together" Maybe, because fluff doesn't cross over into real-world nursing practice?

I realize that nursing schools are geared towards passing the NCLEX, and that will never change. People in the nursing adovacy groups want nursing to be a profession, no problem with that, but our hands-on skills are being "outsourced" by RTs, techs, therapists, etc. We are "losing" our skills. Nursing students are graduating and have never even put in a foley. What's happening?

I'd like to know what experienced nurses, novices, instructors and new grads feel should be included, or tossed out of the nursing curriculum. Who knows, maybe reform will come?

[KatieMI, BSN, MSN, RN]

IMHO, there should be different pathways in Nursing, just like there are different pathways in education, for instance. Elementary school teacher with 50 y/o diploma should be able to deal with stubborn and capricious 6 y/o. Same school's principal may have Ivy League diploma and PhD and never ever teach ABCs in her life, but she should be able to deal primarily with adults. Both of them are educators, both are necessary for the school, yet their professional qualifications can have little in common.

I can honestly tell you that one of the most common topics in doctor's lounge is "how I, the big and great one, put down that stupid nurse". Those who love to tell that kind of stories usually argue that "nurses can do a lot, but they still know nothing" in terms of pathophysiology, psychology, EBM, pharm and so forth. The same doctors are also the most active and vocal in opposing the emerging trends in Advanced Nursing, including doctorate, independent practice, spesialisations and so forth. And they do have the extremely good reason to feel threatened, for whatever they did and do with patients, the general trend in US citizens' health looks quite abysmal. We're seeing more and more people getting morbidly obese, getting vital diagnoses later, undergoing the newest, costliest and most advance treatments available in the whole world, yet living literally through hell b/o "unforeseen" complications, etc, etc. The doctors form the category mentioned above are not blind, and they are not stupid. They see it all, too, and they are plain and simple afraid of the whole new generation of health care professionals who, by their "short", "stupid" and "incomplete" education, are prepared to deliver different model of care, which can be more attractive, more human, and (BTW) more cost-effective to at least SOME patients. Because of in that case those patients will not go to the doctor. They will see a nurse-practitioner, and doctor won't get his dear $$$.

As we're all health care providers, future and present, are in the same boat, it will be good for everyone to just work together for the patients' benefit. But, as so far here nothing can be held as the truth unless it is within 0.95 confidence interval, therefore we will have to play the game according to the rules. AANA recently did the right thing by providing financed but independently executed research based on big numbers which showed that there were no differences in quality of care between CRNAs and MDs. Of course, there were waterfalls of critique as well, but within months another state gave CRNAs right to do their job without MD supervision. So, in order to overcome the situation we should at least let these nurses who wish to do so to study the "fluff" of statistics, phylosophy, psychology and so forth, and then use it just the way doctors do it (or supposed to do). Only by actually having and USING this "fluff" we can earn our proper place in healthcare system and use knowledge and wisdom, not emotions, for dealing with those who used to attach a "VIP" stamp to themselves and bear it there with much proud. It takes only a day or so to learn how to place foley. To learn when you may, may not or must not push the foley takes more time, but actually not that much more. To learn how to explain a vigorous 55 y/o father, husband and CEO, who was healthy as a bull 2 weeks ago and today is day 4 after cystectomy done for advanced bladder cancer, that he's gonna to have that ugly rubber thing sticking out of his privates from now on indefinitely and not making him suicidal in the process takes a very special person learning for lifetime. A CNA can insert the foley. Doctor can prescribe the foley. But who usually do the last and most difficult thing? Yes... seems like "patient education"still is a nursing responsibility.

[SummitRN, BSN, RN]

My BSN program has skill sheets with two columns. One for lab checkoffs (which must be done first) and the second column is for real world check offs on real patients.

We have ~800 hours of clinicals and our final 200 hours are 1:1 with a preceptor working like a nurse. I think this is a great model.

I think this is an outstanding method to cement the theory with applications. I am a huge believer in the underlying understanding though. The so called "fluff" and theory is what makes you a thinking clinician with skills rather than just a technician. That's why nurses can get decent pay.

One thing I do think there should be MORE of: NURSING RESIDENCY. There are just a few of these programs, and more growing, but it needs to be the standard.

[GreyGull]

no problem with that, but our hands-on skills are being "outsourced" by RTs, techs, therapists, etc. We are "losing" our skills. Nursing students are graduating and have never even put in a foley. What's happening?

