2
What to Teach

Throughout the discussions at the three forums on the future of nursing, members of the Institute of Medicine (IOM) committee heard informative evidence and memorable and insightful observations about the scope of nursing’s contributions to the delivery of care and the advancement of science, said Dr. Michael Bleich, dean, and Dr. Carol A. Lindeman, Distinguished Professor for the School of Nursing at Oregon Health & Science University. Nursing education is the foundation for nurses’ ability to assume a variety of challenging roles throughout the health care system. The preparation of nurses “requires a great deal of intelligence, integrity, and focus,” Bleich said.

As moderator of the first armchair discussion, which considered the topic “What to Teach,” Bleich focused the discussion on the educational needs at both basic and advanced levels to ensure a well-educated, competent workforce. He led an engaging and interactive discussion with four prominent leaders in nursing education: Dr. Linda Cronenwett, professor and dean emeritus for the School of Nursing at the University of North Carolina–Chapel Hill; Dr. Terry Fulmer, Erline Perkins McGriff Professor and dean of the College of Nursing at New York University; Dr. Marla Salmon, Robert G. and Jean A. Reid Dean in Nursing and professor in the School of Nursing at the University of Washington; and Dr. M. Elaine Tagliareni, chief program officer for the National League of Nursing and former professor of nursing and Independence Foundation chair in Community Health Nursing Education at the Community College of Philadelphia. The discussion touched on many concerns and areas of opportunity to improve nursing education.

Bleich opened the conversation by asking the four expert discussants what every nurse’s education should include: “What is the knowledge



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2 What to Teach Throughout the discussions at the three forums on the future of nursing, members of the Institute of Medicine (IOM) committee heard informative evidence and memorable and insightful observations about the scope of nursing’s contributions to the delivery of care and the advancement of science, said Dr. Michael Bleich, dean, and Dr. Carol A. Lindeman, Distinguished Professor for the School of Nurs- ing at Oregon Health & Science University. Nursing education is the foundation for nurses’ ability to assume a variety of challenging roles throughout the health care system. The preparation of nurses “requires a great deal of intelligence, integrity, and focus,” Bleich said. As moderator of the first armchair discussion, which considered the topic “What to Teach,” Bleich focused the discussion on the educational needs at both basic and advanced levels to ensure a well-educated, com- petent workforce. He led an engaging and interactive discussion with four prominent leaders in nursing education: Dr. Linda Cronenwett, pro- fessor and dean emeritus for the School of Nursing at the University of North Carolina–Chapel Hill; Dr. Terry Fulmer, Erline Perkins McGriff Professor and dean of the College of Nursing at New York University; Dr. Marla Salmon, Robert G. and Jean A. Reid Dean in Nursing and professor in the School of Nursing at the University of Washington; and Dr. M. Elaine Tagliareni, chief program officer for the National League of Nursing and former professor of nursing and Independence Founda- tion chair in Community Health Nursing Education at the Community College of Philadelphia. The discussion touched on many concerns and areas of opportunity to improve nursing education. Bleich opened the conversation by asking the four expert discussants what every nurse’s education should include: “What is the knowledge 7

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8 FORUM ON THE FUTURE OF NURSING: EDUCATION needed to ensure a competent practitioner?” He continued by asking about the knowledge needed in a range of advanced nursing roles: “How do you see the roles and the education essential for preparing competent nurse specialists evolving?” Bleich also asked discussants to provide key recommendations they would like the committee to consider as it concludes its deliberations and develops the recommendations for its final report. BASIC NURSING EDUCATION As the largest component of the health care workforce, nurses play a vital role in delivering care across a wide range of settings: from acute care and long-term care facilities, to public health and community health clinics, to schools and homes, and everywhere in between. In addition to delivering care, nurses also fill leadership and advisory positions and serve as researchers, scientists, and educators. As Bleich said in his in- troductory remarks, education gives nurses the ability to fill these posi- tions; basic education is particularly important because it provides the foundation on which everything else is built. Salmon highlighted four realities that are driving changes in nursing education: more nurses are working outside of hospitals as care shifts formally and informally into communities; evidence that could inform practice is growing rapidly, but is not well integrated into either educa- tion or practice; the need for nurses to effectively work in and lead teams is increasing; and numbers alone will not fill the widening gap between the supply of nurses and the growing need for their services—additional research and new knowledge will be required. Tagliareni added that changes in patient demographics, care needs, and job demands have pro- duced a need for changes in the nursing curriculum, particularly at the basic education level. Building a Strong Foundation Nursing education needs to provide all students with the scientific background, practice-based knowledge, clinical reasoning skills, and ethical comportment to enter the practice of nursing, said Cronenwett. To better prepare students with the necessary scientific background, curricu- lums would benefit from the creation of a common base of prerequisites.

