TRENDS AND ISSUES IN CONTEMPORARY NURSING EDUCATION

TRENDS AND ISSUES IN CONTEMPORARY NURSING EDUCATION

 

The Influence of Contemporary Trends and Issues on Jsfursing Education

Nursing education (and practice) is influenced by a number of emerging trends in society, some of which are described in this chapter; others also are important and are discussed elsewhere in this book. The selected trends are presented with related issues for students and faculty to provide a broader view of education. The American society is increasingly diverse; thus each trend precipitates different issues and problems. Trends result from issues in the past, just as these issues will lead to other trends in the future; this is the never ending process of change. These trends are complex and overlapping but are presented here as separate categories to emphasize their importance; all of them influence nursing education. The chapter is brief and should be considered as a guide to more in-depth resources, including the print and Internet website references listed at the end of the chapter; explore them as much as possible.

The most influential trend is the rapid development of knowledge and information fueled by expanding communication technology and the Internet. This in turn precipitates expectations for nearly instant access and response to almost everything and results in multiple problems for students and faculty. A related trend is the increasing urgency for competence, focused on specified outcomes and validated through objective performance assessment methods. Competency outcomes and performance-based evaluation now are required and are more stringent to safeguard consumers, nurses, and employers; therefore they are essential in nursing education. Other trends focus on ethics and bioethical developments and personal choice. Expanding scientific research and innovations have led to amazing new treatment modalities, but also to a multitude of issues. Expectations of personal freedom of choice raise ethical issues related to abortion, the right to die, and lifestyle preferences. Several highly interrelated trends include the changing characteristics of the population and the political and economic influences on health and health care. Collectively they have influenced the trends of community- and consumer-oriented health care, interdisciplinary health care, use of alternative health practices, and increased collaboration among various agencies and institutions. Two other trends that affect nursing education are the increasing shortage of qualified nurses, faculty, and students and the increasing stress related to personal and professional responsibilities.

These trends influence the number and types of nursing programs for basic and experienced students. Students and the effective contemporary practitioner need to understand these trends and issues to cope with them and help change them into more positive trends (ANA, 1999). At the end of the chapter, interactive learning activities are suggested under each learning outcome.

TRENDS AND ISSUES IN CONTEMPORARY NURSING EDUCATION

In many ways nursing education is the same as it always has been: concerned with preparing nurses with enough knowledge and skills to meet the health care needs of the community with compassion. How it does this is shaped by a number of trends and issues in society, which change continually and with increasing complexity. This chapter presents a concise review of selected trends and related issues that influence the content, expected outcomes, learning processes, and assessment methods of nursing education today. Heller, Oros, and Durney- Crowley (2000) summarize similar trends that influence nursing. Baer (2000) and Kalisch and Kalisch (1995) are basic resources for detailed content; also review AACN (1999b), ANA (1976, 1991), and Schorr and Zimmerman (1990).

These trends and issues illustrate nursing's complex environment and help to explain how and why nursing education needs to change and function in contemporary society. The final trend focuses on nursing education itself and on its continuing and emerging issues. Although listed separately, the trends actually should be viewed as a constellation of factors that simultaneously influence nursing education and practice.

Knowledge Expansion and Use of Technology and the Internet

With the ever-expanding developments in computer technology, the volume of knowledge is expanding exponentially. From e-mails to complex research documents and video images, nurses and students, like everyone else, are communicating more frequently, with more contacts and with the speed of light. This ability to access and disseminate unlimited information almost instantly has enormous benefits but also presents major issues. Computer-accessible knowledge has become the potential content for nursing and other courses and the standards for practice. Textbooks and journal articles are considered nearly obsolete by the time they are published, and an expanding array of websites has become a major learning resource. Websites generally are more interactive than texts and link to multitudes of other helpful resources (Nicoll, 2000; Skiba, 1997). Even though updated frequently, they also become outdated quickly. Students easily can become lost in the interesting web of links while they search for assignments and communicate with others in class or around the world. Thus it actually may take more time to find and learn content, although it provides broader, more specific, and more accurate information.

Herein lies the conflict and the issues: almost unlimited information is available, but it requires more time and skill to navigate the web and learn, even though most students seem to have less time for study (Focus, 1999; Mallow and Gilje, 1999). Learning from the Internet requires disciplined focus and clear guidelines and expected outcomes related to assignments. It also develops skills in analytic thinking, decision making, and reflective judgment, all of which are essential competencies for nursing practice but are not easily learned. Other issues relate to time management, the integration of all the information available, keeping up with changes in technology, and meeting the expectations for immediate responses to an everwidening web of contacts.

