Thoughts About Nursing

A graduate of Quincy City (Massachusetts) Hospital School of Nursing and holding the BS degree from Teachers College, Columbia University and the MS degree from Harvard University, Dorothy Smith was dean of the College of Nursing and chief of nursing practice at the J. Hillis Miller Health Center, University of Florida, Gainesville from 1956 to 1972. In that capacity, Smith pioneered the development of the unified model of nursing education and practice in which nursing faculty provided the clinical, scholarly and administrative leadership in the teaching hospital to create an environment for students to learn professional nursing practice by example. The unification model at the University of Florida has been replicated in varying degrees in many of the nation's leading health sciences centers. Dorothy Smith, probably more than any other single nurse leader in America, influenced nursing education's renewed commitment to clinical nursing—a commitment that eventually spawned clinical nurse specialists and nurse practitioners, organizational reforms in hospitals that promoted professional nursing practice, and the evolution of clinical nursing research.     

Preparing nurses for the 21st century: reenvisioning nursing education and practice.

Significant advances in biomedical science and in the complexity of health care, coupled with a worsening nursing shortage and numerous reports of unsafe and inadequate patient care, have prompted concerns about both nursing education and nursing practice. Beginning in 2000, the American Association of Colleges of Nursing (AACN) made a thorough study of nursing education, regulation, and practice issues. Input and consultation were sought from AACN members, nursing practice leaders, regulators, and other health professionals. Results of this work indicated the need for a new nursing professional, the clinical nurse leader, who could effectively coordinate, manage and evaluate care for groups of patients in complex health systems. Master's-degree education is proposed for piloting the preparation of clinical nurse leaders. Close coordination with nurse executives and administrators to develop the new education program and new models for care delivery is planned. Critical components of the pilot testing will be evaluation of the patient and nurse outcomes associated with the use of clinical nurse leaders and focused work to develop a new legal scope and credentials for them.     

Population health as a framework for forensic nursing curriculum

The American Association for the Colleges of Nursing (AACN) has recommended that master's level graduate programs prepare nurses as generalists. There is, however, a gap in the educational ladder at the master's level when current master's clinical nurse specialist (CNP) and nurse practitioner (NP) programs are reconfigured as doctoral programs. To fill this gap, a curriculum model using population health as a framework is proposed.     

Advancing health policy in nursing education through service learning

Knowledge of health policy is an increasingly important aspect of nursing practice and education, especially as nurses strive to improve the rapidly changing health care delivery system. At the same time, many educators, researchers, foundations, and government officials are touting the benefits of service learning. In particular, service learning offers ways to enhance partnerships between academia and community agencies and to extend learning beyond the traditional classroom. We present a model for educating nurses as advanced practice nurses in health policy that links service learning with a framework for the political development of nurses. Under the rubric of service learning, the curriculum is based on the overlap among health policy, the role of the nurse as consultant, and community-based care. After discussing the importance of health policy for graduate nursing education and reviewing the essentials of service learning, we describe a three-semester graduate sequence in health policy service learning. The focus is on the clinical and classroom components of both individual and group practica and their relationship to stages of nursing's political development. The article concludes with evaluation considerations and the implications of our work for nursing theory, research, practice, and education.     

The education of advanced practice nurses: a contemporary approach

The Advanced Practice Nursing of Adults and the Elderly graduate program at San Diego State University School of Nursing prepares experienced professional nurses with primary and specialized care (acute or critical care) knowledge and skills to deliver health care to adults and elders across practice settings as nurse practitioners and clinical nurse specialists. Emphasis is placed on health care that is research based and congruent with national standards of practice. This approach to graduate education is congruent with recommendations of professional nursing organizations and responds to the educational needs of professional nurses and the health care needs of adult and elders.     

Nursing first year of practice, past, present and future: documenting the journey in New Zealand

Aim  Documenting the journey of graduate nurse support in New Zealand from local programmes to a nationally consistent framework.
Background  Education of nurses in New Zealand has changed over the decades, from apprenticeship-style hospital-based training to academically prepared registered nurses. Newly graduated nurses require time to become confident within the clinical setting. To achieve this, a well-supported graduate nurse programme is required.
Evaluation  The authors utilized historical reviews of nursing education within New Zealand and current work being undertaken by a national working party to implement a nationally consistent graduate nurse programme.
Key issues  Disparity between locally delivered graduate programmes. Lack of funding to provide a well-structured programme and the impact on the recruitment and retention of new nurses.
Conclusions  It was identified that there was a strong need to ensure graduate nurse programmes were consistent across New Zealand in order to support graduate nurses and retain them in the workforce.
Implications for nursing management  The first year of practice remains a challenging transition time with a need for a well-structured and supported programme. Key needs include learning activities grounded in practice experience, robust programme coordination, skilled clinical educators, preceptors, and a structured learning framework.     

