The Carnegie Foundation National Nursing Education Study AACN March 18, 2007

Transcription

1 The Carnegie Foundation National Nursing Education Study AACN March 18, 2007 Patricia Benner, R.N., Ph.D., FAAN Molly Sutphen, Ph.D. Lisa Day, R.N., C.N.S., Ph.D. Victoria Wynn Leonard, R.N., F.N.P., Ph.D. Lori Rodriguez, R.N., M.S., Doctoral Student William Sullivan, Ph. D., Anne Colby, Ph.D. and Carnegie Scholars

2 The Carnegie Foundation for the Advancement of Teaching Preparation for the Professions Program (PPP) A series of comprehensive studies of professional education. An integrated, comparative study of education for professional understanding, integrity, and practice in these five fields (three in Phase I and two more in Phase II). Clergy Engineering Law Medicine Nursing

3 The Carnegie Preparation for the Professions Program Each study involves intensive site visits in a set of professional schools chosen to represent geographic and institutional diversity. In these visits, we interview administrators, faculty, and students conduct focus groups collect course syllabi and other documents observe classes and clinical practica

4 The Carnegie Preparation for the Professions Program National surveys of nurse educators and nursing students in collaboration with: American Association of Colleges of Nursing National League for Nursing National Student Nurses Association

5 To capture the full range of crucial dimensions in professional education, we developed the idea of a three-fold apprenticeship: The First Apprenticeship: Intellectual training that provides: the academic and theoretical knowledge base required for practice in the discipline the capacity to think in ways important to the profession

6 To capture the full range of crucial dimensions in professional education, we developed the idea of a three-fold apprenticeship: The Second Apprenticeship: A skill-based apprenticeship of practice Learning the habits of mind required for competent practice in the profession

7 To capture the full range of crucial dimensions in professional education, we developed the idea of a three-fold apprenticeship: The Third Apprenticeship An apprenticeship to the ethical standards, social roles, and responsibilities of the profession, through which the novice is introduced to the meaning of an integrated practice of all dimensions of the profession, grounded in the profession s fundamental purposes.

8 To capture the full range of crucial dimensions in professional education, we developed the idea of a three-fold apprenticeship: The different kinds of learning suggested by the three apprenticeships often require quite different pedagogies. Students apprentice to the whole experience of professional education, including what is unspoken as well as spoken in the classroom, in settings of professional practice, and in the campus culture.

9 Teaching a Practice Requires Students and Faculty to Engage In: Experiential teaching and learning Situated cognition Thinking-in-Action (The logic of practice) Situated teaching and learning (Readiness) Reflection on particular cases and situations Development of ethical comportment (In dispositions and actions, not just beliefs and decisions)

10 Appraisal of the Three Apprenticeships in Nursing. The Cognitive Apprenticeship. Uneven and often inadequate teaching in the cognitive apprenticeship across types of schools. High variability in cognitive apprenticeship found across types of nursing schools.

11 Cognitive Apprenticeship cont. Almost no interdisciplinary teaching. Evidence-based literature searching and questioning weak. Teaching to the NCLEX Test prevalent renders the test less reliable.

12 Cognitive Apprenticeship cont. Confusion and high variability over what is critical thinking. Teaching as distracting rather than engaging entertainment.

13 Cognitive Apprenticeship cont. Limited integration of the apprenticeships. Proliferation of taxonomies, medical and nursing. Substitute and redundant language. Maxim: Subsuming things under categories is not the same as productive thinking. Logstrup

14 I already have a BS in International Business so I am returning to school for a BSN. Because of that, I am more demanding, perhaps, and I am disappointed in the level of knowledge of the instructors. I would like cutting-edge instructors with extensive current knowledge. Student in Traditional BSN program

15 What Is Missing? Interdisciplinary teaching Searching and evaluating evidence-based literature

16 What Is Missing? Agreement about what constitutes critical thinking Integration of the apprenticeships Proliferation of taxonomies and exhaustive cataloguing Often separation of theory and practice

17 What Is Needed? Add-on solutions will not work What is needed: curricular redesign and reorganization More integration in the classroom and the clinical setting More appropriation and integration of the natural sciences, social sciences, and humanities with nursing science

18 Building on Excellence Integration of the apprenticeships Teaching for a sense of salience

19 What Is Missing: Cognitive Apprenticeship Background natural sciences relevant to nursing practice Chemistry Microbiology Physics Genetics

20 What Is Missing: Cognitive Apprenticeship Chemistry Cellular energy production and use Acid-base balance Electrolytes and solutions Biochemical cascades Coagulation and fibrinolysis Inflammation and immunity

21 What Is Missing: Cognitive Apprenticeship Microbiology Human-pathogen interactions Appropriate use of antibiotics Interpretation of laboratory findings Physics Hemodynamics and cardiac function Respiratory dynamics and gas exchange

22 Genetics What Is Missing: Cognitive Apprenticeship Human genomics Pharmacogenomics

23 Research Question How can nursing faculty in collaboration with clinical nurses and faculty from natural science disciplines design a curriculum in the natural sciences that is relevant to nursing practice? This curriculum must be: Sufficiently in-depth to support current and future practice Different from the route medical schools took after the Flexner report!