Like students, faculty also have similar issues related to knowledge and technology expansion, the scope of information, and the time to use it. They have to make rational decisions about what and how much students need to learn at a given level, and they, too, can become entranced by and lost in the learning opportunities available on the Internet. Teachers also have to learn and keep updated with content and technology to be able to effectively help students stay ahead of the curve. Unlike students, faculty also are constantly in the process of making curriculum and course revisions and modifying teaching and evaluation methodsall of which are time-consuming and greatly influenced by the knowledge and technology explosion.

Practice-Based Competency Outcomes

Trends in business and commerce often find their way into higher education and nursing education. The current emphasis on using competency outcomes to set directions and goals related to real-world practice is one of them. To focus on outcomes is to focus on results. In business the outcome of spending time and resources based on actual needs is what counts in determining financial success. The same is true for nursing practice and nursing education. What really matters is that students (nurses) achieve the competency outcomes that specify the skills actually needed in practice. They are the measurable results of time and efforts spent in learning. Competence in realistic practice-based outcomes is the target, the goal to be reached.

However, this outcomes approach is very different for most teachers and students from the past ways of thinking, teaching methods, and evaluation. It is not just changing words. For teachers it requires considerable rethinking and time to revise course syllabi, reassess and specify the competencies nurses actually need for practice in the changing and complex contemporary health care environments, and design ways to help students learn them. For students it means a change from memorizing class notes and readings to learning to integrate knowledge, make decisions, and be competent and confident in the abilities contained in course outcomes. Practice-based competency outcomes specify the destination students need to reach, the interactive learning strategies are the directions and guidelines for getting there, and performance-based assessment confirms they have arrived at the right place. The process is important, but achieving final competency outcomes is the bottom line. These changes in the entire education process pose threats and concerns to all the stakeholders that need to be resolved (Bargagliotti, Luttrell, and Lenburg, 1999).

Redefining practice-based competencies is a complex issue, and, although many educators and organizations are engaged in this process, no single method has emerged as predominant. Lenburg (1999a, b) created the Competency Outcomes and Performance Assessment (COPA) Model as a way to change and reorganize the curriculum to emphasize competence and assessment. Using this framework, she developed a master list of eight core practice competency categories under which all of the skills nurses use in practice can be listed. They include assessment and intervention, communication, critical thinking, caring relationships, teaching, management, leadership, and knowledge integration.

Competency outcomes incorporate these practice-based skills, as well as the course content. Learning strategies and performance examination are based on outcomes and content. Several articles describe the model, process, and related issues as used by others (Luttrell et al., 1999; Redman, Lenburg, and Walker, 1999). Critical thinking is perhaps the most pivotal competence, as seen in many resources (Critical thinking, 2000; Rubenfeld and Scheffer, 1995).

Performance-Based Learning and Assessment Methods

A change in methods used to promote learning and evaluate competence is another trend closely linked to competency outcomes. In the era of cost containment, finding the most effective and efficient ways for students to become competent is paramount. Related issues include:

Changes in roles of teachers and learners

Refocusing responsibility and accountability

Shifting the perception of students from passive receivers of information to active learners responsible for being competent in the array of specific practice-based skills

In actual clinical practice, nurses must be competent in creative and effective problem solving, communication, teaching, caring, and management. Rather than lectures and multiple-choice tests, these skills are learned more effectively through activities such as problem-based learning, case studies, and diverse projects in many community agencies. In addition to hospitals and extended care agencies, settings include congregational health, parish nursing, hospice care, homeless clinics, rural migrant workers, schools, and prisons (Brendtro and Leuning, 2000; Mathews-Smith et al, 2001; Mundt, 1997; Palmer, 2001; Solari-Twadell and McDermott, 1999).

The concept of evaluation also is changing to focus on documenting actual competence in the most realistic circumstances. This requires performance examinations that specify the critical elements, or behaviors, that must be met according to the standard for practice (Lenburg, 1999b; Luttrell et al., 1999; Scanlon, Care, and Gessler, 2001; Tracy et al., 2000). Developing a structured portfolio is another method used to document competence (Serembus, 2000; Trossman, 1999). The rapid expansion of knowledge and technology and related changes in competency outcomes in education and practice require major changes in teaching-learning methods and evaluation of performance.