The nursing faculty shortage: Is there hope?

The present nursing faculty shortage is linked to the general nursing shortage. Without enough nurse educators to teach the increasing number of nurses that are needed, the health of U.S. residents is at stake. This article examines progress made on solutions proposed over the past decade such as increasing graduate and certificate programs for nurse educators, more aggressive recruitment of graduate students into faculty roles, and delayed retirement of current faculty. Potential new solutions are proposed. These include: fast-track bachelor's of science in nursing to doctor of philosophy curricula; recruiting advanced practice nurses (APNs) into faculty roles with arrangements made for clinical practice time; raising the image of nursing education as a prestigious career; developing national certification for nurse educators; and partnering with health care agencies. Linking the general nursing shortage with the faculty shortage may provide a stronger case for public policy and funding initiatives. There are signs that some initiatives are working. Present faculty need to maintain a culture of hope while potential solutions are being implemented.     

The clinical nurse leader: a response from practice.

In October 2003, over 200 nurse leaders from education and practice met at the invitation of the American Association of Colleges of Nursing. A newly released white paper, describing the role of the clinical nurse leader, was discussed at the conference. This article outlines a response to that white paper from one practice setting. The article shares information about another role, that of team coordinator, that is similar to clinical nurse leader and has been implemented at an integrated not-for-profit health care system in 5 hospitals. The comparison of the team coordinator role to the clinical nurse leader role might assist in visualizing such a role in practice. Although the roles are not identical, many of the driving forces for change were similar; these included the need to meet the changing demands for improved patient outcomes and nurse retention. The team coordinator role has 4 domains of practice that are crosswalked against the clinical nurse leader 15 core competencies. An evaluation of the team coordinator role showed changes that need to be made, such as placing more emphasis on clinical progression of patients. Lessons learned are shared, including keeping the scope of the role manageable, providing documentation standards for new roles, and the leadership required of the nursing executive to implement change.     

Exposing the tensions of implementing supervision in pre-registration nurse education

This discussion will examine the complexities of implementing group clinical supervision in pre-registration nurse education. Exploration is based upon the authors’ experiences of facilitating clinical supervision with mental health branch students on the Diploma/BSc program at one higher education institution in the UK. It will provide the history and context of clinical supervision in nursing and apply this to the educational setting.This discussion aims to move beyond the rhetoric surrounding clinical supervision to expose the underlying tensions which we propose influence the clinical supervision process in pre-registration nurse education. These include the potential confusion of role for the supervisor, conflict of responsibilities and the potentially vulnerable position they may adopt. However, despite these tensions it is proposed that clinical supervision has a key role within graduate pre-registration nursing education.     

Teaching Systems Transformation

BACKGROUND Students in the undergraduate and graduate programs at Saginaw Valley State University (SVSU) are taught to use NANDA, NIC, and NOC to guide their practice. The nursing faculty developed a population‐focused, phenomenon‐based curriculum incorporating standardized nursing languages. The population focus of the undergraduate program changes each semester. Students begin by learning to intervene with individuals, and spend their final semester focusing on special populations and health systems. The graduate program expands on previous learning, focusing on leadership activities with special populations, communities, and health systems. Students in both undergraduate and graduate programs build competence in systems change while completing assignments based on the NIC Health System and Community Domains. The complexity of assignments and expected outcomes vary by the level of student, with undergraduates learning how to influence health system transformation and graduate students learning how to lead the transformation process. MAIN CONTENT POINTS Seniors in the nursing program have three assignments that provide experience with health system transformation. The professional issues class has an assignment based on the NIC intervention of “health policy monitoring,” which is found in the classes of “information management” and “community health promotion.” Students learn to access action alerts on nursing organization Web sites and use them as a guide for communicating with legislators, with the goal of transforming health policy. In the practicum course, seniors use case studies to describe how NANDA, NIC, and NOC guide their clinical practice related to the several NIC classes, including those of “health system mediation” or “health system management.” Another practicum assignment requires utilization of “health policy monitoring” interventions for health system transformation that is community based and population specific. Master's students also have multiple assignments providing experience with health system transformation. One of the required core courses contains an assignment comparable to that used to teach seniors to influence health policy, but also provides the opportunity to develop skill in policy analysis. In addition to analyzing legislative policy, all graduate students learn to evaluate and develop organizational policy using national standards (including the Health System Domain of NIC) as a guide. Students in the Health System Specialist track are preparing for positions in nursing administration, education, and informatics. They have a three‐part assignment that requires analysis of NIC's usefulness for decision support by nurse educators, administrators, and informaticists. They evaluate learning process and management process roles as they relate to selected NIC “health system management” interventions. They also evaluate the information process role as it relates to selected NIC “health system management” and “health information management” interventions. CONCLUSIONS The learning activities engaged in provide experience in practical application of standardized language. This model of applied learning can be used in any setting to facilitate staff or student understanding of NIC's applicability to situations where system improvement is desired. NANDA, NIC, and NOC have been well developed when it comes to guiding clinical practice. While NIC has incorporated Health Systems and Community into its taxonomic structure, the linkages of those interventions with diagnoses and outcomes need further refinement.     