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9 WHAT TO TEACH Additionally, educators should work to improve the links among knowl- edge, practice, and clinical reasoning skills in courses, Cronenwett said. The approach to the basic curriculum is currently “siloed”; this approach may limit the ability of graduates to understand, manage, and make judgments in complex emerging care environments and community-based practice, Tagliareni said. Today, nursing education focuses on patient–nurse interactions, but to improve quality of care, nurses also need to think in terms of health care systems. They need to understand quality and safety issues, the importance of team approaches to problem solving, and the need for patient education. The nursing pedagogy needs to be linked with the dissemination of knowledge, Tagliareni said. Nursing education needs to move away from the “additive curriculum” toward a curriculum that emphasizes compe- tent performance through active learning. In addition, Salmon said stu- dents need to learn how to assess, use, and manage knowledge so they can access it when needed instead of being something they “cram into their heads” during the learning process. Once nurses have entered the profession, they need to further de- velop their knowledge in relation to specific settings, patient or commu- nity populations, and care teams, Cronenwett asserted. Having a strong foundation in these key areas will better prepare nurses to acquire this additional knowledge throughout their careers. To improve the transition to practice, she suggested a mandated, postlicensure transition-to- practice residency program that would facilitate continued learning and increase the depth of knowledge needed to practice. Educating to Meet the Health Needs of Americans Basic nursing education needs to reflect the new world that is taking shape and the changes in U.S. patient populations, Tagliareni and Fulmer emphasized. The demographics of the American population are shifting; the population is aging and becoming more diverse. The way health care is provided is also shifting; care frequently requires a team of providers working together across settings. Fulmer said the health care system is moving from an urgent situa- tion to a crisis, given that the population of people over 65 will double over the next 20 years, with an additional 10 million more people over the age of 80 by then. Older adults account for 35 percent of all hospital stays, 34 percent of all prescriptions, 38 percent of all emergency medi-

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10 FORUM ON THE FUTURE OF NURSING: EDUCATION cal responses, and 90 percent of all nursing home use (IOM, 2008). Basic nursing education needs to cover topics such as geriatric syndromes, sleep disorders, dementia, delirium, depression, and chronic care man- agement. “This is highly complex nursing,” Fulmer explained. Tagliareni added that when educating students, care for older adults should be the prototype used for the future of nursing. Such care involves assessment of function and expectations, health promotion and self-care, chronic care management, life transitions, and the promotion of human produc- tivity despite loss and frailty. Interdisciplinary team skills and collaboration will be essential for coping with the complexity of care for an older population and to ensure that patients receive continuous care across settings and providers. Nurses need to know how to work with patient care attendants, with phy- sicians, and with specialists across teams under a variety of circum- stances. Salmon said nurses have never been able to “go it alone,” which means that basic nursing education must prepare graduates to work in teams. Nurses need to be able to lead effectively across settings and within groups, she said. Fulmer noted that simulations could be particu- larly valuable in conveying this type of knowledge. Basic nursing education also needs to devote more effort to fostering diversity, including culturally sensitive and relationship-centered care, Tagliareni said. Institutionalizing a commitment to diversity has posed substantial challenges in education institutes, but it also has led to power- ful examples of faculty creating innovative models that tackle issues of inclusion, justice, and diversity in a world that is increasingly without borders, she said. Educating for Continuous Improvement Nursing education needs to prepare graduates who understand that part of the daily work of nurses is to continuously improve the delivery of nursing care and health care in local settings, Cronenwett said. Gradu- ates need the competencies and skills required to participate in and lead quality improvement efforts wherever they practice. “Those two things are very important—how to do the work, and how to improve the work,” she noted. Both the IOM and the Robert Wood Johnson Foundation have de- voted considerable attention to problems with quality and safety in health care, Cronenwett pointed out. Nurses should be able to help solve these

