a nurse's viewpoint
a new beginning
by roberta b. abrams, rnc, ma, lcce, for healthleaders.com, april 10, 2002
the calendar says that it's finally spring. here in southeast michigan, the spring bulbs are emerging, the perennials are poking their heads above the snow, and the robins have returned.
spring is a season of new beginnings. as part of the renaissance ("rebirth") which is being sought in nursing, we need to take a new look at the beginnings of nursing: nursing education. having spent many years of my career in nursing education, i'd like to propose some changes in the way we prepare our students for their careers in nursing. let's explore them from a nurse's viewpoint.
most nursing education programs undergo almost constant review and revision. among the most recent changes in basic programs are increased concentrations on nursing in the community, on pain management and on end of life care. in addition, there is a wonderful proliferation of programs for advanced practice nurses. all of these are needed. all are appropriate.
the problem is with the courses and experiences included in programs in basic nursing education. all basic nursing education programs share a similar goal: preparation of the graduate for a first level position in nursing. my experiences in work with new graduates over several decades leads to my conclusion that many current programs do not succeed in this goal.
the blame for the failure of nursing programs
to succeed in basic preparation of the nursing student rests in part with the educators, and in equal or larger part with the practice environment.
the type and amount of clinical experience given to student nurses has decreased considerably over the past two decades. in the past, nursing education included extended periods of "clinical experience" - a euphemism for "staffing the hospital". the "over 40" nurses had more than a surfeit of in-hospital patient care. their experiences included all in-patient services and all shifts. the major transition that they experienced as "new graduates" consisted of being paid for the work that they had done for so long.
the decrease in the type and amount of clinical experience received by student nurses emanates from two sources: the need to increase theoretical knowledge commensurate with changes in practice and the perceived need to decrease the length of basic programs. my basic nursing program was almost 5 years long. we were well grounded both in theory and practice.
the regulatory agencies that credential current nursing education programs believe that students do not require the depth of clinical preparation historically provided. instead, they believe, vastly reduced time would be supported by increased supervision. they are at least partially correct. but the pendulum has swung too far. most new graduates today need a year of experience to achieve basic proficiency. in a situation where staffing and patient acuity were appropriate for extended orientation and support, this would not be problematic. unfortunately, that situation does not exist.
the new nursing graduate usually begins her / his professional life on an inpatient hospital unit. most, if not all, hospitals have orientation programs. these programs are focused on teaching the new graduate about the facility. they do not profess to teach nursing, and, as orientation programs, are not expected to do so. to further aggravate the situation, the acute shortage of staff has resulted in decreasing the length and scope of orientations. new graduates are being expected to be fully functional as staff members far too soon. the outcome of these behaviors is increased stress for the new graduates and other staff, increases in clinical mishaps and increased turnover.
in clinical nursing today we seek evidence-based practice. we are carefully examining long cherished traditions - shining the light of exploration to examine their cogency -assessing their validity. we need to examine our current new graduate behaviors from that perspective, and to subject changes made to the same scrutiny. with that as a predicate, and with a focus on outcomes, i propose that we re-examine the entire nursing curriculum.
the goal is to eliminate courses that lack cogency in nursing, and to substitute those that will assist the nurses in their professional careers. while certain "liberal arts" courses are meaningful in the nurses' preparation, each should be scrutinized to determine its value to the students' career preparation. courses in psychology, sociology, anatomy and physiology are necessary and appropriate. perhaps foreign language courses could be supplanted by a course in cultural awareness and sensitivity; which, incidentally, might also be useful for the business school students. in this examination, we need to include sufficient academic enrichment to produce a well-rounded student.
at the same time, we need to explore different modes of providing extended clinical experience. one way to accomplish this might be to extend the basic nursing education program for six months or more of "externship." in this capacity, students would spend most of the academic week in focused clinical activities - developing and polishing knowledge and skills directly related to patient care.
a different mode involves a collaborative effort between the academic institution and the clinical facility. programs could be developed jointly that provide employment for the student in the hospital. the roles would increase in scope and complexity in a manner commensurate with the students' preparation. hours of work would be determined by the student's desire and availability and would change with the academic schedule. the faculty would provide clinical supervision. the rationale for this provides continuity of experience and avoids increased stress or workload for hospital staff. faculty could either be employed as consultants by the hospital or could have their academic schedules adapted to include the clinical experience. students' reimbursements could either be in traditional wages or in tuition credits.
structuring a program in this manner requires close collaboration between the involved institutions. it also entails clear descriptions of changing roles and responsibilities. the endeavor, while complex, provides rewards for all involved. consider the following:
*the student gains much needed clinical experience - and financial assistance.
*the faculty maintain clinical acumen and increased compensation (do you mean money? "recompense" is a term associated with paying back victims).
*the inpatient care facility gains a more professionally-oriented staff as the students gain experience. this also serves as a high level recruiting mechanism, when the students become graduates.
there are a few models of the collaborative program in existence. they need to be studied to see if there is evidence of their validity for the involved participants.
do the graduates enter nursing with better preparation for the roles and responsibilities entailed in their positions?
do they remain with their affiliating institutions?
do the affiliating institutions find improvements in performance? is turnover reduced?
are the faculty involved benefiting from the experience?
do they see this as making a positive contribution to their careers?
are the changes in responsibility creating an overwhelming workload?
there are many different ways of improving the current student experience to enhance the value of that experience for the student, for the faculty and for nursing. the only certainty is the need for change. soon.
roberta b. abrams, rnc, ma, lcce is principal of rba consults, in farmington hills, mich., and is on the adjunct nursing faculty at madonna university. she may be contacted at firstname.lastname@example.org