These trends precipitate issues for students and teachers. Both need to change ideas about learning. Sometimes students think it is easier just to figure out "what the teacher wants" and "study for the test" rather than engage in interactive group projects in and out of class that require more decision making, group process, and time. It is easier to take written tests than to demonstrate actual competence through performance examinations that require 100% accuracy of specified critical elements. Yet demonstration of competence is what employers expect, consumers need, and practitioners must do. Memorization is not adequate; abilities to assess, solve problems, and communicate effectively in diverse circumstances require far more skill. The increase in reported medical-related errors also vividly emphasizes the need for more effective performance validation (IOM, 1999; NCSBN, 1997-2001)

Issues for faculty also include creating interactive learning strategies and making arrangements for them. This means contracts with many agencies, working with preceptors and community leaders, and having students in multiple settings simultaneously. Again, the issues are time, creativity, and a very different way of thinking about learning. It also means creating more complex performance examinations both in class and in clinical settings to help students gain confidence and demonstrate achievement of essential competencies (Fig. 4-1). No easy task, but one required in contemporary education and practice.

Sociodemographic, Cultural Diversity, and Economic and Political Changes

From rural to metropolitan areas throughout the United States the population is undergoing significant transformation (Baer et al., 2000; Nursing, 1994). Many articles and websites provide details about the aging of the population (i.e., the rapidly growing percentage of those over 65 and even 85 years of age). Others describe the number of ethnic minority groups and the increasing number of those in poverty, homeless, or under-insured. Other changes of note include differences in lifestyle choices and arrangements. For example, the definition of "family" is radically different as evident in the number of single individuals living with other singles, single-parent households (many by design) and same-sex couples (with and without children). Other changes pertain to economic and political trends related to population and to health care delivery. These changes present many issues for nursing and education; students are urged to explore the following references: Hurst and Osban, 2000; Lutz, Herrick, and Lehman, 2001; and Lenburg et al., 1995. Increasing violence in society and the workplace is another concern among health care providers and educators (Melamed, 2000; ANA, 1999).

Some of the issues for students are the distinct differences among patients in their responses to illness, treatments, and caregivers, which are based on differences in age, culture, re ligion, and life experiences in family and community (Ryan et al., 2000). Additional factors pertain to the heritage of their geographic location. For example, issues related to nursing care may differ considerably among those in areas that are rural or urban, mountains or plains, north, south, east, or west. Ways of healing and caring may include many alternative, nonmedical, natural remedies and embrace the benefits of religion, rituals, and traditions (LaSala et al., 1997; Moylan, 2000). How the nurse responds to these modalities may make all the difference in the therapeutic relationship and outcome of care.

Effective and thoughtful nursing care is individualized according to client characteristics and circumstances, which is why students need to learn as much as possible from sociology, cultural diversity, psychology, religion, economics, history, and literature, as well as basic sciences. Moreover, learning the stories of diverse peoples, their customs, life experiences, and expectations is interesting and expands human understanding and creativity for personal and professional life.

Issues for faculty include the need to modify curriculum and learning experiences to help students prepare for increasing diversity in the population and healing modalities, in health care costs, and in the consequences of inadequate insurance or resources to support health. Teachers need time to learn about and establish trusting and caring relationships among leaders in various communities and to create new learning opportunities. Case studies (i.e., projects related to community health and ethnic and lifestyle diversity) are essential.

Community-Focused Interdisciplinary Approaches

These societal trends described in the preceding paragraphs helped create the current focus on community-focused health with an interdisciplinary emphasis. The large-scale economic and political influences to reduce health care costs also played a part. For example, the extraordinary expansion of knowledge and creative treatment technologies made it common practice for complex surgery to be performed in ambulatory settings on an outpatient basis or for drugs to be used instead of surgery. In addition, diverse health-conscious groups slowly made progress to change the national orientation from "illness care" to promoting health more efficiently and effectively. Another contributing factor is the increasing emphasis on health of the family as a whole and on entire communities and populations (Kiehl and Wink, 2000; Lutz, Herrick, and Lehman, 2001). The concept of community now is perceived as groups of individuals who share particular characteristics that shape their collective relationships, regardless of where they are located. Some examples are religious communities, ethnic communities, and homeless communities. The concept of community agencies also is redefined; acute hospitals are viewed as one of many community resources rather than in a totally different category. These changes require a radically different philosophy of care, one that creates a culture of interdisciplinary collaboration. This health care culture incorporates concepts of shared responsibility for health promotion among individuals, family, community, and multiple care providers. More than ever, family and neighbors need to become competent caregivers and members of the health care team.