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11 WHAT TO TEACH problems by working with empowered patients, collaborating in a team environment, being familiar with the tools of quality improvement, un- derstanding cultures of safety, and knowing how to use informatics to enhance the reliability of care, she concluded. A Spirit of Inquiry and Life-Long Learning Students need to learn the fundamentals of their profession, but they also need to develop a “spirit of inquiry,” Tagliareni said. This spirit of inquiry will allow nurses to examine the evidence that underlies clinical nursing practice, learn to access research evidence, question underlying assumptions, and offer new insights to improve the quality of care for patients, families, and communities. Nurses need to be encouraged and engaged to continue life-long learning in formal ways, Bleich asserted. Such learning can occur on top- ics such as collaboration, team work, and health systems. “[Nurses] need to be engaged in a commitment to and a passion for education in all its various forms,” Bleich said. Salmon added that initial education for nurses is just that—education needs to continue over time. Additionally, people intending to become nurses should see the profession as “a call- ing, a commitment, and an intellectual adventure,” she said. Future Directions for Basic Education As requested by Bleich, each discussant offered recommendations to the committee about necessary actions to improve basic nursing educa- tion. According to Cronenwett, scholarships, loan forgiveness programs, and institutional capacity awards could increase the number and propor- tion of newly licensed nurses graduating from baccalaureate and higher degree programs, which would produce more prelicensure graduates who would be more likely to go on to graduate school. Tagliareni said basic nursing education should refocus on the funda- mentals to reflect the expanded settings of care. “What is fundamental may not be accomplished by running students through subspecialties,” such as obstetrics and pediatrics, she said. Basic nursing education also should rethink approaches to safety, patient-centered care, cultural com- petence, and clinical judgment.

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12 FORUM ON THE FUTURE OF NURSING: EDUCATION Fulmer emphasized that nursing schools should teach all students about geriatric syndromes, chronic care management, team skills, col- laboration, and communication. Salmon said nursing schools need to develop knowledge manage- ment, access, and use of tools and strategies rather than burdening stu- dents with information that is hardwired into the curriculum. “What we ought to be hardwiring is the ability to manage and use knowledge in real time in both education and practice,” she said. ADVANCED NURSING EDUCATION Beyond basic education, advanced nursing education is critical to the profession for several reasons, Bleich said. It prepares nurses for a vari- ety of specialized advanced practice roles that are essential in the health care system; these advanced roles include nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, and certified nurse midwives. It produces the nurse educators who will prepare future generations of nurses, and it equips nurses to do research to advance care, including research done as members of interdisciplinary teams of health care experts. The Pipeline In the next 10 years, Fulmer noted, more than 40 percent of regis- tered nurses will approach retirement age, creating a large gap in the workforce at all levels of education (Buerhaus et al., 2000). Tagliareni expressed concern about the low number of prelicensure students who are progressing to the advanced practice role. “We are not moving them in the numbers that we need in order to develop those roles both in prac- tice and certainly for nurse educators,” she said. Cronenwett said the number of people getting master’s and doctoral degrees in nursing is unlikely to rise appreciably until more people come into nursing through universities. “That is overwhelmingly the group of people who go on,” she said. A state-by-state commitment is needed to increase the percent- age of people who are exposed to nursing in universities, she added. To prepare future generations of nurses and move students to higher levels of education, the education system requires an adequate number of well-prepared faculty. More focus is needed on the specialized role of

