What Do You Think About the "Nurse Generalist" Movement?

[VickyRN, MSN, DNP, RN]

There is a concerted movement in undergraduate nursing programs towards the "nurse generalist." Part of this is due to pressure from state boards of nursing to "cut out" unessentials and to focus on the basic education that a new graduate needs to function safely and competently in today's very complex nursing practice environment. There is also the tyrannical pressure of "additive curricula" due to the unrelenting acceleration of medical knowledge and technology. Yes, we keep adding bits and pieces to our lectures year by year, but don't take anything away. Yikes! After awhile, we are "speed lecturing" just to keep up, while the bewildered students just try their best to keep up under the piles and piles of information.

So, in our associate-degree program, we will be cutting out fetal monitoring, neonatal resusciation, the stressed neonate (three of my favorites ), all but basic ECG, and many other items. We will probably be cutting down on the amount of time our students spend in the pediatric and postpartum units, and redouble time on basic medical-surgical units instead. We will be focusing afresh in our program on developing critical thinking skills in our students and prioritization. Nursing in the community (as opposed to acute care) is also coming more and more into the forefront.

So my question to you, my fellow educators, is--what are your opinions about these very significant changes in emphasis? How do your programs handle the burden of "additive curriculum?" What types of content are being emphasized in your programs?

Awaiting eagerly for your comments....

[llg, PhD, RN]

I have been in the staff development end of things for many years and have lots of experience with new staff orientation programs for NICU and peds.

In general, I am in favor of the basic principles you have described above -- though, of course, the devil is in the details of how those principles are implemented. Hospital care has become so complex that we must expect new employees to require a significant amount of orientation. That should be taken as a given. For schools to think they can prepare beginner-level students all the specialized skills is absurd. What a new grad needs is a good head on his/her shoulders, a solid grounding in the basic principles of care, and a willingness to continue to learn.

Your fetal monitoring topic is a perfect example. Very few nurses will actually have to do fetal monitoring in their jobs. Those who do need this skill will be taught by their employer. So, it seems silly to me to waste valuable school time on such a skill. The same can be said for a whole host of other technical skills that vary from specialty to specialty, hospital to hospital.

Also, I agree that not all students need to spend the same amount of time in all clinical areas. I like the curriculums that give everyone a "brief" exposure to all the major fields, then allow the students the opportunity to re-vist some of those fields in more depth during their last semester. Pediatrics and maternity are great examples. Some people know that they have no interest in these areas and only the need the basic level of education in them. So just do the bare minimum for them.

Other students have a great interest in these areas -- so, let them go into more depth as part of a senior year special practicum or something. We have found that students who do such practicums are much better prepared as new graduates than those who don't. By shortening the peds exposure for the students who have no interest in the field, it opens up more and better peds opportunities for those that do have an interest. Everybody wins.

What I worry about is that some people will mistakenly believe that an exlusive focus on "adult med-sug" experience would provide an adequate foundation for all types of nursing practice. Adult med-surg is its own specialty and should be respected and treated as such. "Basic principles" can be found in all the different clinical areas and are not synonymous (spelling?) with adult med-surg nursing. I strongly support schools putting a greater emphasis on general principles and reducing some of the content related to specialized technical procedures -- but I am adamantly against the view that adult med-surg IS the foundation of all nursing.

llg

[VickyRN, MSN, DNP, RN]

I have been in the staff development end of things for many years and have lots of experience with new staff orientation programs for NICU and peds.

In general, I am in favor of the basic principles you have described above -- though, of course, the devil is in the details of how those principles are implemented. Hospital care has become so complex that we must expect new employees to require a significant amount of orientation. That should be taken as a given. For schools to think they can prepare beginner-level students all the specialized skills is absurd. What a new grad needs is a good head on his/her shoulders, a solid grounding in the basic principles of care, and a willingness to continue to learn.

Your fetal monitoring topic is a perfect example. Very few nurses will actually have to do fetal monitoring in their jobs. Those who do need this skill will be taught by their employer. So, it seems silly to me to waste valuable school time on such a skill. The same can be said for a whole host of other technical skills that vary from specialty to specialty, hospital to hospital.

Also, I agree that not all students need to spend the same amount of time in all clinical areas. I like the curriculums that give everyone a "brief" exposure to all the major fields, then allow the students the opportunity to re-vist some of those fields in more depth during their last semester. Pediatrics and maternity are great examples. Some people know that they have no interest in these areas and only the need the basic level of education in them. So just do the bare minimum for them.

Other students have a great interest in these areas -- so, let them go into more depth as part of a senior year special practicum or something. We have found that students who do such practicums are much better prepared as new graduates than those who don't. By shortening the peds exposure for the students who have no interest in the field, it opens up more and better peds opportunities for those that do have an interest. Everybody wins.