The issues for teachers and students flow from these changes in philosophy, from "nursing as illness care in hospitals" to "nursing as health promotion and care management for individuals in the context of family, and family within the community." This requires a different perception and integration of core practice competencies (see Box 4-2); care delivery is more complex since general hospitals have become large critical care units, and less acute patients receive care in ambulatory settings or at home. Thus many acutely ill and post surgical patients now need illness nursing care, as well as health promotion, in their homes or other settings (Mathews-Smith et al., 2001; Mitty and Mezey, 1998; Ryan et al., 2000). Patients in hospital, at home, or in extended care settings are sicker and need interdisciplinary care that often is coordinated and managed by nurses.

This new reality poses a bipolar dilemma: how to prepare nurses who will be competent to manage illness and health care to diverse clients dispersed throughout the community and at the same time able to provide critical care to patients in hospitals who are sicker and stay for shorter periods of time. These changes require reorganization of the curriculum so that multiple aspects of community health and illness care are emphasized in courses throughout the program rather than in one course in community public health. Students need very different clinical experiences dispersed throughout the community and under the supervision of preceptors and nursing staff (Kiehl and Wink, 2000; Bringing healthcare, 1996). Like a row of dominoes falling, these changes pose yet more issues.

Some issues for students include changing their image of where they will work, the kinds of patients they will care for, and the skills they will use. Although many will work in acute care hospitals, others will provide care in diverse community settings to those who are culturally diverse or elderly and have multiple chronic and/or acute conditions that require long-term nursing management. This requires skill in all core practice competencies, especially creative problem solving, interdisciplinary collaboration, and ability to use computers and communication technology effectively and independently (Engelke and Britton, 2000). The Nightingale Tracker system is an example of such technology currently being tested by the Fuld Institute for Technology in Nursing Education (FITNE); access its website and reports through www.fitne.net.

Other issues include working with preceptors and staff in multiple locations with less one-on-one instructor interaction. This requires planning, time, and resources for travel to diverse clinical locations and out-of-class peer group work and projects. But it provides opportunities for students to learn collaboration and diverse approaches to care in multiple settings and to develop confidence and competence. Useful experiences may include projects in congregational health, parish nursing, rural health care, and alternative health practices (Brendtro and Leuning, 2000; Palmer, 2001). Service-learning projects also are relevant parts of community health (Green and Adderley-Kelly, 1999; White and Henry, 1999). Explore websites in Table 4-2.

Consumer-Oriented Society

As consumers have become more knowledgeable about illness care, health promotion, and the consequences of errors in care, they also have become more assertive about their rights to competent and prudent care. The economics and politics of health care and access to comprehensive information via the Internet have promoted more consumer involvement in setting health care standards and policies (Lewis, 2000; see Table 4-2 for multiple websites). Consumers are more active on health-related boards and committees and consumer advocacy groups. Their involvement has helped bring attention to needed revisions and also has precipitated some issues that influence nursing education.

For example, nurses need to change their approach from "giving care" to the patient, to "working with" the patient as a member of the health care team. This involves a different emphasis on interpersonal communication and making decisions for outcomes. A more informed and engaged patient is better able to make effective decisions, and thus patient teaching is a core practice competence. Interactive learning and service-learning projects are valuable ways for students to learn to work with consumers in planning projects to promote safety and health and community responsibility for health (Hurst and Osban, 2000; White and Henry, 1999).

Other issues pertain to the increasing number and consequences of serious medical errors made by health care professionals. These errors have led to an increased number of lawsuits with high associated costs, which further increase the cost of health care and tarnish the belief in the quality of health care in this country. The Institute of Medicine (IOM, 1999) conducted a major study, which was widely reported in professional journals and national newspapers; nursing organizations also responded (ANA, AACN). A large percent of errors are attributed to nurses, and therefore nursing faculty and administrators are increasingly concerned with ensuring the competence of students and nurses. These issues have in large part supported the need to insist on competency-based performance examinations in schools of nursing and as part of employer annual evaluations, and accreditation (JCAHO, 2000)

Ethics and Bioethical Concerns

Another trend closely connected to those in the preceding paragraphs is patients who have different ways of responding to illness, care providers, and therapies, which raises ethical issues of who is right and who has the right to prevail. This is particularly relevant regarding end-oflife issues (Rushton and Sabatier, 2001).

Issues for students include the separation of professional practice behaviors from personal beliefs and preferences and acceptance of the concept of "a gray continuum" instead of simplistic black-and-white interpretations. Diversity of backgrounds also conveys diversity in interpretation of behaviors, events, and language. Some of the most controversial issues include the right of individual choice regarding abortion, organ transplant, preference in sexual partners, and euthanasia or right to die a dignified death. Other issues may include the use of alternative remedies that may not be in the mainstream, even among those who engage in complementary health practices.

