October 2002 TN Nurse Feature Article

CHANGES THAT CHALLENGE NURSING EDUCATION

By Carrie B. Lenburg, EdD, FAAN

 At times, I am amazed by what I read about what nurses do–the scope, intensity and diversity of their work. At the same time, I am troubled about the insane pace of change in healthcare and our society in general and the deepening and complex challenges we all face today…and the human errors that result (1). True: Nursing was born out of crisis, has been nurtured and challenged by crisis, and has matured by crisis…decade after decade. The current challenge to the profession, however, is the escalating multiciplicity, complexity and rapidity of change to which its members must respond effectively. As an educator, I am particularly concerned about the compelling challenges that confront those responsible for teaching nurses for beginning and for continuing practice. Not an easy job when superimposed on the increasing need for and emphasis on documented core competencies in practice at all levels, the “graying” of teachers, the decreasing number of graduate students obtaining essential preparation in education and the increasing competencies required for today’s nurse educators. And all of this is taking place in an environment of decreasing resources.

Before we can think effectively about what to do about the challenges of change, we need to identify in some rational, systematic way what the changes are. We need to cluster the seemingly endless lists of specific issues, problems and concerns that nurses, teachers, students, administrators and others face into a more organized and manageable set. Only then can we determine the priorities and create a realistic plan of action. The changes, I think, can be formulated under an array of broad general categories under which specific concerns can be listed depending on settings and other circumstances. Within the framework of these change categories, each of us, independently or collectively, needs to identify and respond to those specific issues and priorities that are most relevant for our roles and settings.

Recently, while writing a chapter for a text on issues and trends (2), I was forced to think about the multitude of current issues and how they influence nursing and education. The list was very long and unwieldy as such, and I decided to create clusters that would be more useful. I identified nine categories of change, but since the events of Sept 11, 2001, I added a tenth. I suggest that teachers, at all levels and in all types of programs, could use this list as part of a framework to more inclusively and effectively deal with the array of specific changes they need to include in the curriculum. Because they influence how we think, work and live, these changes also could be used by nurses, administrators, researchers and others to revise statements of mission, vision, programs, outcomes and methods and related work. 

The changes that challenge us are outlined below.

1.         rapid knowledge expansion and use of changing information technology

2.         necessity for documented practice-based competencies; evidence-based practice

3.         sociodemographic, cultural, economics, political influences on healthcare, education, community 

4.         community-based, collaborative, interdisciplinary healthcare and education

5.         consumer-oriented society and impact on healthcare and education

6.         ethics and bioethical issues, dilemmas; biotechnology, biogenetic advances

7.         shortage of qualified nurses, teachers, and other healthcare personnel; aging

8.         increasing professional and personal responsibility and accountability; required continuing competency

9.         diversity, flexibility, mobility, and delivery of education; changing methods for learning and assessment of competence for practice

10.       increasing reality of terrorism in various forms; fear, preparedness, consequences 

Another essential component in the framework for preparing to meet the challenges that educators (as well as others) face is a more deliberate focus on core competencies required for all practice roles. One way to characterize the essential components of what we do is summarized under the eight competency categories identified in the Competency Outcomes and Performance Assessment Model (COPA) developed by Lenburg (3, 4). They are: Assessment and intervention, communication, critical thinking, human caring relationships, teaching, management, leadership and knowledge integration. These eight core competencies are applicable to all of us, regardless of the level or type of work we do; they are universal in nature. Whether we function as nurses, teachers, students, administrators, researchers, or in other capacities, we are responsible and accountable for competence in the specific skills that could be listed under each of these categories to fit our particular roles.

Another realization we all face is that having learned once is not enough, the pace of change mandates continual learning, lifelong learning, updating and ongoing documentation of competence. The list of eight core competencies provides a way to organize an individual or group plan to deal with the multiple changes categorized above. The challenge is to deliberately and thoughtfully analyze our individual abilities and limitations under each competence category and to map out a realistic, systematic plan to improve them within the context of changes specific to us (5). By using this systematic approach, we are more likely to meet the challenges and help others to do so as well. This is an admirable goal in and of itself. Increasingly, however, the profound changes in society have made it a regulated requirement, not only in nursing but also in many professions and occupations. The American Nurses Association and the National Council of State Boards of Nursing, as well as a host of specialty organizations, are making progress in requiring documented continuing competence for licensure and certification (6, 7).

Finally, another challenge we face in the profession relates to the inadequate preparation of those who teach students. A trend, precipitated in part by the changes listed above, is the increasing use of clinicians as part-time instructors, preceptors, mentors, facilitators and full-time teachers. Clinical competence is essential, but that alone does not convert to competence as educators. Typically, many clinicians and novice teachers have little or no preparation in curriculum and course development, competency outcomes orientation, effective interactive learning strategies, test construction or evaluation and performance assessment methods (8). 

