3
How to Teach

Health care needs in the United States have changed over time, said Dr. Linda Burnes Bolton, vice president for nursing, chief nursing officer, and director of nursing research at Cedars-Sinai Medical Center. After World War II, many people returned from the war with specific health care needs, and the nursing education system at the time was inadequate to meet those needs. Today the aging of the U.S. population has created a new set of needs and new strains on nursing education. “How do we ensure the availability of a qualified workforce that is able to meet the public’s needs?” Burnes Bolton asked. “That is part of our work on the Initiative on the Future of Nursing.”

Burnes Bolton moderated the second armchair discussion, which examined the topic “How to Teach.” This armchair discussion featured five education experts: Dr. Divina Grossman, founding vice president of engagement and former dean of Nursing & Health Sciences at Florida International University (FIU); Dr. Pamela R. Jeffries, associate dean of academic affairs at Johns Hopkins University School of Nursing; Cathleen Krsek, director of quality operations at the University Health-System Consortium (UHC); Dr. Robert W. Mendenhall, president of Western Governors University (WGU); and Dr. John A. Rock, senior vice president for medical affairs and founding dean of the Herbert Wertheim College of Medicine at FIU. Burnes Bolton asked the discussants to describe the strategies their respective institutions have adopted to improve the education of nurses. She also asked them to provide their recommendations to the committee for advancing the mechanisms used to educate students. The discussants focused on innovations in technology, online learning, nurse residency programs, and interpro-



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3 How to Teach Health care needs in the United States have changed over time, said Dr. Linda Burnes Bolton, vice president for nursing, chief nursing offi- cer, and director of nursing research at Cedars-Sinai Medical Center. Af- ter World War II, many people returned from the war with specific health care needs, and the nursing education system at the time was in- adequate to meet those needs. Today the aging of the U.S. population has created a new set of needs and new strains on nursing education. “How do we ensure the availability of a qualified workforce that is able to meet the public’s needs?” Burnes Bolton asked. “That is part of our work on the Initiative on the Future of Nursing.” Burnes Bolton moderated the second armchair discussion, which examined the topic “How to Teach.” This armchair discussion featured five education experts: Dr. Divina Grossman, founding vice president of engagement and former dean of Nursing & Health Sciences at Florida International University (FIU); Dr. Pamela R. Jeffries, associate dean of academic affairs at Johns Hopkins University School of Nursing; Cathleen Krsek, director of quality operations at the University Health- System Consortium (UHC); Dr. Robert W. Mendenhall, president of Western Governors University (WGU); and Dr. John A. Rock, senior vice president for medical affairs and founding dean of the Herbert Wertheim College of Medicine at FIU. Burnes Bolton asked the discussants to describe the strategies their respective institutions have adopted to improve the education of nurses. She also asked them to pro- vide their recommendations to the committee for advancing the mecha- nisms used to educate students. The discussants focused on innovations in technology, online learning, nurse residency programs, and interpro- 19

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20 FORUM ON THE FUTURE OF NURSING: EDUCATION fessional collaborations that are being used across the country to improve access to high-quality educational opportunities for nurses at all levels. TECHNOLOGY IN NURSING EDUCATION One way to ensure the availability of a qualified workforce is through the enhanced use of technology, Jeffries said. Nursing education today is very “siloed.” There are theory classes with lectures and Power- Point presentations and laboratories where students learn specific skills. “Then, by magic, we take [nurses] to a clinical practicum where they are supposed to be putting everything together and [demonstrating a] higher order of learning and critical thinking. But they have never practiced that,” Jeffries asserted. The use of technology in nursing education offers opportunities to break down some of the silos and prepare students for decision making in complex care environments. Learning Through Simulation Simulations employing technology can allow students to practice skills, learn professional behavior, and demonstrate clinical reasoning in a safe environment, Jeffries said. Though more evidence is needed on the outcomes of using simulations as a teaching strategy, it engages students and provides them with higher-level learning opportunities they have not had before, such as clinical decision making, prioritization, and delega- tion skills. Clinical simulations can be incorporated across theory, laboratory, and clinical courses. If done correctly, simulations enable a student- centered approach in which students are immersed in situations where they have to solve problems and think critically. “Every time I see stu- dents in simulations, I learn something new,” Jeffries said. The most critical component of a simulation is the debriefing afterward; this proc- ess of guided reflection is where students learn the most. “They don’t know what they don’t know until you immerse them in a simulation,” she said. The use of simulations has exploded in the past 5 years, and federal funding may further increase their use. Regional “sim” centers are being built across the country and around the world, Jeffries said. More ad-

