Educating Nurses E-Book

Patricia Benner

• Herausgeber: John Wiley & Sons
• Kategorie: Bildung
• Serie: JB-Carnegie Foundation for the Advancement of Teaching
• Sprache: Englisch

Seitenzahl: 495

Veröffentlichungsjahr: 2009

Beschreibung

The authors outline a clear vision of what nursing education can and should be and provide practical exemplars of how we can achieve this vision. This is a call for us to work together as guardians of the discipline to assure that future nurses enter the health care system ready and able to meet the challenges ahead. -- PAMELA M. IRONSIDE, director, Center for Research in Nursing Education, Indiana University The profession of nursing in the United States is at a significant moment. Since the last national nursing education study almost forty years ago, profound changes in science, technology, and the nature and settings of nursing practice have reshaped the field. Yet schools have lagged behind in adapting to these changes. Added to this, the profession faces a shortage of nurses and nursing faculty. To meet these challenges, the authors assert that schools, service providers, and the profession must change. They recommend four controversial yet essential changes that are needed to transform nursing education. A volume in The Carnegie Foundation for the Advancement of Teaching's -Preparation for the Professions series, the book discusses key topics for the future of the field and offers revolutionary recommendations for change.

Leseprobe

Table of Contents

Title Page

Copyright Page

THE PREPARATION FOR THE PROFESSIONS SERIES

Foreword

Acknowledgements

THE AUTHORS

Introduction

A Crisis of Numbers

Improving Patient Care Outcomes Through Nursing Education

Opportunity at a Time of Crisis

Hope for New Resources Uncertain

Toward a New Vision for Nursing Education

The Research Behind This Book

Three Major Findings

The Plan of the Book: Paradigm Cases

A Call to Action

PART ONE - TRANSFORMATION, CRISIS, AND OPPORTUNITY

Chapter 1 - A PROFESSION TRANSFORMED

A Health Care System Transformed

Integrating Nursing Science and Caring Practices

A System Inadequate to the Task

Multiple Pathways

Raising a Bar Too Low for Entry Standards

Chapter 2 - TEACHING AND LEARNING IN CLINICAL SITUATIONS

High-Stakes Learning

Developing Clinical Reasoning and Judgment

Challenges to Clinical Teaching

Chapter 3 - TEACHING AND LEARNING IN THE CLASSROOM AND SKILLS LAB

Teaching and Learning—Removed from Practice

Teaching and Learning in the Classroom and Skills Laboratories

Games and Entertainment in the Classroom

Fragmentation

Toward a Goal of Integration

Chapter 4 - A NEW APPROACH TO NURSING EDUCATION

Four Essential Shifts for Integration

Paradigm Cases of Excellence in Nursing Education

PART TWO - TEACHING FOR A SENSE OF SALIENCE

Chapter 5 - PARADIGM CASE

Drawing from Practice

Cases, Vignettes, and Stories

Knowing Her Students

Coaching

Teaching from Her Stance in Practice

Chapter 6 - STRATEGIES FOR TEACHING FOR A SENSE OF SALIENCE

Creating Continuity and Coherence in Learning

Using Questions

Rehearsing for Practice

Reflecting on Learning

PART THREE - INTEGRATIVE TEACHING FOR CLINICAL IMAGINATION

Chapter 7 - PARADIGM CASE

Mrs. G.

Using Knowledge

Developing a Complex Response

Chapter 8 - DEVELOPING A CLINICAL IMAGINATION

Learning to Stay Open

The Power of Context

Learning to Make a Case

Chapter 9 - CONNECTING CLASSROOM AND CLINICAL THROUGH INTEGRATIVE TEACHING AND LEARNING

Integrative Teaching, Integrative Learning

PART FOUR - TEACHING FOR MORAL IMAGINATION

Chapter 10 - PARADIGM CASE

The Case

Modeling Ethical Comportment

Chapter 11 - BEING A NURSE

Doing, Knowing, Being

Strategies for Teaching Skills of Perception and Involvement

Focal Practices of Nursing

Meeting the Patient as a Person

Preserving Personhood

Patient Advocacy

Chapter 12 - FORMATION FROM A CRITICAL STANCE

Nursing’s Social Contract: Civic Professionalism

PART FIVE - A CALL FOR RADICAL TRANSFORMATION

Chapter 13 - IMPROVING NURSING EDUCATION AT THE PROGRAM LEVEL

Entry and Pathways

Student Population

The Student Experience

Teaching

Entry to Practice

National Oversight

APPENDIX - METHODS FOR THE CARNEGIE NATIONAL NURSING EDUCATION STUDY

REFERENCES

INDEX

Copyright © 2010 by The Carnegie Foundation for the Advancement of Teaching, 51 Vista Lane, Stanford, CA 94305-8703. All rights reserved.

