The nursing educator of today has at their disposal a veritable goldmine of techniques, curricula, models, and simulators as well as other modern technological advances which make it possible to teach a class and impart clinical knowledge from thousands of miles away. With these advancements come challenges: some which are peculiar to the online world and unknown two decades ago. How does one teach from a distance, how can the nurse educator ensure that the pupil on the other side of the computer is in fact who they say they are, and what about the cost of this education? In order to effectively teach current and future nurses, the modern nurse educator must have a command of not only the clinical facets of the concept being taught, but also must master the various methods of delivery for that information. Lecturing still has a place in nursing education, but this is now being augmented by various knowledge delivery systems to help bring the education experience alive and demonstrate to the student how best to implement new knowledge. Education and educational techniques will continue to advance as new technologies are discovered and implemented.
Nursing education has progressed rapidly over the past 100 years. Although the art of caring has its roots far back in history, the immediate post-Nightingale nursing education represents a more formal, modernized, and to some extent standardized approach to nursing education. During the late 19th and early 20th Centuries, the primary focus of nursing education was to enable intelligent and able women of the post-Victorian age to assist physicians. Indeed, the physician and medical leadership of that time period played a dominating role in shaping nursing education and the epistemological development of nursing as a profession (Walker and Holmes, 2008). The expectation at that time was that nursing education would never rival that of physicians and early curriculums included courses to train nurses to suppress their own feelings and thoughts especially if they conflicted with the physicians own plan of care. Dr. K. Watson (1907) writes “it is common knowledge that the more highly qualified the nurse is the less likelihood there is of her attempting to usurp the medical man…” In some ways, vestiges of this anachronistic power imbalance remain today even as nursing educators try to throw off the traditional orders of medical power and knowledge and impart in their students a new sense of responsibility with the patient (and not the physician) as the center of power.
Review of Literature
This literature review will trace the intellectual development of modern nursing education and covering the transition to online delivery of education. Future challenges to not only the nurse educator but the nursing student will also be reviewed.
Several themes emerged during the literature review. Nursing education is changing as rapidly as healthcare itself. The Institute of Medicine (IOM) is clearly concerned that nursing education must advance in order to prepare future nurses for effective and collaborative clinical practice. While focusing on need, access, and cost, the nurse of the future will have to balance clinical skills with more advanced skills such as a working knowledge of financial implications and considerations for not only the patient, but also the entity which the nurse is employed. The IOM has suggested that while the Bachelors of Science in nursing would not address all of the future educational and clinical expectations; it would at least expose future practitioners to these fields and would help engender a broader knowledge base of healthcare and its place in society (IOM, 2011). Others, notably Charles Foster (2012) suggest that the Bachelors of Science is important, but also recommends professional specialty certification as evidence that nurses are engaging in lifelong learning. Other studies, notably by Lea, Skirton, Read, and Williams (2011) and Halcomb, Salamonson, Raymond, and Knox (2011) have touched on not only the need to update nursing education, but also to take into account the rapid growth of information regarding the human genome and how nurses can best teach and educate patients in this extremely delicate area of healthcare and to incorporate this knowledge into practice. Williams, Prows, Conley, Eggert, Kirk, and Nichols (2011) have gone as far as saying that genomic education should be permeating all nursing curricula and that current courses be examined carefully for incorporation of genomic content. This is interesting when considering that barely ten years ago, the discussion of genetic issues and implications were left to the physician or counselors with extensive experience.
Critical care nurses also are requiring more intense education prior to graduation based on the fact that nurses are frequently working in critical care immediately post graduation. There is a growing expectation that these nurses should be equipped with the basic skills to function in a hospital, but also armed with the ability to rapidly learn and inculcate new information relevant to critical care practice (Lawrence, 2011). A pre-graduation critical care course has been offered as a possible solution. The course would be in the format of a two day workshop and taught by clinical content experts in critical care. A study by Gallagher, Rice, Tierney, and McKinney (2011) found that such a course significantly increased the confidence of a nursing student’s ability to recognize and act to reverse the deterioration of a patient’s clinical status. This type of training is completely relevant even if the student does not plan to specialize in critical care. The sicker hospitalized patients of today combined with the inherent complexities of managing patients with various and sometimes chronic pathologies make the ability to critically think and act especially important.
Modern nursing education employs old fashioned and time-tested methods such as lectures blended with either web-based or web-enhanced content. Teaching an online course, contrary to the belief of some, can be a labor- intensive and formidable challenge (Zsohsr and Smith, 2008) and (Weiner, 2010). Yet, the effective transition to this form of education must continue with some sense of urgency as the new realities of healthcare emerge. Nurse educators must be willing to part with ‘sacred cows’ in lieu of more mobile and easily modified courses designed to meet the needs of a more mobile nursing society (Garrett, 2012). Care must also be taken in the regulatory sphere that emerging nursing courses and online schools of nursing as well as nurse educators who teach these courses meet the accepted standards by graduating safe practitioners and by maintaining appropriate accreditations (Murray, Philipsen, Pope, Hart, Wood, Lamm, Tolson, et al, 2012 ; Smyer and Colosimo, 2011).