The concept of clinical leadership

This paper examines the concept of clinical leadership and finds that the concept has been used in a number of ways within the nursing literature. The paper argues that in a nursing practice setting the concept of clinical leadership is an appropriate one. In the clinical setting the nurse leader often has followers in the health care team, patients and their relatives. Thus it is argued that clinical leadership can be defined as the expert nurse who leads patients to better health care.     

A framework for addressing health inequities in sexual and gender diverse populations by nurses

There is a need to increase health equity in sexual and gender diverse (SGD) populations, a medically underserved group with widening health disparities. To better understand and address SGD health disparities, we have developed a multi-level conceptual framework for nurse scientists that incorporates the concepts of stigma, intersectionality, identify affirmation, and life course trajectory. Social determinants of health formed the background of our conceptual framework. Using this framework, we proposed recommendations to promote SGD health equity through nursing research, health care practice, health care education, and public health care policy. These recommendations align with the National Institute of Nursing Research's goals of dismantling structures that perpetuate racism and impede health inequity and the need to implement interventions that address social determinants of health. As a result, nurse scientists are poised to influence health care policy by translating effective interventions to reduce health disparities for the SGD population into practice.     

Education for differentiated role development for NP and CNS practice: one nursing program''s approach

Development of nurse care providers who best meet the public's health care needs is imperative. Some nurses believe the functions of nurse practitioners and clinical nurse specialists should be combined. However, the experience of the authors' nursing program argues otherwise. Two graduate nursing tracks, family nurse practitioner and rural health specialist, were developed to meet the health care needs of rural populations. Although the two tracks share expected competencies and areas of expertise to some extent, differences in practice are apparent in identified domains of practice and terminal competencies. Family nurse practitioner practice focuses on assessment, diagnosis, and management of health and illness conditions of individuals and families across the life span. Clinical nurse specialist practice incorporates traditional roles of client assessment, monitoring and coordination of care, outcome assessment, and client, family, and community education, with a new focus on case management strategies. These differences are important to care delivery in the managed care era.     

Innovative strategies for nurse recruitment and retention in behavioral health

Successfully recruiting licensed nurses to work in behavioral health is challenging. This article describes and illustrates methods one hospital successfully used to attract, orient, and mentor new graduate nurses to work in mental health. The New Horizons program included a paid internship for new graduate vocational nurses, a mental health curriculum, preceptorship, a state board review course, and a new graduate program. Since 2003, the program has recruited 37 new graduates for the unfilled licensed staff vacancies in mental health who continued their professional education and pursued degrees as registered nurses. The evaluations indicated that more than 100% of graduates rated the program as excellent as well as recommended it to their friends, and retention has been more than 90%. New Horizons graduates have received promotions; one has assumed a new role as a clinical resource nurse who teaches nursing orientation. All stakeholders including nurse management, patients, other disciplines, and coworkers have high praise for the program graduates. The program increased the cultural diversity of the mental health staff because the graduates included high percentages of African Americans, Hispanic Americans, and Asian Americans and less than 10% of White Americans. Adult learning technologies were used including teaching with films, role-playing, case studies, reflective thinking, evidence-based practice, and group performance improvement projects. Research-based fact sheets were used for the course and continued education. These 1-page fact sheets help nurses apply the evidence to improve nursing practice.     

Population health as a ‘platform’ for nurse education: A qualitative study of nursing leaders