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21 HOW TO TEACH vanced simulators that replicate human responses are on the way. Virtual-world and second-life simulations will also be used more. E-Learning and Mobile Devices E-learning, which employs a variety of electronic media to promote learning, also offers great potential for nursing education, according to Jeffries. It provides students with the educational mobility to take courses and learn any time and anywhere. It also provides many students and practicing nurses with an opportunity to advance their careers— opportunities that may not have been available for some students if e- learning were not available. Mobile devices are also valuable in nursing education. They include hand-held devices known as “clickers” for use in classes, personal digital assistants for use at the point of care, clinical information systems, and other technologies that are readily available and portable. Some of these devices are expensive, but “we have to teach students how to use these technological devices by incorporating them into the curriculum because they are used across clinical settings and teach students real-life skills,” Jeffries said. The use of technology also engages students in active learn- ing, such as when the clickers are used in a classroom to elicit student participation and responses during lectures. A number of studies have compared traditional instructional methods with technology-based methods; many of these studies have found no significant differences (Jeffries et al., 2002, 2003). However, at other times, students learning through e-learning platforms and in online envi- ronments are more satisfied with the format and are learning just as much (Armstrong and Frueh, 2003; Billings and Halstead, 2009; Buckley, 2003; Simonson et al., 2000; Wills and Stommel, 2002). For example, outcomes data are appearing on the use of simulations to teach specific skills, such as pediatric resuscitation (Cheng et al., 2009; Childs and Sepples, 2006; Rauen, 2001). As simulations, e-learning, and mobile devices become more sophisticated, they will be merged so that learning can take place 24/7. Today’s students embrace technology, which means that technology offers a tremendous opportunity to enhance teaching and learning, Jeffries said.

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22 FORUM ON THE FUTURE OF NURSING: EDUCATION Advancing the Use of Technology in Education The largest barrier to greater use of technologies is convincing fac- ulty to use them, Jeffries noted. Faculty members may not know how to use technologies, or they may believe that students cannot learn content this way. But e-learning and the use of technology in education is here to stay, she said. Faculty development is needed in using this pedagogy and capturing data to measure outcomes. Jeffries made two recommendations for the committee’s considera- tion. First, educators must be willing to try new, innovative strategies to engage students. To create this willingness, faculty should be provided with development opportunities in the use of technologies. Like students, faculty members “don’t know what they don’t know” unless they learn about new devices and technologies and their potential. It is difficult for educators to embrace simulations if they are not informed and do not have experience in these areas. The Health Resources and Services Ad- ministration is providing funding in that area, and this funding should continue, said Jeffries. Federal funding could also be used to identify standards and perform evaluations of simulations. With the current lack of standards, a simula- tion used in Ohio might be very different from one in Iowa. Additionally, the proportional use of simulations as a substitute for clinical experience varies from place to place, noted Jeffries. ONLINE EDUCATION The WGU online nursing program offers a variety of nursing pro- grams, including a B.S.N. for initial licensure, R.N. to B.S.N., R.N. to M.S.N., and two master’s degree programs. Launched in 2009, more than 600 nursing students are now enrolled from all 50 states. Tuition is $6,500 per 12-month year; the program is self-sustaining on tuition and requires no external support. Didactic instruction is delivered online while hospital partners provide clinical rotations, coaches, and clinical supervisors. WGU offers a B.S.N. for initial licensure in partnership with major hospitals, including Cedars-Sinai, Hospital Corporation of Amer- ica, Kaiser Permanente, and Tenet. The success of the WGU program answers an important question in nursing education, Mendenhall said, “How do we create systems that are scalable, affordable, and have a greater throughput of students?”