Many gaps were noted in the literature which will provide ample opportunity for further investigation and research. While there are many articles addressing the need for educators to change their methods, there are only a few articles that posit more concrete examples of exactly how that should look and more importantly how these changes can be effectively implemented. There is significant information on web-based information and how online learning compares with a more bricks and mortar approach and also information regarding faculty shortages. The gaps lies in the follow up…where are we with these changes and how are they impacting the bedside nurse or the patient? The literature also seems to be strongly encouraging the rapid adoption of online curricula as well as increasing the pace of approvals of new nursing programs, but there is a lack of information on how to best assess these programs for their utility and effectiveness in the training of new nurses. Also of great concern to this researcher was the lack of information regarding the proliferation of illegitimate nursing programs which threaten not only the student, but also potentially the patient. Part of the reason for the number of gaps noted in the literature is likely the rapidity in which healthcare is advancing which contributes to a research lag which should correct given time.
The current challenges to nursing students include the continued matriculation from traditional classroom-based educational programs to web-based programs, the academic preparation of adequate numbers of registered nurses to meet the growing healthcare demands, the rapid pace of healthcare changes which demand almost constant re-assessment of nursing curriculums, and the recruitment and retention of qualified nursing faculty to teach students.
There is little question that online education is here to stay. The advantage of online nursing education is clear: it allows flexibility to view lectures and course material in an asynchronous format…choosing to view the material at a time convenient to the learner. Online courses are now becoming an integral part of formal nursing education (Zsohar and Smith, 2008). Younger students may possess a definite advantage in utilizing the online format as they have likely grown up with the requisite technology while older learners are more likely to be technologically naïve. This can pose issues and can cause the older students to feel disengaged. Key to diminishing this is a full orientation to the web-learning environment prior to classes with ample opportunities to engage the faculty in more traditional formats if there are specific barriers (Weiner, 2010).
According to the Institute of Medicine (IOM), The Affordable Care Act, which passed in 2010, as well as an increasingly complex and technical clinical environment has created the almost immediate need for nurses to fill expanding roles which they may not be prepared for (IOM, 2011). In short, nursing education of the last decade is rapidly devolving into obsolescence and is being replaced by education which is considerably more technically oriented, geared toward evidence-based practice, concept-based instruction and includes other competency expectations such as leadership development, teamwork, informatics and collaboration (Hyrkas, Randall & Meinersmann, 2016; Kalb, O’Conner-Von, Schipper, Watkins, and Yetter, 2012; National League for Nursing, 2015). The challenge for nursing educators is to rapidly reassess and if necessary generate new classes and curricula which address the new recommendations.
Faculty shortages in nursing are nothing new. As early as 2002, the journal Nursing Outlook termed the nursing faculty shortage as “a dire situation” (Berlin and Sechrist, 2002). One of the main issues facing nursing educators is that compensation rates are considerably higher in the acute care or clinical setting (Siela, Twibell, and Keller, 2009). Another reason for the faculty shortage is the wave of faculty retirements which are ongoing and are contributing to the 200-300 nursing faculty positions which open up each year (American Association of Colleges of Nursing, 2012). The lack of available faculty impacts the student nurse in several ways. The most obvious of which it limits the number of students that can be accepted into a nursing program. Another impact is that it lessens the availability of required classes resulting in competition for space in classes and possibly delays in graduation.
One possible solution which has been proposed to alleviate the faculty shortage is for unit-based clinical nurse specialists and advanced practice nurses to assume some aspects of clinical education. From an operational point of view this makes sense since the instruction would be given by a clinical expert in the field. Connolly and Wilson (2008) studied advance practice nurses and nurse practitioners and found that they were underutilized in the education role. Barriers to implementing this were found to be lack of support from the hospital educators, an increase in responsibility without a concomitant increase in salary, and the existing nurse shortage which made it difficult if not impossible to assume additional responsibilities.
The proliferation and influence of social media must be considered as an adjunct to the nursing education process. With all the pitfalls and risks that are associated with social media, it is not going anywhere. As a conduit for disseminating current trends in education as well as serving as a rapid-fire means of assessing new technologies and therapeutic regimens, the nursing student must use extraordinary discretion when consulting social media outlets for current information. The lack of peer-reviewed information and the proclivity for pithy short statements or sound bites, critical or nuanced aspects of the subject may be lost or ignored completely. Nursing information present on social media should be taught as an interesting sidelight, but not to ever replace sound judgment (Carroll, Bruno & Tschudi, 2016).