Recently, the National League for Nursing has created a partnership with Indiana University-Purdue University to offer online faculty development courses (9). It continues to promote its faculty summits and other faculty development programs (10). The aging of current faculty, the decreasing number of graduate students in an educator major, and the attraction of other employment opportunities have contributed to the growing and alarming shortage of qualified nurse educators at all levels of programs (11).

This situation is even more troublesome when put in the context of profound changes in higher and professional education. Innovative practices that were considered an anathema a few years ago are now the norm and are expected by students and institutions (1, 12, 13). Most programs offer some forms of distance learning, computerized learning, various local to international learning technologies and interactive learning networking methods, and performance assessment of competencies. More than ever, faculty need specific preparation in the skills required for such programs (14).

Some serious questions come to mind: Who teaches these under-qualified “teachers?” Who holds them accountable for competence in the skills required to be effective educators in preparing future nurses for competent practice? The challenge is to educate those who are–or will be–teachers in those competencies required for the education specialty, as well as essential clinical skills within the context of contemporary circumstances and requirements.

The changes that challenge the profession are multiple, complex and not easily resolved in light of the frantic pace of change, work and daily living.  The final report of the Pew Health Professions Commission reveals the serious problems faced by nursing and other disciplines and outlines its recommendations (15). We would do well to review these findings again. For educators, the changes that challenge us are as difficult in their own way as the changes for clinical practitioners.

I believe that a realistic analysis of the current changes in society, a focus on the eight core competencies required for diverse practice, and the specific preparation of teachers with competencies in the specialty of education as well as clinical practice are essential to confront the challenges of the profession in the 21st century. Meeting these challenges will take a commitment to collaboration and deliberate efforts to use the skills of creativity, flexibility, sensitivity and persistence. The commitment to quality service to consumers begins with quality education for contemporary practice, but it continues for a lifetime. 

 1.        Institute of Medicine (IOM). (1999). To err is human: building a safer health system, National Academy of Science Press. (Available: www.iom.edu/. See nursing response: www. aacn.nche.org and www.nursingworld.org)

 2.        Lenburg, C.B. (2002). The Influence of contemporary trends and issues on nursing education. In B. Cherry and S. Jacob, Contemporary Nursing: Issues, Trends & Management, 2nd edition. St Louis: Mosby, p. 65–94.

 3.        Lenburg, C.B. (Sept, 1999). The framework, concepts and methods of the competency outcomes and performance assessment (COPA) Model. Online Journal of Issues in Nursing. Washington, DC: Amer Nurs Assoc. (Available via: www.nursingworld.org/ojin. See related articles in same issue).

 4.        Lenburg, C.B. (2001). The competency outcomes and performance assessment model applied to nursing case management systems. In E. Cohen & T. Cesta, Nursing Case Management: From Concept to Evaluation (3rd ed.). St. Louis: Mosby, 269–279.

 5.        Lenburg, C.B. (July/Aug 2000). Promoting competence through critical self–reflection and portfolio development: The inside evaluator and the outside context. The Tennessee Nurse, Nashville, TN. (find via: www.tnaonline. org/portfolio/competencyarticle.)

 6.        Trossman, S. The professional portfolio: Documenting who you are, what you do,  The American Nurse, Mar/Apr 1999. (Available: www.nursingworld.org/tan/)

 7.        National Council of State Boards of Nursing. See www.ncsbn.org for multiple articles related to continuing competence efforts in several states.

 8.        Siler, B.B. and Kleiner, C. (2001). Novice faculty: Encountering expectations in academia. J. of Nursing Education 40:9, 397–403.

 9.        NLN Update:  Letter from NLN CEO Ruth Corcoran. (Jan 4 and July 8, 2002). (See biweekly articles related to faculty online courses and faculty shortage: www.nln.org/newsletter/index. htm. 

10.       NLN Update: Letter from NLN CEO Ruth Corcoran. (August 5, 2002). Summit highlights—coming in September. (All issues of NLN UPDATE available on–line: www.nln.org/newsletter/index. htm.

11.       Buerhaus, P.I. (2001). Aging nurses in an aging society: long–term implications, Reflections on Nurs Leadership, 27:35–36. (Available: www.nursingsociety.org).

12.       Heller, B.R., Oros, M.T., Durney–Crowley, J. (2000). The future of nursing education: 10 trends to watch, Nurs and Health Care Perspectives 21:9–13.

13.       Skiba, D.J. (1997). Transforming nursing education to celebrate learning, Nurs and Health Care Perspectives 18:124–129 ff.

14.       Chastain, A.R. (2002). Are nursing faculty members ready to integrate information technology into the curriculum? Nurs Education Perspectives 23:187–190.

15.       Bellack, J.P. and O’Neil, E.H. (2000). Recreating nursing practice for a new century: Recommendations and implications of the Pew Health Professions Commission’s final report. Nursing and Health Care Perspectives 21:14–21. 

Carrie Lenburg, EdD, FAAN, is president of Creative Learning & Assessment Systems (CLAS, Inc.), Roan Mountain, TN.