What's happening is that the other professions have advanced their education and have proven (see statistics section) to be a benefit of the patient. Sorry to break the news to some but the ADN or even BSN program does not make you an RRT, Radiology Technologist, SLP, OT, PT or SLP. There is barely enough time to make you a nurse. Other professions have realized the OJT and two year programs were not enough due to rapidly advancing EBM. Some also have 6 - 18 months post grad for additional clinicals beyond what they did in the degree program.

Skills are important but are of little use if you do not know why you are doing them or can not convey the reasons effectively to the patient. This also includes teaching students or new grads. How many times have you heard someone reply to "Why?" by saying "because that is the way I've always done it".

Also, if you want to adequately learn skills of other disciplines such as Speech, Respiratory and PT/OT, there should be a structured segment of multidisciplinary education by educators from those departments incorporated into the clinical education.

I did tons of papers, presentations, posters, and skits (that's right...skits.)

Maybe your teachers did not explain the purpose of those activities or relate them to the patient care environment. These assignments should help with your creativity for conveying your messages to others. I do skits, presentations and posters everyday as part of my communication with patients and co-workers. I often will get people who speak different languages or who forgot their hearing aide but I still must find a way to communicate. For teaching, if you just give a few dry statements to a patient who is already overwhelmed with information, you may think you've done enough to check the education box but in realty the patient may have gotten nothing from your words. Just writing the instructions down may not be enough either. I use the dry erase board frequently to draw a picture. When doing a skit or presentation in class you should be instructed on how to read your audience to know your message is being received. This translates into the patient care environment. If you don't know your patient is not understanding, just checking off the "done task (education)" box is not good enough. One problem when some just focus on skills or tasks is that the job becomes just a bunch of checkboxes.

You might also look at some of the visual aides that other professions come equipped with. If you ever work with brain injured patients, pay attention to what the SLPs, PTs and OTs utilize to stimulate their patients' learning and comprehension abilities.

Also for posters, how many have some learning aide for EVDs, PA catheters or some other complex piece of equipment or protocol? Generally the manufacturer poster comes with fine print and distracting advertisement. We place that one in the toilet and make up a user friendly poster that is relevant to our needs.

For patients who are kids (young and old) we have dolls rather then boring medical manikins to teach them about their medical needs. Some of these dolls were a creative multidisciplinary project.

As for all the reading and writing, have you ever read documentation that looks like a 3rd grader wrote it or have you gotten a report from someone who organized their thoughts at the level of a 3rd grader? The tech schools served a purpose but they are also designed to have people who were barely literate learn skills. To be a professional, you need the education to express yourself in all forms of communication. The days of the stereotyped nurse in a short white uniform holding a needle/syringe and preparing a bed bath while appearing to be without a brain should be vanished which is why a variety of educational courses to stimulate or compliment critical thinking were incorporated into the nursing programs. Credibility through education did move nursing towards becoming a profession. However, there is just not enough time in the programs. Having excellent communication skills which can be learned from presentations also give you an edge during rounds with doctors and other professionals. You can convey your thoughts using all the education, body language, speech class and skit skills from your college days.

I'll let you know when I run into a bedside nurse who uses advanced statistics in nursing practice on a daily basis.

Hint: Don't hold your breath.

It is sad when reading the medical journals and looking at EBM or EBP for nursing is not promoted. Other professions actually have journal clubs or their medical director tells (expects) them what articles they should be reading so he/she can set up some clinical guideline, protocol or research based on that article. I also believe that just one statistics class is not enough but a 2nd semester should be taken geared just for medicine. After a couple of stats classes and reading many, many journal articles I can tell you if the article that usually makes one of the minor journals was written by a professional or by someone cramming to finish a college paper and used an anonymous forum for research by posting a few random questions. Unfortunately even the articles in the best journals do not always present a valid argument. Thus, it is up to the person reading them to weed out the less pertinent info and still salvage the intent. Or, one could wait for an oversimplified review in a fluff profession magazine and miss the entire point of the researcher.

My recommendations would be:

* Raise the entry level education requirements to include more base sciences and yes, reading/writing courses. General math is also not enough especially when computers have made so many people stupid to where they need the calculator on their cellphone to add 1+1. We no longer have to calculate meds, hemodynamics or respiratory equations. Computers do it all at bedside. Anybody remember the old days of doing cardiac outputs, Fick equation and all the other hemodynamics that were calculated from data you physically obtained? You actually had to use some Algebra for the variables. At one time some nursing programs did contain more or higher prerequisites but during a "nursing shortage" in the 80s, they were decreased to encourage more students to enter the programs. Of course, how many would be discouraged if they had to complete the entry requirements of PT?

* Restructure to clinicals to meet skills and coincide with theory.