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Library of Congress Cataloging-in-Publication Data

eISBN : 978-0-470-55715-0

1. Nursing - Study and teaching. I. Benner, Patricia E. II. Series: Jossey-Bass higher and adult education series. III. Series: Preparation for the professions series. [DNLM: 1. Education, Nursing-trends. WY 18 E235 2010] RT73.E38 2010 610.73076-dc22

2009031936

HB Printing

The Jossey-Bass

Higher and Adult Education Series

THE PREPARATION FOR THE PROFESSIONS SERIES

THE PREPARATION for the Professions Series reports the results of the Carnegie Foundation for the Advancement of Teaching’s Preparation for the Professions Program, a comparative study of professional education in medicine, nursing, law, engineering, and preparation of the clergy.

FOREWORD

SOME WORDS ARE regularly misspelled. Among them is the word foreword , often spelled forward. The pages that follow are not intended to look forward beyond the narrative, argument, findings, and recommendations of this volume on the preparation of nurses. They are intended as a set of reflections that come “before the word,” as antecedent to the texts that constitute the heart of this book. Forewords are appetizers rather than main courses. Indeed, they are not even that substantial; perhaps they can be compared to the bite-size amuse-bouche that chefs present before a meal as a small conceit to remind the patrons that there’s a serious cook in the kitchen. Its intent is to amuse or tickle the tongue but also as a subtle communication, a wink from the kitchen. Shall we think of the foreword as an amuse-pensee or even as an amuse-esprit?

Ironically, the foreword is typically the last piece of text composed for a book and nearly always by someone who is not among the authors. Although it is the first word to be read, it is the last to be written. So it is on this occasion. Indeed, I prepare this Foreword looking back not only on the Carnegie studies of nursing education, but on the full series of Carnegie’s program on preparation for the professions that took place over more than a decade. Law and engineering, the rabbinate, priesthood and ministry, medicine and nursing, school teaching and university professing, all were objects of inquiry and deliberation, of data gathering and analysis, of investigations and convenings, within and beyond the Carnegie Foundation’s hillside home.

From my vantage point in the kitchen, I take this occasion to reflect on our studies of nursing education through the lens of all the other studies we conducted during the past decade. What is particularly striking is the extent to which nursing is a hybrid, a profession whose distinctive features mirror many of the central attributes of other professions while also creating a singular identity of its own. Indeed, when I look at the work of nurses, I see reflections of each of the other professions we have studied.

I will never forget the response we received from a group of nurses in North Carolina when we asked, “What is a nurse?” Their response: “As a nurse, I am the patient’s last line of defense.” No other conception of the nurse’s role prevailed in our interviews and observations as much as the role of the nurse as patient advocate, that last line of defense against the impersonal nature of the health care system. Repeatedly we heard nurses, nursing students, and nursing faculty refer to “patient advocate” as the central role of the nurse, the heart of nursing identity. As we came to appreciate in our studies of legal education, advocacy is no simple concept. It is more than defending the rights of the client; there are times when clients must face their responsibilities and obligations, not merely defend their rights. What are the limits of zealous advocacy? The nurse is also a member of the health care team and shares responsibility for maintaining the quality of health care for the larger community.

As an educator, in particular as an educator of teachers, I was equally struck by the attention to the role of nurse as teacher. The work of a nurse is not complete, we were told, when a disease has been healed but when a patient has been prepared to return to a life that is self-managed and independent. For this nurses regularly are expected to teach: to explain to patients how they must care for themselves and why, what new habits of eating and exercising, self-examination and self-regulation they need to develop in order to live healthy productive lives. Who teaches? Nurses teach.

One need only spend a few hours with nurses on a hospital floor or in a cancer treatment room, in an individual office or even during a home visit, before being struck by the varieties of technology with which the nurse must competently cope. Some technologies are as exotic as the now-typical arrays of sensing devices in an ICU or the daunting devices needed for dialysis. Others appear as pedestrian as a hypodermic syringe or a blood pressure cuff. And computers are ubiquitous for record keeping, communications, and the monitoring of drugs. All these now fall within the nurse’s responsibilities, and he or she is expected to understand what and how to perform in those circumstances. There is an element of engineering and technology in that role, as much Star Trek as ER.