What I worry about is that some people will mistakenly believe that an exlusive focus on "adult med-sug" experience would provide an adequate foundation for all types of nursing practice. Adult med-surg is its own specialty and should be respected and treated as such. "Basic principles" can be found in all the different clinical areas and are not synonymous (spelling?) with adult med-surg nursing. I strongly support schools putting a greater emphasis on general principles and reducing some of the content related to specialized technical procedures -- but I am adamantly against the view that adult med-surg IS the foundation of all nursing.

llg

Thank you for your insightful comments, llg--as always they are most appreciated. We are struggling now, trying to recreate our program according to the new guidelines. I especially like your suggestion:

I like the curriculums that give everyone a "brief" exposure to all the major fields, then allow the students the opportunity to re-vist some of those fields in more depth during their last semester.

We will have to discuss this idea and other of your ideas at our next faculty meeting. I also agree with you, that med-surg is not the foundation of all nursing. Finding the balance is key. Again, thanks.

[llg, PhD, RN]

Thanks, Vicky ... good topic for a thread. Let's hope some other people join in.

The children's hospital where I work (and some others that I know of) give a hiring preference to those new grads who have done senior year practicums in a relevant areas. Our stats show that such in-depth experiences in the senior year really help the new grad to transition to a staff nurse role. If I could make one recommendation to any school at any level, it would be that. It gives the student the opportunity to explore an area of interest indepth (consistent with your thoughts on student-led learning in another thread) and allows people not interested in that area to not be quite so over-burdened with details and advanced skills they are never going to use.

Take care,

llg

[purplemania, BSN, RN]

We have always trained nurses to be generalists, only now they work as specialists and there is no way you can prepare every student for every speciality. In Europe several countries start each student out with generic knowledge/comprehension coursework, then divide them up into specialities (this means the student has to decide what area of practice appeals to them EARLY). They take a test designed for nursing in that speciality area. If the nurse later decides to change specialities he/she must re-test (most take review courses first). This is sorta like the medical model but MD's take longer to study their speciality. Anyway, like you said, we may be seeing some changes due to expectations of various stakeholders.

[VickyRN, MSN, DNP, RN]

We have always trained nurses to be generalists, only now they work as specialists and there is no way you can prepare every student for every speciality. In Europe several countries start each student out with generic knowledge/comprehension coursework, then divide them up into specialities (this means the student has to decide what area of practice appeals to them EARLY). They take a test designed for nursing in that speciality area. If the nurse later decides to change specialities he/she must re-test (most take review courses first). This is sorta like the medical model but MD's take longer to study their speciality. Anyway, like you said, we may be seeing some changes due to expectations of various stakeholders.

Novel idea. Thanks for sharing this. There is so much pressure now to produce large numbers of high quality nurses as quickly as possible for the shortage. I personally would not be surprised, if, in a few years, nursing schools start gravitating towards this model.

[live4today, RN]

Novel idea. Thanks for sharing this. There is so much pressure now to produce large numbers of high quality nurses as quickly as possible for the shortage. I personally would not be surprised, if, in a few years, nursing schools start gravitating towards this model.

If they do go forward with this model, the hospitals better start putting their pennies in a cookie jar to boost the salary of all the highly qualified nurses with specialties. Shaping nursing like med school is going to up the ante in salary, responsiblities, and independent contracting every specialty nurse should be granted the right to become. No longer will it fly to have specialty nurses at the bedside making a piddly hourly rate while their medical counterparts continue to collect the big bucks. Are doctors ready for this competition? Are nurses? Are hospital CEOs and health insurance companies? This could cause healthcare to really skyrocket to astronomical dollars!

[stbernardclub]

This is agood post....thanks to all :)

[jnette, ASN, EMT-I]

Very interesting.. a good thread to watch.

Thank you.

I tend to agree with Vicky and llg.. I do like this model and it makes sense to me. :)

[Kokomo]

I think this is an excellent idea to structure nursing in the same format as MD's. Not only would this guide the students to their area of interest but it could also prevent nurses from becoming frustrated in working in areas of nursing that just does not fit. Also, it is my belief that nursing would then (hopefully) gain the respect that is so needed. The last benefit would be that nurses could acheive the financial rewards that are long overdue. After all, we should no longer be viewed as bedpan yeilding handmaidens.

[llg, PhD, RN]

I really don't think it would require a dramatic change in the payscales. The new graduates would not be "more educated" or have "more education" than they do now. It would just mean that the "shape" of their education would be a little different.

Many schools in the US already have senior year preceptorships, practicums, etc. that allow the student to develop a little more depth in a specific area of interest -- so, the changes required should not be all that big of a deal when considered on a large scale. For example, a school that now has clinical rotations of 8 weeks in length could decrease that to 6 weeks, cutting out a little advanced content in each. That would give them a few "left over" weeks in the senior year to allow students to re-visit areas of special interest to them develop more depth.

It wouldn't have to be a revolution, just an evolution.

Also, countries that already prepare nurses in this fashion do not pay nurses more than we are paid in the US.

llg

[purplemania, BSN, RN]

Agreed. Although I believe nurses should be paid well, I do not believe that being certified in a specialty demands large salaries. After all, there are many nurses currently certified in various specialities. I am also aware that the European model places RN's on the floor as charge nurses and case managers but LVN's do the direct patient care. (This may not be true everywhere, of course).The result is, fewer RN's to pay. So there are advantages and disadvantages to the plan. Our Canadian friends have similar options for nurses. Perhaps they could enlighten us.