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13 WHAT TO TEACH nurse educators and on the preparation and development of faculty, Tagliareni said. Faculty need to understand the best practices and strate- gies in learning and teaching to ensure the development of critical think- ing skills in their students. Nursing schools and programs need to place additional emphasis on faculty recruitment and retention strategies, Tagliareni added. Advanced Curriculums and Competencies Current advanced practice curriculums provide only limited exposure to information about how to achieve change and how to evaluate the im- pact on quality when evidence-based solutions are adopted, Tagliareni said. Advanced practice nurses (APRNs) 1 need these important tools, as well as critical thinking skills to optimize patient care. Obtaining and applying necessary skills and knowledge to implement and evaluate change requires education in a wide portfolio of topics, new pedagogies, and graduate-level competencies. APRNs will be increasingly responsible for primary care; already, there are nearly 600 million patient visits to nurse practitioners each year (AANP, 2010). APRNs need to be able to deal with the complexity of not just a disease or disorder, but also the care environment, including multiple specialists and disciplines, Fulmer said. To manage this com- plexity, teaching about teamwork and collaboration “has to be in every single class.” In addition to competencies for primary care, the aging of the population will require nurses, especially APRNs, to have competen- cies to ensure quality care outcomes for older adults, Fulmer explained. Salmon called for a distinction to be made between what nurses need to learn as they prepare to enter practice and what information and knowledge is needed to continue their practice across their career. Too much knowledge is compressed into advanced degree programs, she noted. The pharmacy profession, for example, has realized that memoriz- ing all drug interactions is impossible because so many exist. Instead, practitioners access drug interaction databases so that “you use that knowledge when you need it,” Salmon said. This strategy could greatly benefit the nursing profession. 1 APRNs meet additional requirements in education and clinical practice, generally a master’s degree or another form of advanced clinical preparation. APRNs include nurse practitioners, nurse anesthetists, nurse midwives, and clinical nurse specialists.

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14 FORUM ON THE FUTURE OF NURSING: EDUCATION Once nurses reach the advanced practice level, they need to be able to ensure their own professional development and that of others, demon- strate leadership, and promote positive change in people and systems. “[APRNs] are change agents . . . for both personal and professional growth of themselves and others, and we count on them for direction,” Tagliareni said. As with basic nursing education, taking on this role re- quires an understanding of the health care system as a whole. APRNs and Nurse Specialists Society needs APRNs now and will continue to need them in in- creasing numbers in the future. Evidence demonstrates that master’s de- gree specialist programs are preparing competent nurse practitioners, midwives, anesthetists, nurse managers, and other APRNs, Cronenwett said. Additionally, a good alignment is in place among the requirements for licensure, certification, education, and accreditation, and this align- ment should not be disrupted, she said. Cronenwett further asserted that advanced practice should not re- quire the attainment of a doctoral degree as the entry to advanced prac- tice. She expressed concern that requiring a doctoral degree would diminish the number of advanced practice graduates per year and in- crease the costs to students and society to produce APRNs. Individuals should make choices about the kind of doctorate they want to pursue after they know more about nursing and about the kinds of roles they want to fill within the profession, Cronenwett said. Nurses also should make these choices once they are competent practitioners and thus capable of developing the doctoral-level skills and knowledge (through the D.N.P. or Ph.D.) to have greater impact on practice, science, health policy, leadership, and the improvement of health care, she said. Improving Practice Through Research “The gap between the need for care and the availability of nurses will only continue to grow, and this gap cannot be filled through num- bers alone,” said Salmon. “For nurses to improve access to and the qual- ity and cost of care, new knowledge needs to be developed.” While other health disciplines, such as medicine and pharmacy, have a strong, well-