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23 HOW TO TEACH Competency-Based Education “What makes our nursing programs unique is that we are entirely competency-based,” Mendenhall said. Competencies are defined by nursing practitioners using nursing standards. Using a student-centric model, students demonstrate competency by passing a series of assess- ments, including objective tests, performance tests, and clinical tests. “When they can demonstrate that they have mastered the competencies, they graduate,” he said. Adult learners come to higher education knowing different things and learning at different paces. Yet traditionally the education system has determined that everyone needs the same courses and the same number of credit hours and that every course should take 4 months. “We have tried to remove those barriers and teach students the way they learn— giving them self-paced, technology-based learning materials that they can do at their own pace,” Mendenhall said. Students move quickly through what they know and take as much time as they need to learn ma- terials they do not know, with content delivered through interactive, self- paced modules. Faculty and Students WGU hires faculty who are interested in the online education model and who went into nursing education because they wanted to work with students. New faculty participate in an extensive, month-long training and development program before they begin teaching and interacting with students. All new instructors are paired with an experienced faculty mentor for a year as they gradually increase the number of students they teach. Faculty members typically have 32 hours of contact time with stu- dents per week via telephone, e-mail, Web discussions, and threaded dis- cussion groups. The role of faculty at WGU has changed from delivering content to being mentors of students; their full-time role is guiding, coaching, and directing students while answering questions and leading discussions. Students, meanwhile, are part of online learning communities where they can collaborate with each other and with faculty. “Faculty stay with students from the day they start until the day they graduate, so we judge faculty based on the retention rates, graduation rates, student progress rates, and student satisfaction,” Mendenhall said. The WGU program has

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24 FORUM ON THE FUTURE OF NURSING: EDUCATION a 50:1 faculty:student ratio as opposed to a more typical 10:1 ratio. Yet, Mendenhall noted, independent national surveys indicate that students report more interaction with their online faculty than do students in brick-and-mortar institutions. The Use of Technology Technology can also be used to improve clinical education, Mendenhall said. Most states require a specific number of hours of clini- cal experience. However, few define what must actually occur during that clinical time. The WGU online program has defined a set of clinical competencies and has used those competencies to develop simulations that teach students essential clinical skills. Experiences in clinical set- tings tend to be random—whatever happens on that day is what is ex- perienced. On the other hand, scenarios can be planned using simulation so that experiences are consistent and every student has the same oppor- tunities to master the same skills and competencies. Simulations are also more effective than clinical practice in allowing students to practice their skills repeatedly in a safe environment. “The clinical rotations are more effective if students are able to use what they have already mastered in simulations,” Mendenhall said. Expanding Capacity and Improving Education During the armchair discussion, Mendenhall offered a number of recommendations for the committee’s consideration in terms of improv- ing the education of nurses, especially through the use of technology and online education. Nursing education has severely constrained capacity, and tens of thousands of qualified applicants are turned away from nursing school every year. “We don’t have the ability to expand that capacity unless we find new ways to teach. In my view, technology is the only real answer to significantly expanding our capacity for teaching in a cost-effective manner,” Mendenhall said. Technology is required to leverage faculty time and clinical spaces to increase nursing education capacity. Accord- ing to Mendenhall, simulation must become a greater percentage of clinical experiences—at least half—and regulatory requirements need to be changed to allow for this. “If we are not willing to use technology,