* Hire clinical educators and not just wage earners. If the clinical educator can not take an active interest in the students or is inefficient in the the role...gone. The same for classroom although tenure goes a long way.

* There should be an orientation prior to enrolling in a nursing program to explain the importance of each class and that it is not just another homework assignment but that there is a purpose to each class you believe to be fluff. Even an art class can have meaning whether it enhances your communication creativity or fosters an outlet to a stressful profession later. No education should ever be considered a waste.

* Set up an additional externship at the end of the program before one officially receives their right to test. Respiratory Therapy is now doing this in some of their A.S. and B.S. programs to where they need 6 additonal months of 24 hour weeks in clinical settings to officially be complete. SLP, OT and PT already have this in their programs in addition to their Masters degree.

It is amazing that a profession as broad as nursing is expected to be taught in an ADN while some specialty professions are now a Masters or Doctorate degree.

So many skills, so much theory and so little time.

[grandmawrinkle]

If you really want to make a difference in nursing education, turn it into a pre-med eligible curriculum to give nurses the ability to transfer the basic science prerequisites for med school later if so desired.

I don't understand this statement. A baccalaureate degree in nursing does not have one enroll in the science prerequisites that are required for application to medical school (although one could probably squeeze them into one's electives if one was really motivated), nor does a BSN prepare you to sit for the MCAT, and why should it? Most nurses don't want to apply to medical school. If the curriculum was changed to include these prerequisites, what would be thrown out? My assumption is that you are suggesting that the "fluff" coursework should be tossed and replaced with the hard sciences. I'm not sure that the hard sciences would be any more applicable to our actual work than the "fluff", to tell you the truth. The hard sciences are certainly more difficult and would raise the bar for nursing programs across the board, but it would also probably prevent a lot of people that could be successful nurses from gaining entry to the profession. Not all of us are capable of college level organic chemistry, physics, and calculus, and I think that's ok.

Part of improving education would be higher standards for entry into a program, as well as culling the weak (both professionally and intellectually.)

In addition, the licensing exam should be more difficult with a cap placed on the number of times one can attempt it before remedial course work is necessary.

I do agree with this. There should be higher standards in some way .. what way, I'm not really sure. Should we pass an entrance exam? Should we have a higher GPA requirement? Should we require healthcare experience? IDK.

Also agreed that the NCLEX is a joke. The nurses that have to take the NCLEX 3 and 4 times before passing scare me.

[Flying ICU RN]

I don't understand this statement. A baccalaureate degree in nursing does not have one enroll in the science prerequisites that are required for application to medical school (although one could probably squeeze them into one's electives if one was really motivated), nor does a BSN prepare you to sit for the MCAT, and why should it? Most nurses don't want to apply to medical school. If the curriculum was changed to include these prerequisites, what would be thrown out? My assumption is that you are suggesting that the "fluff" coursework should be tossed and replaced with the hard sciences. I'm not sure that the hard sciences would be any more applicable to our actual work than the "fluff", to tell you the truth. The hard sciences are certainly more difficult and would raise the bar for nursing programs across the board, but it would also probably prevent a lot of people that could be successful nurses from gaining entry to the profession. Not all of us are capable of college level organic chemistry, physics, and calculus, and I think that's ok.

All very true you'd get no argument from me on those points. My statement, is based on several debates within other threads about raising the entry level bar for nursing to the BSN, and a common complaint among nurses about a lack of professional perception within the industry.

It seems to me, that you could kill both birds with one stone if you did this. The entry level bar would be raised to something more significant than the current BSN curriculum, and the professional perception of Nursing would be different if everyone was an MCAT away from medical school admission. Short of this, I don't see those two issues ever going away otherwise.

As you noted, it's way too much of a hurdle. The rank and file must be filled with able bodied and capable nurses to serve the public interest.

[linguine]

Nursing schools should link into nursing residencies. When we have new nurses all varying durations of on the job training, this inconsistent does not produce cohesision within the profession. Some new grads have 2 weeks on the floor. Others have 6 months. others, 12 months (very reasonable, especially on acute units.) Match day for nurses? :)

[klone, MSN, RN]

Match day for nurses? :)

Ha! A month ago I would not have known what this meant. I just finished reading the book "Match Day" (fascinating insight into medical school and medical internships/residency!).