The nurse “ministers” to patients; he or she offers care and consolation, encouragement and understanding. Much like clergy, we expect nurses to understand how to respond to pain and anxiety, to nurture patients in the face of the terror of the unknown, and to offer hope when there appears to be little available. At times, nurses act as rabbis or priests, comforting family members and caring for the ill. There is a recurring element of spirituality in that caring, even aspects of faith and dedication.

Thus when I think about the preparation of nurses, I see key elements of preparing lawyers and teachers, engineers and ministers, physicians and psychotherapists, social workers and institutional managers. The work is physically grueling and intellectually taxing. It is both routine and filled with the unexpected and the surprising. Nursing education is preparation for remarkably hard work.

This complexity and richness characteristic of the nursing profession is paralleled by the complexity of its contexts of practice. In most other professions, the practitioners maintain a certain modicum of control over the pace and density of the services they render. They normally can limit their attention to a single patient, client, case, or design at a time. But in nursing, much like teaching, many clients are present at the same time, often all needing attention and care. Some form of “batch processing” may be possible in teaching, as when a teacher instructs a large or a small group. But nursing typically requires one-on-one attention and treatment. Thus, some form of “triage” is needed on a continuing basis.

Nursing is indeed a hybrid profession, an interdisciplinary and interprofessional nexus of roles and obligations. At its core, however, remain the expectations for caring and advocacy, for ministering to the needs of those who are ill. Hybrids are often particularly robust because they combine the strengths of several species into one. But they may also be particularly vulnerable.

The historian Susan Reverby has made the poignant observation that nurses are “obliged to care” in a society that does not value caring. Not only are nurses offered little respect and only moderate financial compensation, they are also licensed to practice with less formal education than any of the other professions. While medicine, law, and the clergy generally expect post-baccalaureate preparation, and teaching and engineering require at least a bachelor’s degree and often more, nurses can currently practice with only a two-year associate’s degree. It is mind-boggling that this profession, this hybrid of advocacy and medicine, engineering and ministry, teaching and caring, can be practiced with less formal preparation than any other academic profession. It is a challenge that the authors of this book address directly. It will be a significant aspect of the issues and controversies that the book provokes.

When the Carnegie Foundation was ready to address the challenges of nursing education, we scoured the country for the ideal person to lead the study. One name was proposed repeatedly; she lived and worked in our backyard at the University of California San Francisco School of Nursing. Patricia Benner was a social scientist and humanist, an experienced nurse and a chaired professor; someone initially trained as a nurse at Pasadena City College who received her doctorate at Berkeley, a distinguished scholar and a conscience to her profession. We asked. Patricia agreed. We had the leader this work required.

As her alter ego, we needed someone who would bring a very different set of perspectives to the inquiry, who would serve as complement and compatriot with both research training and scholarly experience from another direction. Molly Sutphen had originally pursued studies as a physical anthropologist and anatomist until she was captured by the history of science and medicine. After completing her doctorate in the history of medicine at Yale, she continued to do research and to teach in medical schools. The opportunity to spend four years studying and writing about the preparation of nurses was irresistible to Molly and her talents were irresistible to Carnegie.

Patricia rounded out the nursing team by going to two of her own former students who were now pursuing distinguished careers as nursing educators and practitioners. Victoria Leonard, now a health consultant at the UCSF California Childcare Health Program, and Lisa Day, a clinical nurse specialist for Neuroscience and Critical Care at UCSF Medical Center, joined the team.

Finally, the work was supported by the senior scholars who had coordinated our studies of education in the professions from the very beginning—Anne Colby and William Sullivan. The former is a notable life-span developmental psychologist with special interest in the moral development of adults, and the latter is a superb philosopher/social scientist who has written extensively about “habits of the heart” and the ethical aspects of professional work. Their role was to collaborate actively in every study we conducted as well as to stitch together the separate professional education studies so they emerged as more than the sum of their parts.

This Foreword cannot do justice to the volume it introduces without acknowledging that this book indeed looks forward with wisdom, courage, and a premeditated dose of provocation to the needed reforms of the field of heath education in general and nursing education in particular. Patricia Benner has served as a beloved gadfly within the nursing community for decades, even as she has been properly admired, even venerated, for her contributions to the theory and practice of the field. This book is neither an apologetic nor a rationalization for current practice. It holds up a mirror to the field and, while applauding it for its superb accomplishments in the face of many barriers, it also is unambiguously critical of the status quo and quite specific about what remains to be done. As such, it is a worthy addition to the lineage of critical Carnegie studies, going back to Abraham Flexner’s 1910 report on medical education a century ago up to the studies on law, the clergy, and engineering published recently. I applaud Patricia Benner, Molly Sutphen, Victoria Leonard, Lisa Day, and Carnegie’s entire staff for the professions programs for this superb contribution. I look forward to witnessing its impact on the field of nursing education.

