Educational silos in nursing education: a critical review of practical nurse education in Canada

Changes to practical nurse education (with expanded scopes of practice) align with the increasing need for nurses and assistive personnel in global acute care contexts. A case in point is this critical exploration of Canadian practical nursing literature, undertaken to reveal predominating discourses and relationships to nursing disciplinary knowledge. The objectives of this poststructural critical review were to identify dominant discourses in practical nurse education literature and to analyze these discourses to uncover underlying beliefs, constructed truths, assumptions, ambiguities and sources of knowledge within the discursive landscape. Predominant themes in the discourses surrounding practical nurse education included conversations about the nurse shortage, expanded roles, collaboration, evidence‐based practice, role confusion, cost/efficiency, the history of practical nurse education and employer interests. The complex relationships between practical nursing and the disciplinary landscape of nursing are revealed in the analysis of discourses related to the purpose(s) of practical nurse education, curricula/educational programming, relationships between RN and PN education and the role of nursing knowledge. Power dynamics related to employer needs and interests, as well as educational silos and the nature of women's work, are also revealed within the intersection of various discourses.     

DNP or PhD? Dispelling Misconceptions

Language used to describe the role of the doctor of nursing practice (DNP) is being used haphazardly within both education and practice settings and has led to misunderstanding. The purpose of this article is to clarify the intended role of the DNP-prepared nurse and dispel misconceptions related to educational preparation and praxis so that the rigor and contribution of those with the DNP degree is respected.     

Nursing competence 10 years on: fit for practice and purpose yet?

Aims and objectives. This paper examines how nurses are prepared to be clinically competent and safe at registration, so that they are fit for practice and purpose. It follows up two papers on competence published in 1997 and 1998 and investigates subsequent developments. Background. In 1979, major changes in nursing affected nurse education and preparation for competence. In the following two decades, it became clear that nurses lacked clinical skills. This paper examines subsequent changes and asks the question whether this crucial shortcoming has now been remedied. This paper considers the background and context of change in nursing and nurse education in the 1980s. It looks at the new ideology, to prepare the ‘knowledgeable doer’ and examines the consequences of the change on nursing competency from the 1990s to the present day. Methods. This is a position paper. Professional policy documents from the English National Board for Nursing, Midwifery and Health Visiting, United Kingdom Central Council for Nursing, Midwifery and Health Visiting and Nursing and Midwifery Council, government reports and legislation on nursing and relevant nursing literature are examined and critically analysed and conclusions drawn. Conclusions. From 1923–1977, mandatory nursing syllabuses set by the General Nursing Council of England and Wales required the registered nurse to have acquired certain specific clinical skills. These were rigorously tested to an explicit standard set by the General Nursing Council before a nurse was awarded state registration. Twenty‐five years later, the loss of this system for ensuring this competence and the implications of this loss, have been widely recognised. As a result, many nurse training institutions have introduced clinical skills laboratories, simulation of practice and the Objective Structured Clinical Examination. However, to the authors’ surprise and contrary to their initial expectations, the Nursing and Midwifery Council has not made these systems uniform or mandatory and so still has no way of ensuring all nurse training is producing safe nurses in the United Kingdom. The authors conclude that the untested educational ideology that brought root and branch change to nurse training in 1983 and which failed to produce nurses ‘fit for practice and purpose’ may still prevail. Relevance to clinical practice. The present paper demonstrates that United Kingdom nurse training still has no uniform and mandatory system in place to ensure, as far as is possible, that all registered nurses are clinically competent and safe to practice.     

Does the use of reflective models restrict critical thinking and therefore learning in nurse education? What have we done?

This article will explore relevant publications relating to practices involving the use of reflective models in UK nurse education. This will then be critically analysed in terms of my personal experiences as a nurse educator. Sch?n's seminal work (1987) on reflection never intended for the process of reflection to become so structured that it actually restricted thinking. Sadly however, it is my personal belief that this is the case within some aspects of nurse education, primarily due to the introduction and overuse of structured models of reflection. A large part of written assessment in nurse education utilises reflective writing, this may not be helpful in terms of learning and exploration of practice experiences. Indeed these models are now being seen by both students and some nurse educators as compulsory. The number of these models available to students within nurse education is phenomenal (Rolfe et al., 2001) and they appear to be a requirement for educators to support their learners in constructing ways of thinking. Further consideration needs to be given by nurses educators to the underpinning philosophy and concepts relating to reflection.     