[Fiona59]

How about a new nursing school model? I'm not certain of the exact timing needed for each of the sections, but: 2 mos to CNA, 10 mos to LPN, 12 add'l mos to ADN, another 18-24 mos to BSN. At any point, the student could opt out to work at that level, or continue part or full time, or opt back in when ready. More "hand on" actual care at the beginning, more higher level skills at the RN level (you'd have more time for that, since the basic care of pts would already be well-known).

http://www.cna-nurses.ca/CNA/documents/pdf/publications/Towards_2020_Snapshot_e.pdf

Is being promoted here in Canada. The difference from your plan is our Practical Nurses require two years education and the ADN does not exist here.

The way it's been explained is the Practical Nurse Diploma being the entry point to nursing and then stepping up the ladder to PhD in Nursing along the way.

Working LPNs aren't holding their breath waiting for it to happen.

[klone, MSN, RN]

How about a new nursing school model? I'm not certain of the exact timing needed for each of the sections, but: 2 mos to CNA, 10 mos to LPN, 12 add'l mos to ADN, another 18-24 mos to BSN. At any point, the student could opt out to work at that level, or continue part or full time, or opt back in when ready. More "hand on" actual care at the beginning, more higher level skills at the RN level (you'd have more time for that, since the basic care of pts would already be well-known).

Many schools already do something like that (especially community college programs). The school from which I got my ADN had a month-long CNA class that was required before starting the nursing program (you had the option to take the state exam after the class was done - some students took it, most opted not to), then after the first year of the nursing program, you could take one additional class over the summer and be eligible to sit for the LPN boards (again, a few opted to do that, most did not), and then after the second year, you received your ADN and could sit for the NCLEX. You could then transfer to a university program that had a satellite campus at the community college to get your RN-BSN (or you could opt to do the RN-BSN program at any other university that offers that), which is another 12-24 months.

[lxpatterson]

It's only natural that as a registered professional you try to protect your own scope of practice; clearly this also occurs within the ranks of nursing between RNs and RPNs.

Of course the same thing occurs between MDs and RNs. For instance, in Canada (ON) there is resistance against NAnesth by the medical colleges and associations, such that even though universities have set up educational programs for NAnesth, it's not a recognized practice yet. I asked an anesthesiologist about this, and he told me that he did not believe it was a likely to happen here and (candidly) that obviously it was invading anesthesiology's scope of practice.

To me, it seems obvious that the friction between MDs and RN concerns funding, prestige and autonomy. However, in my nursing theory classes, texts like Doane and Varcoe consistently talk about this conflict (and it's a subtext throughout most of the book) in terms of feminism v. paternalism, individualism v. collectivism, EBM v. holistic care, etc. I feel like nursing theory and those who teach it either have completely lost touch with reality, either that or they are just people who ended up in nursing, but really should have been in political sciences or the humanities.

I feel that people like that are a detriment to the profession and when we use texts (Doane and Varcoe) that speak glowingly about things like "therapeutic touch", I can completely understand why some MDs ridicule nursing. Indeed, my fellow nursing student and I worry that this will affect the future funding, prestige and autonomy of nursing...yes, we are all very bourgeois and institutionally socialized!

[Fiona59]

It's only natural that as a registered professional you try to protect your own scope of practice; clearly this also occurs within the ranks of nursing between RNs and RPNs.

.... However, in my nursing theory classes, texts like Doane and Varcoe consistently talk about this conflict (and it's a subtext throughout most of the book) in terms of feminism v. paternalism, individualism v. collectivism, EBM v. holistic care, etc. I feel like nursing theory and those who teach it either have completely lost touch with reality, either that or they are just people who ended up in nursing, but really should have been in political sciences or the humanities.

I feel that people like that are a detriment to the profession and when we use texts (Doane and Varcoe) that speak glowingly about things like "therapeutic touch", I can completely understand why some MDs ridicule nursing. Indeed, my fellow nursing student and I worry that this will affect the future funding, prestige and autonomy of nursing...yes, we are all very bourgeois and institutionally socialized!

Basically, it's a case of those who can do and those who can't teach. Nursing instructors are often so high in their ivory towers that they have NO clue of what it is like to work on the floor. Don't even start me on how little the BScN instructors know about the scope of an LPN in my province.

[regularRN]

I graduated in 1987 from a three year three month program that was essentially clinical with a few weeks of theory here and there... but, I know the evidenced-based rational behind the tasks I perform everyday, including those that involve an understanding of statistics - nursing is, after all, a science based profession.

I even know how to arrive at a nursing diagnoses, not that I have ever needed to, ever. I can write a detailed care plan, but in reality who has the time... what I do not know how to do is relate to students who are too scared to even talk to a patient, let alone touch them, help them to the bedside commode etc. or are so overwhelmed by clinicals that they cannot administer meds on time, even when they only have one patient... flame away.