Future challenges to nursing education include ensuring that nursing students be instructed in the care of an increasingly non-hospital based patient population, the development of new electronic platforms to enhance the learners’ educational experience, the art and science of collaboration, and finally maintaining integrity of scholarship in the online learning process.
While the shift has been subtle from hospital based care to an increasing emphasis on community based care, some nursing educators feel that nursing schools in the future will need to produce graduates that can provide competent care to a diverse patient population. This will require broad education in symptom management, community based point of care testing techniques, and the ability to systematically assess chronically ill patients for system deterioration (Waters, Rochester, and McMillan, 2012). For a hospital based patient, this is a complex task for the new nurse and it can take months to develop this skill, but it can be very challenging for a new nurse to provide this level of expertise to a community based client. Nursing schools will surely feel this pressure to produce graduates that can safely practice in both the hospital and the community setting.
There has been an explosion of online or web-based nursing classes in the past ten years. What is the future of this type of learning? Susan Petula (2011) surmises that systems or concept theory will eventually overtake traditional nursing instruction. Systems theory as applied in this circumstance would mean an integration of nursing education programs, boards of nursing, and information technology. The proposed benefits of such an approach to nursing education would be improved interagency communication, improved regulatory compliance, and data generation. The data generation piece is critical since this would provide evidence for future policy creation as well as identifying and disseminating evidence-based practice findings in an expedited manner.
The Joint Commission maintains that poor communication is at the root of most patient care incidents in United States hospitals (The Joint Commission, 2014). Nursing education should be playing the key role in cross-professional collaboration. One college of nursing in Texas has modeled and implemented a transformational program in which senior level nurses are teamed with 4th year medical students in a controlled simulation environment (Booth and McMullen-Fix, 2012). Prior to the program, a pre-assessment showed that neither profession even realized the scope or magnitude of their respective positions. This exercise also revealed that new or inexperienced nurses were frequently hesitant when informing the physician was the appropriate course of action. This is valuable information and since it was detected early in the study, prior to the students’ graduation, further education in assertive and effective physician communication could be instituted. Faculty-driven efforts to increase collaboration by nurses with other key members of the healthcare team can only serve to benefit the patient.
There has been a proliferation of nursing schools in both the United States and in foreign countries which have not been accredited by a recognized governing body (Morgan, 2012). While most of these programs concentrate of the preparation of the medical assistant, there are an increasing number of programs which are attempting to graduate practical nurses and also some which guarantee eligibility to sit for the board examination for registered nurses. In 2008, the Texas Board of Nursing identified and advised regulators that several nursing programs had opened in Texas without requisite approval from either the National League for Nursing Accrediting Commission (NLNAC) or the Commission on Collegiate Nursing Education (CCNE) (Texas Board of Nursing Quarterly Report, 2008).
In the United States, there is a triad approach to governing educational institutions. The three entities are the federal government, state government, and accrediting agencies. In principle, this system should yield protection against an unaccredited nursing program slipping through the cracks. Yet because of gaps inherent in all three entities, this system has failed (Morgan, 2012). Credential evaluation will become even more important in the future as nurses from an array of different countries continue emigrating to the United States and with the expectation that they will be able to immediately practice as registered nurses (Shaffer and Dutka, 2012).
In 2008, foreign educated registered nurses comprised 13% of the employed registered nurses in the United States (Schumacher, 2011). While the Philippines have long had a pipeline into United States hospitals, nursing graduates from other countries have recently begun to appear in increasing numbers. Countries such as Ghana, Gambia, Nepal, and Saudi Arabia are now the countries of origin for many new nursing graduates who are immigrating to the United States in search of a more stable political climate and enhanced employment opportunities (Shaffer and Dutka, 2012). Evaluating the nursing curriculums from so many different countries requires painstaking and diligent work, but is critical to ensure that these nurses have had comparable training to the nurses in the United States.
Nursing education is experiencing many changes. From the traditional classroom to web-based clinical instruction, the transition continues. Accompanying the transition come the challenges which nursing educators must identify and remedy. From enabling, encouraging, and coaching the technologically naïve student to success to generating new technological pathways for the more technologically experienced, nursing education continues to be a dynamic field.
Themes which were generated during the literature review and the discussions on future and current topics in nursing education, several gaps in research were identified and will provide fertile ground for further nursing research and the acquisition of new nursing knowledge. The end user of course is the patient. It is incumbent upon nursing educators to inspire their charges while challenging them to deliver competent, culturally aware, and evidence-based care.
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