Changes in nurse education: being a nurse teacher

The aim of this study is to examine changes in nursing education through the personal accounts of nurse teachers. This paper is based on 37 in-depth interviews within a central London Healthcare Faculty, which took place between August 2003 and March 2004 and totalled 34.4h or 305,736 words. There were thirty female and seven male participants, who between them shared 1015 years of nursing experience, averaging at 27.4 years (min7-max 42). These nursing years included 552 years of teaching practice, the average time being 15 years spent in a formal teaching role (min 0.5-max 29). Each interview was subjected to a process of thematic content analysis as described by Miles and Huberman. This paper identifies how nurse teachers try to combine teaching with a nursing role. The Government, the NHS, the Universities and the Nursing and Midwifery Council all articulate contradictory visions of the nurse teacher role, which raises the question of what additional value (if any) is gained from combining nursing practice and its teaching. This tension has led to a default situation where the longer a nurse works as a teacher the less likely it is that they will maintain any nursing practice.     

临床护理教学中预防护生发生差错事故的做法与体会

目的预防护生发生差错事故。方法抓好护生临床实习每个阶段的教育和技术培训,即:岗前防范教育、岗前技术培训、在岗教育、实习末期教育。结果增强了护生法律意识和安全意识,提高了护生自身素质和各项技术操作水平,以零差错事故率完成临床实习任务。结论抓好护生实习每个阶段的教育和技术培训,是防止护生差错事故发生的有效对策。     

The theatre of high-fidelity simulation education

High-fidelity simulation is a useful mechanism to aid progression, development and skill acquisition in nurse education. However, nurse lecturers are daunted by sophisticated simulation technology. This paper presents a new method of introducing human patient simulation to students and educators, whilst seeking to demystify the roles, responsibilities and underpinning pedagogy. The analogy of simulation as theatre outlines the concepts of the theatre and stage (simulation laboratory); the play itself (Simulated Clinical Experience, SCE); the actors (nursing students); audience (peer review panel); director (session facilitator); and the production team (technical coordinators). Performing in front of people in a safe environment, repeated practice and taking on a new role teaches students to act, think and be like a nurse. This in turn supports student learning and enhances self confidence.     

The use of skills inventories to assess and grade practice: Part 1--design and implementation

Employers increasingly require evidence of competent practice and cost-effective education that is fit for purpose. Historically, universities providing nurse education have been more concerned with the testing and grading of theory at undergraduate level which ultimately defines degree classification. This may be at the expense of recognising excellence in clinical practice which should be the ultimate goal of any nurse education programme. This paper reviews the development and introduction of an assessment tool to grade clinical competence in higher education level 6 post-registration critical care courses using a skills-based assessment strategy. The knowledge and practice components for each skill are defined within a standardised template. A number of skills pertinent to the area of practice and academic module are then collected in a skills inventory for assessment and grading which contribute to degree classification.     

Enabling disabled people: responsibilities of nurse education

This article examines some evidence concerning the approach nurse education takes in relation to disability issues and considers whether it is 'disabling' or 'enabling'. The role and purpose of education and training, along with an analysis of simulation as a teaching method and skills development, are explored. It is argued that nursing curricula has a key responsibility in ensuring that nursing practice is enabling rather than disabling in relation to patients with impairments who may be classed as disabled people by themselves or within society more generally.     

A preliminary framework to guide implementation of The Flipped Classroom Method in nursing education

Healthcare environments have increased in complexity over the last 30 years. However, educational methods to prepare nurses have remained virtually unchanged. To prepare nurses to practice in today's complex practice environment, there are calls for change and transformation in how nursing education is implemented. This transformation requires nurse educators to shift their epistemic beliefs about teaching and learning by considering theories that promote effective learning. An innovative method being used in nursing education is the Flipped Classroom Method (FCM). The FCM is a teaching strategy that encourages critical thinking and application of knowledge obtained outside of the classroom to real-world situations and problems within the classroom. This paper presents a preliminary framework synthesized from multiple theories including andragogy, constructivism, self-efficacy, and diffusion of innovations. The purpose of this preliminary framework is to support the nurse educator's reflections about the learner, their abilities to implement the FCM and to synthesize theoretical constructs to implement the FCM.     