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15 WHAT TO TEACH funded research foundation, nursing has not experienced the same level of support or engagement, she said. Federal funding for nursing research is insufficient to meet the chal- lenges of advancing care for the future, Salmon said. Of the more than $30 billion the National Institutes of Health spends on research, only about $145 million is committed to nursing research through the National Institute of Nursing Research (NIH Office of Budget, 2010). “That is paltry,” she said, and indicates a devaluing or inattention to the develop- ment of the science as a foundation for nursing. “Lack of funding and support for training nurse scientists poses a significant threat to the future of care; additionally, the underpinnings of care and research around care [are] being eroded,” Salmon said. Nurse scientists often carry significant financial burdens, which ultimately af- fect their career trajectories and contributions to research. Predoctoral nursing students generally do not earn a living wage, she said, which re- sults in the need for students to make money while pursuing graduate education and to find ways to pay off debt after completion of their de- grees. With an average age of completion of 46 (compared to 33 in other disciplines) for a nurse Ph.D. and heavy loan burdens, nurse scholars often forego important postdoctoral training and make career choices that may divert their focus on science, she said (Berlin and Sechrist, 2002). The net result is that nurse scholars have significantly fewer years and opportunities to contribute to and engage in the development of nursing science to improve practice and care. “Ultimately, it is the health of the public that loses,” she concluded. Bleich said additional nurse scientists are needed to be part of the in- terdisciplinary research dialogue. Nurses bring a needed lens to research teams that gather, analyze, and look at new interventional models and understand the health care system and policy. Tagliareni added that multiple entry points are needed to create more minority nurse researchers. When mentoring and funding are available, minority nurses can move from these multiple access points into ad- vanced practice and research. Future Directions for Advanced Education Each discussant offered recommendations about advanced education of nurses for the committee’s consideration.

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16 FORUM ON THE FUTURE OF NURSING: EDUCATION Cronenwett said many of the funds for nursing education currently included in general medical education funding should be redirected to support either graduate nurse education or “transition to practice” resi- dency programs. Additionally, she said policies should ensure that schools produce increasing numbers of nurse practitioners for primary care roles because expanded access to health care will increase society’s need for primary care providers. Tagliareni urged a reconfiguration, rethinking, and refocus on recog- nizing the value of nurse educators. Academic nursing education should be valued as a specialty area of practice and as an advanced practice role within the nursing profession. Tracks within master’s and D.N.P. pro- grams should focus on developing specialized knowledge, skills, and abilities that are specific to nurse educators. Fulmer advocated teaching complex geriatric syndrome content and chronic care management in family- and patient-centered contexts. Few nursing educators who teach geriatrics are certified in the field, she said. She also urged that education about team and collaborative care be inte- grated into nursing curriculums in new ways. Salmon said the importance of nursing science and its contributions to improving care and health should be raised on the national agenda. Greater support for predoctoral and postdoctoral nursing education, with an emphasis on training in research-intense environments, is needed. This would allow scientists to begin their careers earlier, with a stronger training trajectory, and would provide the benefit of working collabora- tively with interdisciplinary colleagues. QUESTION AND ANSWER SESSION During the question and answer session with the committee, the armchair discussants focused largely on how nursing education should change as health care increasingly migrates from acute care settings into the community. Nurses must be able to work within the community and to shift care toward prevention to the greatest extent possible, said Salmon. Cronenwett said what people in a nursing home or in their own homes want is for nurses to apply to the community the skills and knowledge used in acute care settings. The notion of where nurses should work needs to be broadened, but “I am very reluctant not to produce the generic, generalist graduate who is capable of doing work in acute care and/or the community,” Cronenwett concluded.

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17 WHAT TO TEACH Fulmer pointed out that the infrastructure for community health care and education are not where they need to be. Nurses and interdisciplinary thinkers need to ask what will enable a new nursing graduate to practice more autonomously in a setting where they will not have colleagues readily available for collaboration and brainstorming. The education of a nurse should be based on liberal learning and en- gagement in society at large, Salmon said. Nursing is part of the fabric of society, and nurses should be leaders in society.

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