I hope that your intellectual palates have been stimulated and your interest provoked. I know that personally I could not imagine being more enlightened and stimulated during the past ten years than I have been by our studies of education in the professions.

Lee S. Shulman President Emeritus The Carnegie Foundation for the Advancement of Teaching Stanford, California

ACKNOWLEDGMENTS

FIRST AND FOREMOST, we wish to thank past Carnegie President Dr. Lee Shulman, who with Senior Carnegie Scholars Drs. Anne Colby and William Sullivan envisioned this large program of research Preparation of the Professions. Dr. Lee Shulman lent generous and inspiring guidance, including participating in one of our site visits and attending our research debriefing meetings throughout the project. Colby and Sullivan guided and coordinated this study with the wisdom that they had gained from the studies of clergy, engineers, lawyers, and physicians. They participated in site visits and debriefings and many nursing study group meetings. We are grateful for their keen scholarly and practical guidance. We also thank senior Carnegie scholars who conducted site visits with us: Gordon Russell (Carnegie board member), Dr. Mary Huber, Dr. Alex McCormick, Molly Cooke, M.D., Dr. David Irby, and Dr. Bridget O’Brien. Dr. Lori Rodriguez signed on at the inception of the project as a research assistant and doctoral student. She designed and completed her dissertation on teaching about practice breakdown and errors in undergraduate nursing education. Dr. Rodriguez went on all the site visits and participated in the site visit instrument development. We are also grateful for the contributions of doctoral students Dr. Liana Hain, Dr. Susan McNiesh, and Mary Nottingham. Thank you for your generous contributions to the project!

We simply could not have done this study without the enthusiastic participation of the nine participant schools of nursing, their administrators, faculty, and students, who opened their schools, classrooms, and clinical sites for us to observe and ask questions. We listened and learned from your experiences and observations. Thank you to the Samuel Merritt School of Nursing; Riverside School of Nursing; Roberts Wesleyan School of Nursing; Saddleback Community College, Department of Nursing; University of California San Francisco School of Nursing; University of North Carolina School of Nursing; University of South Dakota School of Nursing; University of Washington School of Nursing; and Villanova University School of Nursing. We appreciate the openness, hospitality, and genuine interest in the study that we encountered at all the schools.

We are also grateful to our nursing organization collaborators and partners whose counsel and support made the project better: the American Association of Colleges of Nursing, American Nurses’ Association, National Council of State Boards of Nursing, National League for Nursing, and National Student Nurses’ Association. In the tradition of the Carnegie Foundation for the Advancement of Teaching, we now give the study to your stewardship, along with students, nurse educators, and all stakeholders in improving nursing education to make the findings accessible and useful within the profession.

Nursing scholars and leaders were frequent and useful advisors on this project. Thank you, Dr. Pat Cross, Carnegie Foundation for the Advancement of Teaching board member and internationally known scholar in higher education, for your careful and most useful early read and critique of the manuscript. We are particularly grateful to Dr. Christine Tanner of Oregon Health Sciences University and Eloise Balasco Cathcart of New York University, who consulted with us all along the way, including reading drafts of this manuscript and making many helpful suggestions. Also many colleagues at AACN and NLN, in particular Dr. Beverly Malone and Dr. Kathy Kauffman, Dr. Pamela Ironside, and Dr. Terry Valiga at NLN; Dr. Polly Bednash, and AACN board members who reviewed the study early and late.

Dr. Ellen Wert, a gifted developmental editor, worked on all the Carnegie Studies of professional education and brought out insights and continuities among the studies at the final writing stages. Thank you, Ellen, for helping us make this research report more accessible and instructive! We had three assistants who helped at one point or another during the project: Megan Mills, Molly Romanow, and Nisha Patel each contributed talent and commitment to the project.

Last but not least, we are grateful to the Atlantic Philanthropies and the Carnegie Foundation for the Advancement of Teaching, who funded this project. The Thelma Shobe Endowed Chair in Nursing and Spirituality at the University of California, San Francisco, contributed to funding our research team and consultants. This study was a focal interest of Thelma Cook, who established and funded the Shobe Endowed Chair. Patricia Benner was the Thelma Shobe Endowed Professor at the time of the study. The Thelma Shobe Chair funded research associates at key points during the study. We are also grateful to the University of California, San Francisco, particularly our dean, Dr. Kathy Dracup, who also supported this project through donating significant portions of the research team’s time, and meeting and workspaces.