Implementing graduate entry registration for nursing in England: a scope review

Aims  A graduate entry workforce for nurse registration has been approved for England by 2010/11. The aim of this research was to discover the immediate tasks facing nurse managers in implementing that change. Previous research has focused on making the case for change rather than on implementation.
Background  Similar to the implementation of Project 2000, this change in nurse education and employment will raise questions for employers and for higher education institutions. It will also raise questions about nurse recruitment numbers, workforce development, and the profiles of entrants to a changing workforce.
Method  In preparation for these changes, we conducted a scope review of published and grey literature in the English language. We also reviewed the earlier experiences of transfer to graduate status amongst other workforces such as teaching and social work and we investigated reported practice in other industrialised countries.
Results  The education provider changes necessary for such a large professional workforce will need considerable leadership skills from within nursing and nurse management. At present, there are too many employers and education providers in England who appear to be relatively unaware of the changes facing nurse education and professional practice and the urgency needed to lead that change.
Conclusions  Education, training and development as well as employer/commissioner practice will rely on leadership from within the nurse profession itself. For nurse managers, this requires a rapid planning process in order to ensure smooth implementation. The danger is that either education providers or commissioners of nursing services will react rather than proactively plan for the changes that are already in progress.     

Implications of multiple-choice testing in nursing education

The evaluation of knowledge/competence is understood as an essential component of nursing education and practice. As such, nurse educators have a plethora of existing evaluation strategies from which to choose. A common written evaluative format used across all higher education settings is multiple-choice testing. This evaluation approach is accepted as a 'user-friendly' strategy to assess knowledge. Researchers from the disciplines of psychology and education have long been concerned with the consequences of multiple-choice testing on learning outcomes, a discussion that is essentially absent from the nursing literature. The purpose of this paper is to address the professional implications of multiple-choice testing in nursing. The potential knowledge consequences for nurse-learners, and by extension the provision of care to healthcare recipients, resultant from use of this testing modality are addressed within the context of the implementation of best practice guidelines in a long-term care home in a mid-sized rural and northern Canadian community with both regulated and non-regulated care providers.     

Clinical simulation using deliberate practice in nursing education: A Wilsonian concept analysis

Effective use of simulation is dependent on a complete understanding of simulation's central conceptual elements. Deliberate practice, a constituent of Ericsson's theory of expertise, has been identified as a central concept in effective simulation learning. Deliberate practice is compatible with simulation frameworks already being suggested for use in nursing education. This paper uses Wilson's Method of concept analysis for the purpose of exploring the concept of deliberate practice in the context of clinical simulation in nursing education. Nursing education should move forward in a manner that reflects best practice in nursing education.     

The nature and purpose of the role of the nurse lecturer in practice settings

This paper examines the role of lecturers in nursing in pre-registration education. It focuses on the nature and purpose of the nurse lecturer's contribution in the practice setting, with particular emphasis on the issues surrounding clinical credibility. This is particularly pertinent in the light of current recommendations, which emphasise the importance of clinical learning in pre-registration education programmes. The purpose of the lecturer's role in clinical practice settings is ill defined. This lack of clear consensus regarding the expected outcomes for lecturers (in practice), leads to difficulty outlining what they should do in practice settings. Although lecturers accept that they have an important part to play in maximizing the learning opportunities for students in both university and practice settings, they are less clear about how this should be achieved in the latter. This paper argues that: It is opportune to examine and realign the lecturers contribution in practice settings given that there has been a shift in the responsibility for clinical learning; nurse education is now embedded in the higher education sector and there is a need for a greater emphasis on practice development. Clinical credibility for lecturers is about the development of nursing practice through education which is not always achieved by 'hands on' care. For example, assisting nurses in a ward area to develop expertise in evidence based practice may not involve 'hands on' care giving but does involve being conversant with current research and practice issues. The lecturer's expertise in practice settings is in teaching and facilitating learning, rather than direct care giving. No one common model for practice may be either feasible or desirable. However, it is important that nurse lecturers do not follow a particular approach because the debate about the nurse lecturer's role in practice settings fails to acknowledge the strengths and weaknesses of each model. It is important that the approach is based on sound rationale.     