BackgroundChallenges to the sustainability of global healthcare systems are prompting a shift towards more population-focused models of care. Nurse educators need to develop courses that prepare students for population health practice. However, the educational approaches that can support this shift are poorly understood. Publication of new standards for nurse education by the United Kingdom's (UK) Nursing and Midwifery Council that place greater emphasis on population health presented an opportunity to seek nursing leaders' views on population health in nurse education.ObjectivesTo assess the views of nursing leaders within a Scottish context on the connection between nurse education and population health for all students, evaluate what student nurses need to know to support population health practice, and draw insights from the UK for pre-registration programmes internationally.DesignQualitative interview study.ParticipantsTwenty-four nursing leaders from academic (n = 15), practice (n = 4) and regulatory (n = 5) sectors.MethodsSemi-structured interviews were conducted face-to-face (n = 21), by telephone (n = 2) or Skype (n = 1). Interviews were transcribed and analysed, using interview questions as structural themes, followed by thematic and content analyses.ResultsNursing leaders encouraged rebalancing nurse education towards population health, suggesting that population health concepts should sit at the core of spiral curricula to enable students to (re)view learning through a population health lens. Seven outcomes were identified to equip student nurses for practice in any setting. These formed the mnemonic FULCRUM: Find and interpret evidence; Understand the psychology of behavior and change; Link epidemiology to population health; Consider others and themselves in context; Recognise social determinants of health; Understand the impact of policy and politics on health; Motivate to encourage behaviour change.ConclusionsFULCRUM can guide nurse educators globally to support preparation of graduate nurses for the significant shifts in healthcare delivery and service organisation towards improving population outcomes.     

A differentiated practice model for school nursing.

School nursing is notable for autonomous practice and independent decision-making. School nurses practice within a complex school health services environment that is subject to constant change, the influence of multiple stakeholders, and a chronic state of uncertain resources. Other professional challenges faced by school nurses are a lack of standardized entry education requirement, inadequate theoretical research with practice application, and expanding role responsibilities. Administrative restructuring of school nursing services using a differentiated practice model could be a method to address the challenges of school nurse practice. A model of differentiated school nursing practice is proposed as a starting point for the national school nurse audience to consider this alternative to the master's entry requirement. School nurse role responsibilities are divided among three levels of practitioners: generalist, master's prepared, and school nurse policy analyst. Each level features an increased scope of responsibility based on higher educational attainment. Research regarding how differentiated practice has been implemented in other health care settings is described. Implications for the implementation of differentiated practice in school health services are discussed, including the need for cooperation among stakeholders, possible cost considerations, and how school nurse education might be affected.     

Supporting graduate nurse transition to practice through a quality assurance feedback loop

This mixed-method study focused on new graduate nurses and their transition to practice. Transition to practice can be a time of heightened stress and anxiety, leaving many new graduates disillusioned and dissatisfied with their work. The study explored how satisfaction levels with transition may improve during their first year, using a unique approach of a continuous quality assurance feedback loop. This assurance framework is utilised in hospitality, automotive and supply chain logistics and in health, primarily to monitor patient outcomes. However, an association with graduate nurse satisfaction has not been previously reported. Graduate nurses from two health services completed a short survey questionnaire every four weeks for 12 months. De-identified aggregated data was sent to health service management, giving them an opportunity to integrate the findings with the objective of potentially increasing graduate satisfaction ratings. Quantitative findings showed no statistical significance of graduate nurse satisfaction scores between health services, however, one health service consistently outperformed the other. Qualitative findings drawn from a seminar and interviews confirmed that one health service took a more proactive stance with the monthly reports, communicating the results to ward managers. Outcomes reflected a greater commitment of support and an overall increase of satisfaction scores.     

A feminist framework for graduate education in women's health

Graduate programs in the area of women's health have focused primarily on childbearing issues. Titles of programs such as Parent-Child Nursing, Maternal-Newborn Nursing, and Maternal-Child Nursing suggest a focus on reproduction and reproductive organs. It cannot be assumed that programs presume a feminist framework or produce graduates who are women-centered and look beyond reproductive issues. It is essential that graduate education in women's health encompasses the values of feminism and women-centered philosophy. Feminist theory, as a world view of women, brings to nursing the underpinnings for a conceptual framework in women's health. Women's health is committed to health promotion, maintenance, and restoration of the whole person through women-centered practice. The graduate curriculum provides students with the philosophy and tools for advanced nursing practice; therefore graduate curricula in women's health must include two important purposes. The first purpose is refocusing the curriculum on the whole person-woman, not solely on obstetrics and gynecology. The second purpose is socialization of students towards feminist practice, in the profession, in clinical practice, and in research.     

Clinical nurse leader and clinical nurse specialist role delineation in the acute care setting

More than 90 members of the American Association of Colleges of Nursing and 190 practice sites have partnered to develop the clinical nurse leader (CNL) role. The partnership has created synergy between education and practice and nurtured innovation and diffusion of learning on a national basis. In this ongoing department, the editor, Jolene Tornabeni, MA, RN, FAAN, FACHE, showcases a variety of nurse leaders who discuss their new patient care delivery models in preparation for the CNL role and CNLs who highlight partnerships with their clinical colleagues to improve patient care. In this article, the authors explore differences and similarities between the CNL and the clinical nurse specialist roles, describing the working strategies between a CNL and clinical nurse specialist, and role delineations that have resulted from their cooperation, collaboration, and planning.