Teachers have similar issues related to which content to include in courses and clinical experiences and how to help students become more respectful of diversity in life practices. One part of the solution is to teach ethical concepts and to use case studies, guided learning experiences, and focused discussions to explore ways of interacting with patients/clients who present behaviors or responses that are very different from the expected norm. The need to explore these ethical issues will become even more essential as the characteristics of the population change further (Riley and Fry, 2000).

Increasing Shortage of Nurses, Students, and Faculty

A recurring trend over many decades is the shortage of qualified staff nurses, teachers, and students. In addition to Chapter 12 in this book, several references provide historical and current details regarding the numbers and causes (e.g., Baer, 2000; Heller, Oros, and Durney- Crowley, 2000; and Nursing shortage, 2001). Most current information and discussion of the consequences also are provided on the website for AACN (2000b), ANA (1999), NFSNO, and other specialty organizations (see Table 4-2). One of the most dire consequences is the increasing number of errors in patient care as reported by the Pew Commission (Bellack and O'Neil, 2000). Two primary aspects of the trend include the predicted short- and long-term shortage and the increased aging of the profession. The current nursing workforce of nurses, teachers, and students is older than ever, and fewer personnel are available. The average age of nurses is in the mid-40s; and, as fewer younger students enter nursing, the average age will continue to rise (Buerhaus, 2001; Buerhaus, Staiger, and Auerbach, 2000).

The shortage and aging of nurses have serious consequences and issues for students, teachers, and the profession. Inadequate clinical staff results in lower quality of care and fewer preceptors with enough time to work with students. More nurses work part time and for agencies, which means that some students may be in clinical settings without adequate supervision or may have fewer opportunities for specific learning experiences. They also may be exposed to nurses with inadequate educational background to help them integrate content and practice and thus precipitate undesirable practices. Therefore students must take more individual responsibility for competence.

Similarly, staff shortage has consequences for teachers as they arrange for supervised learning experiences for students in multiple and diverse clinical settings throughout the community. These conditions may lead to frustration and disappointments, as well as limited competence in the very abilities required for contemporary professional practice. These circumstances present special concerns for students in distance learning and Internet-based programs who are more dependent on qualified nurses to be preceptors.

The number of qualified student applicants is declining, and many of those who enroll are older and/or have prior education in nursing or in other fields (Frik, Speed, and Pollock, 1996). They often seek kinds of learning experiences that are different from those of young students, and they may find course offerings and experiences frustrating. Nursing programs also are faced with shortage of qualified teachers because of the declining number of master of science in nursing and doctoral graduates prepared in education, which in turn, may lead to higher student-teacher ratios at a time when the complexity of clinical learning requires even more one-on-one supervision. These issues require multilateral planning by teachers, students, the profession, and the broader community.

Increasing Professional and Personal Responsibilities

In the context of all these trends, another one with multiple related issues has become increasingly evident. Students, teachers, and nurses confront increasing life responsibilities and associated stressful demands on time and resources. In summary, they simultaneously must cope with the explosion of new information and technology; changing health care systems; more precise expectations for learning outcomes; more interactive and out-of-class methods of learning; different expectations for competent performance; shortage of nurse preceptors and teachers; and multiple cultural, ethical, and legal aspects of an ever-changing society. In addition, most also have the responsibility of caring for dependent children, as well as aging parents.

At the same time, the profession requires its members to keep current and pursue planned professional development. Complexities in practice increase the need for nurses, teachers, and administrators to document continuing competence for relicensure and recertification. Changes in multistate regulations also draw attention to the need for initial and continuing competence (Gaffney, 1999). In many states continuing education is mandatory, and state boards of nursing have changed or are in the process of changing requirements to validate continuing competence (see websites for NCSBN and specific states, such as California, Kentucky, Tennessee). The American Nurses Association has cited the continuing competence of nurses as one of its focus issues of concern (ANA 1999; ANA, 2000; multiple issues of The American Nurse, 2001).

The related issues are almost universal, and solutions are difficult and multifaceted. The high stress levels associated with both professional and personal demands have consequences for one's own health and that of those around them. These issues illustrate how important it is for all of those involved in the educational process to be more caring, understanding, respectful, and helpful to each other. Teachers, students, administrators, staff nurses, employers, family, and friends need to learn anew the meaning of "caring community" in the context of rapid change.