The state board of nursing and its role in continued competency

Many agencies and individuals are involved with nurse competency, but within this cooperative effort, state boards of nursing have the unique role of assuring the public, through the issuance of licenses, that nurses are competent. The purpose of the board of nursing, as defined by public lawmakers, is to protect the public. There are public members on most boards. Boards of nursing are involved with nurse competency at the time of the nurse's initial entry into practice, on an ongoing basis at the time of license renewal, when the nurse reenters practice after a time of voluntary absence, and after disciplinary action of the nurse. The participation in continuing education activities is one major method for nurses to meet continued competency requirements.     

An exploration of tripartite collaboration in developing a strategic approach to the facilitation of practice learning

Pre-registration nurse education in United Kingdom has to be delivered within a complex system. Theoretical components are delivered by a Higher Education Institution and the practice components, facilitated and assessed by clinical practitioners within a health service provider institution. The previous decade witnessed a gradual divorce between these two institutions, leading to a confidence and competence deficit in the newly qualified practitioner. The new national agenda for pre-registration nursing was set out in the fitness for practice document, [UKCC, London, 1999]. It required a refocus on the practice aspects of nurse education. It identified the need to strengthen the links between higher education providers and service providers to ensure the delivery of a seamless curriculum. The report recommended closer collaborative working to bridge the theory–practice gap and develop nurses that were competent and fit for purpose at the end of the course. Several pilot sites were identified throughout the country to deliver the new practice focussed curriculum; The University of Wolverhampton was one of these. The focus of this paper will identify the multifaceted developments that facilitate effective practice learning for students, which have been achieved through partnership working and will include the following areas; creation of new practice support roles, communication systems, modes of learning (technology supported learning, problem based learning, experiential learning and simulation), the learning environment, learning opportunities and resources. It is clear that practice learning has many influences, which can either enhance or undermine the student's ability to assimilate knowledge and experience into personal, professional practice. We acknowledge that there are still many areas to be developed and anticipate that these will be informed by the findings of research currently being undertaken within the University and NHS service providers.     

Applications of complex systems theory in nursing education, research, and practice

The clinical and administrative processes in today's healthcare environment are becoming increasingly complex. Multiple providers, new technology, competition, and the growing ubiquity of information all contribute to the notion of health care as a complex system. A complex system (CS) is characterized by a highly connected network of entities (e.g., physical objects, people or groups of people) from which higher order behavior emerges. Research in the transdisciplinary field of CS has focused on the use of computational modeling and simulation as a methodology for analyzing CS behavior. The creation of virtual worlds through computer simulation allows researchers to analyze multiple variables simultaneously and begin to understand behaviors that are common regardless of the discipline. The application of CS principles, mediated through computer simulation, informs nursing practice of the benefits and drawbacks of new procedures, protocols and practices before having to actually implement them. The inclusion of new computational tools and their applications in nursing education is also gaining attention. For example, education in CSs and applied computational applications has been endorsed by The Institute of Medicine, the American Organization of Nurse Executives and the American Association of Colleges of Nursing as essential training of nurse leaders. The purpose of this article is to review current research literature regarding CS science within the context of expert practice and implications for the education of nurse leadership roles. The article focuses on 3 broad areas: CS defined, literature review and exemplars from CS research and applications of CS theory in nursing leadership education. The article also highlights the key role nursing informaticists play in integrating emerging computational tools in the analysis of complex nursing systems.     

Issues surrounding educational preparation for intensive care nursing in the 21st century.

Major changes in intensive care provision, nursing and nurse education over the last ten years mean that it is a crucial time to take a look at the effectiveness of the post-registration intensive care nursing course [ENB 100]. This article examines whether nurse education is able to meet the current and future challenges. A call for more research regarding the effects of nurse education courses on participants' clinical practice is advocated. Key factors examined include teaching and learning strategies, the identification of common threshold core and specific competencies, and the assessment of practice. Post-registration assessment of practice within the writers' own educational institution is evaluated. Valid and reliable assessment which differentiates between the level of skills attainment of students and identifies the stage of development of the nurse (Benner 1984) is recommended. The question of who benefits from the current provision of ENB 100 courses is considered. It is argued that clinical and educational staff should work together to ensure nurses who undertake ENB 100 courses emerge 'fit for purpose' (DoH 1997a).