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25 HOW TO TEACH and in particular simulations, we are not going to magically get twice as many clinical spots,” he concluded. Mendenhall also indicated that institutional and regulatory require- ments need to be changed from hours to competencies, both for didactic and for clinical learning. “It’s important to measure learning rather than time,” he said. NURSE RESIDENCY PROGRAMS The first few years of practice can be difficult for new nurses. Turn- over rates as high as 60 percent have been reported in the first year of nursing, and the most recent national data, collected in 2007 by Pricewa- terhouseCoopers’ Health Research Institute, indicated a 27 percent turn- over rate in the first year (PricewaterhouseCoopers’ Health Research Institute, 2007). Nurse residency programs can reduce these difficulties, said Krsek. Although many question the cost-effectiveness of nurse residency programs, these programs can generate considerable savings by reducing high rates of turnover. Cheryl Jones, associate professor at the University of North Carolina School of Nursing, has calculated that the expense for each new graduate who leaves nursing in the first year is $88,000 (Jones, 2008). By contrast, UHC has calculated that the expense for a residency program is approximately $50,000 to $75,000 for administration and ap- proximately $900 to $1,000 per resident, which is ultimately much less than the turnover costs. “That is a tremendous return on investment,” Krsek said. In fact, the Methodist Hospital System in Houston has esti- mated an 884 percent return on investment after its turnover rate fell from 50 percent to 13 percent in one year, with further reductions in sub- sequent years to less than 5 percent following the implementation of a residency program (Pine and Tart, 2007). Krsek said the UHC/American Association of Colleges of Nursing (AACN) Nurse Residency Program had a turnover rate of 4.4 percent last year. Easing Transitions Nurses enter the workforce as advanced beginners and need support as they transition to becoming competent professionals, Krsek said. They come out of school with a solid theoretical foundation, but they need to

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26 FORUM ON THE FUTURE OF NURSING: EDUCATION be able to apply that knowledge and develop their situational decision making. “It takes about a year for a new graduate to become competent, so they are left after orientation expecting to be able to fully function, yet they don’t feel functional,” Krsek explained. Residency programs give nurses a way to learn to feel functional. Typical programs cover topics such as conflict management, interdisci- plinary communication, diversity, and nurse-sensitive outcomes. During the program, nurses work with an advanced practice nurse in a nonthreatening arena away from clinical situations, said Krsek. All of the residents in the UHC/AACN program are also required to do an evidence-based project in the second half of their residency year. The National Council of State Boards of Nursing recommends a residency program for newly licensed nurses (NCSBN, 2009). Addition- ally, Patricia Benner and her associates, in their new book, Educating Nurses: A Call for Radical Transformation, call for a 1-year residency program for all new graduates to support the clinical application of theo- retical knowledge (Benner et al., 2009). Residency programs produce “safe, quality, competent care with a stable workforce,” said Krsek. Krsek had just one recommendation for the committee’s considera- tion: Organizations should provide the resources to support the transition to practice of new graduates with 1-year residence programs. These resi- dencies also could take place in community-based settings, she said. A MODEL FOR INTERDISCIPLINARY EDUCATION Florida International University, as described by Grossman and Rock, is a research university that serves a diverse student body. FIU has a new college of medicine and is in the early stages of implementing a community-centric, interprofessional program called Neighborhood HELP (Health Education Learning Program). This program will integrate classroom learning, community experiences, and clinical activities for students in medicine, nursing, social work, public health, and allied professions, including occupational therapy, physical therapy, speech/language pathology, and dietetics and nutrition.

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27 HOW TO TEACH Curricular and Pedagogical Goals An interprofessional team of faculty has been meeting since fall 2008 to develop a community-based curriculum and pedagogical strate- gies for course content and clinical activities. As part of the curriculum, medical, nursing, and social work students will be required to take an interprofessional course that will cover topics such as quality and safety, crosscultural communication, collaboration, conflict management, pro- fessional bias, and leadership. The class will also include case-based group discussions and visits to community agencies and hospitals to ob- serve interprofessional care teams in action. The cornerstone of the Neighborhood HELP program is the community-based clinical experience and education. Interprofessional teams of students, including medical, nursing, and social work students, will be assigned to 2 of 1,400 households in underserved communities that have agreed to participate and were identified in collaboration with community leaders and stakeholders. The medical students will work with these two households for the 4-year duration of their academic pro- grams and will partner with nursing students at different levels of educa- tion. For example, first-year medical students will be partnered with junior nursing students, while fourth-year students will be partnered with nurse practitioner students. Students working with these households will be able to assess the health care and social service needs of families, learn about the social determinants of health, identify gaps in health care, provide health educa- tion, and make referrals to appropriate community agencies. Beginning in May 2010, the nursing, medical, and social work students will conduct regular household visits. During those visits, student teams will interview family members about their health, conduct standardized assessments of their social service and health needs, and collaboratively develop and implement a health care plan. Expected outcomes include improvements to quality of life and health in these neighborhoods, increased health lit- eracy, and effective interprofessional communication and collaboration among faculty and students in the teams. Links with the Community FIU was fortunate in that it recently established a new medical school after the schools of nursing and public health were already in