Thank you all for your contributions to this work!

Patricia Benner Molly Sutphen Victoria Leonard Lisa Day

THE AUTHORS

Dr. Patricia Benner is a senior scholar with the Carnegie Foundation for the Advancement of Teaching. She is also a professor emerita at the University of California San Francisco School of Nursing. She is a noted nursing educator and author of From Novice to Expert: Excellence and Power in Nursing Practice, which has been translated into eight languages. She is the director of this Carnegie Foundation for the Advancement of Teaching National Nursing Education Study, which is the first such study in forty years. Additionally, she collaborated with the Carnegie Preparation for the Professions studies of clergy, engineering, law, and medicine. Dr. Benner is a fellow of the American Academy of Nursing. She was elected an honorary fellow of the Royal College of Nursing. Her work has influence beyond nursing in the areas of clinical practice and clinical ethics. She has received two honorary doctorates. She is the first author of Expertise in Nursing Practice: Caring, Ethics and Clinical Judgment (2009) with Christine Tanner and Catherine Chesla, and she has coauthored twelve other notable books.

Dr. Molly Sutphen is a research scholar at the Carnegie Foundation for the Advancement of Teaching and co-director of the Carnegie Foundation National Nursing Education Study. She is also an assistant adjunct professor in the Department of Social and Behavioral Sciences at the University of California, San Francisco. She is a historian of public health, medicine, and nursing. She has taught history, ethics, and global health to medical, pharmacy, and nursing students at the University of California, San Francisco. She has published numerous articles on nursing education and the history of public health and is finishing the book An Imperial Hygenist. She received her doctorate from Yale University in the history of medicine and the life sciences.

Victoria Leonard is a family nurse practitioner and child care health consultant at the University of California San Francisco (UCSF) California Childcare Health Program. She is a trainer for Child Care Health Consultants in California and does trainings and presentations, as well as writing educational materials on health and safety issues for child care providers in the state. She has taught health policy and ethics and pediatrics in the nurse practitioner program at UCSF and has worked with children and families with chronic illnesses in pediatric subspecialty clinics. Leonard was a research associate for the Carnegie Foundation National Nursing Education Study and participated in the data collection, analysis, and writing up of the findings. She has also consulted on a longitudinal research study of teen mothers and their infants for the past fifteen years. She received her Ph.D. from the UCSF School of Nursing.

Lisa Day graduated from Long Beach City College in California with an associate degree in nursing in 1984. She has worked as a nurse in a postanesthesia recovery room, a medical cardiac intensive care unit, and a neuroscience critical care unit, and she completed her B.S.N, M.S., and Ph.D. (with Patricia Benner) at the University of California San Francisco School of Nursing. She taught prelicensure nursing in an accelerated second degree program for eight years before recently returning to clinical practice; she is now the clinical nurse specialist for neuroscience and critical care at UCSF Medical Center. Day has been involved as a consultant in several projects related to nursing education, including the RWJ-funded Quality and Safety Education in Nursing (QSEN), the Helene Fuld Health Trust-funded project Evaluating the Outcomes of Accelerated Nursing Education, and evaluation of the Oregon Consortium for Nursing Education (OCNE); and she participated in the 2008 National League for Nursing think tank on Transforming Clinical Nursing Education.

INTRODUCTION

THE PROFESSION OF nursing in the United States is at a significant moment. Profound changes in science, technology, patient activism, the market-driven health care environment, and the nature and settings of nursing practice have all radically transformed nursing practice since the last national nursing education study, almost forty years ago (Lysaught, 1970). The changes in nursing practice, in turn, have enormous implications for nursing education.

Indeed, a list of just a few of the changes in nursing practice suggests many implications for nursing education. Nurses now do most bedside monitoring, make almost all home visits, assist and teach aging patients to manage multiple chronic illnesses, and deliver much of everyday primary care. Nurses maintain patient safety while managing multiple intrusive technologies where the margin of error is extremely narrow, and they do so in increasingly complex, hazardous work environments. Nurses administer care in widely diverse settings, ranging from specialized acute hospital bedside care to in-home and long-term nursing care for the technologically dependent and aging, as well as school and community nursing care. Although charged with caring for patients with increasingly complicated diagnostic and treatment regimes in hospital settings, nurses may also deliver care to patients with similar needs in ambulatory settings, the community, and the home.