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28 FORUM ON THE FUTURE OF NURSING: EDUCATION place and active, which meant that the medical school did not have a preestablished culture, Rock said. “We could think completely outside the box” in making the school patient- and community-centric and with a curriculum based in the community, he said. Over the past 2.5 years, FIU has been able to develop relationships with the primary cultural stake- holders represented in the community, including leaders in the Hispanic, African-American, Haitian, and Jewish communities. Additional com- munity partners include neighborhood businesses, the fire department, the police department, the schools, faith-based organizations, primary care providers, and the Jackson Health System. “We have the entire loop covered,” said Rock, “when we are in households, the patients can be redirected to a community health center, and if they are admitted into the hospital our students can go there and then return home with them.” The social mission of Neighborhood HELP program is “to improve the quality of life for the citizens of South Florida household by house- hold,” Rock said. At the same time, the program will be able to train “culturally competent students who celebrate diversity and appreciate the wonderful benefits from understanding different cultures and the chal- lenges they have in meeting a variety of health care needs.” Traditionally, Rock said, outcomes were measured by the numbers of graduates successfully matriculated by a program. But another important part of an institution’s mission should be to improve the quality of life of a neighborhood or community. “That is another return of investment on the educational dollar. We have this huge amount of good will among our students who want to do good when they come to be educated. We have not effectively used that energy to meet the challenges we have in our neighborhoods,” he concluded. Improving Education Through Collaboration Grossman and Rock had several recommendations for the committee to consider with regard to improving education through interprofessional collaboration and community partnerships: • Use a community-centric approach in education so that students learn through discovery how to improve health not only for indi- viduals, but also for families and communities; • Create more interprofessional education models to socialize stu- dents to teamwork and cooperative learning;

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29 HOW TO TEACH • Provide leadership from the top by having deans of nursing, medicine, public health, and social work model interprofessional collaboration; and • Transcend issues of turf, tradition, and power so that interprofes- sional education models can flourish. QUESTION AND ANSWER SESSION During the question and answer session, one committee member asked Rock about the best ways to establish interprofessional collabora- tion and partnerships between nursing and medical schools in situations where the medical school is already well established. Rock said that col- laboration has to be endorsed by the institution or university as a whole and become a mandated challenge. Interprofessional collaboration needs to become part of a consensus among stakeholders and be incorporated into a redefined strategic program. Another member of the committee asked about the cost of the model at FIU compared to a more conven- tional classroom approach to health professional education. Rock an- swered that the pedagogy is embedded in the curriculum, so it is part of the overall cost of the medical school and is treated as a fixed cost. Grossman noted that the establishment of the program is part of a cur- riculum redesign that integrates all aspects of the program, effectively shifting the costs. Additionally, FIU has received funding from several foundations to endow the program in perpetuity, in part because of the benefits to the community of having such a program. In response to a question about how to achieve interdisciplinary col- laboration through an online community, Mendenhall said that capturing the interdisciplinary nature of education remains an evolving challenge in online education, especially because WGU does not have a medical school or other institutions at which students may work. Instead, WGU partners with acute care centers and community health centers to provide students with practical experiences and expose them to other professions in the clinical setting. Mendenhall explained that at WGU, the clinical experience for students is based on cohorts. Students are organized into groups that become part of online learning communities that interact with each other. Mendenhall also said that the WGU program defines the competencies that are needed, including interdisciplinary competencies, and finds the best content available, regardless of the source.

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