24 Proposal Convene a group of master educators in nursing and the natural sciences and expert clinicians to design an experimental natural sciences curriculum appropriate to clinical practice Pilot and evaluate in B.S.N. Programs

25 What Is Missing: Cognitive Apprenticeship Social sciences and humanities relevant to nursing practice

26 What Is Missing: Cognitive Humanities Communication Apprenticeship Writing, speaking, listening Reflective and interpretive skills Grammar and syntax Being able to articulate practical knowledge and experiential learning

27 What Is Missing: Cognitive Apprenticeship Humanities: Understanding and constructing narrative Using the power and logic of narrative understanding In understanding patient-family illness experience In constructing a narrative that makes a case In synthesizing patient and family information from many different sources

28 What Is Missing: Cognitive Apprenticeship Humanities Ethics Ethics of care and responsibility Biomedical and dilemma ethics Ethical theories

29 What s Missing? In social sciences: Relational skills Coping with illness Linking the social and the medical Psychosocial epidemiology related to chronic illness and accidents Relationships between family coping and family health

30 What s Missing Social Sciences? Patient education and counseling skills Communication across cultures and classes Organizational and healthcare services research Healthcare policy Social impact on health (e.g: violence, health disparities, crowding, pollution, migration etc. )

31 Research Question How can nursing faculty in collaboration with clinical nurses and faculty from humanities and the social sciences design a curriculum in the humanities and social sciences that is relevant to and tailored for nursing practice? This curriculum must be: Sufficiently in-depth to support current and future practice

32 Proposal Convene a group of master educators in nursing, humanities, the social sciences, and expert clinicians to design an experimental humanities and social sciences curriculum appropriate to clinical practice in multiple settings Pilot and evaluate in B.S.N. Programs

33 Skill-Based Apprenticeship for Practice Often quite strong situated teaching and learning in clinical practice settings Situated clinical learning especially strong when clinical faculty, rather than staff nurses, coach students in the clinical setting

34 Skill-Based Apprenticeship for Practice Pedagogies of being with and responding to suffering are excellent in the clinical teaching and almost absent in classroom teaching Students describe transformative experiences of learning from patients but faculty do not often attend to or extend this rich source of learning The added value of time for nursing care for the student nurse fosters integration of the apprenticeships

35 Second Apprenticeship: Practical Reasoning and Clinical Skilled Know-How Problem: Limited good clinical placements for student nurses. Heavy reliance on staff nurses for teaching without mentoring the staff nurses in teaching.

36 Clinical Practice and Skilled Know- How Apprenticeship Students have few habits of following through on the outcomes of clinical situations and problems that they encounter with their patients, after their clinical shift. Often students quite imprecise about the medical condition, patho-physiology and therapeutic interventions for the patient.

37 Clinical Practice and Skilled Know- How Apprenticeship Lack of teaching for marshalling evidence and making a clinical case and communicating clinical interpretations and data to other team members.

38 Third Apprenticeship: Ethical Comportment A pervasive concern in classroom and clinical practice. Language of Bioethics not relational and particular enough to capture ethical concerns of nursing students. Students imagine ethics as abstract principles, and often do not recognize when their concerns in practice are ethical concerns.

39 Examples of Student Nurses Ethical Concerns: Meeting the patient as a person. Preserving dignity and personhood of patient. How to respond to sub-standard practice. Patient advocacy. Students and Faculty seriously engaged in learning to do good nursing practice.

40 Dilemma Student overload. Major issue in all nursing education programs.

41 One Student s Perspective The amount of information to be learned is overwhelming, but none of the content is actually difficult. Sometimes it feels as though the tests are deliberately confusing because the material we learn is so simple that if the questions were presented in a straightforward manner everyone would get A's. First problem: standardized tests that don't test my actual knowledge or anything I value.

42 One Student s Perspective Cont. Second problem: an emphasis on skills when these are the easier part of nursing. Bedside manner, social interaction, calming difficult patients, dealing with intense emotion, communication with patients with whom you do not share a common language are all much harder than learning to start an IV, yet the emphasis on skills over theory and thought pretends otherwise.

43 Conclusion The transformation from an outsider s lay perspective to that of member-participant in a practice requires actual experiences that change capacities to act in complex situations, and character-skill formation that enables the nurse to respond and relate to people who are vulnerable and in need. Bourdieu P. (1980/1990) The Logic of Practice (Richard Nice, Trans.), Stanford, CA: Stanford University. Merleau-Panty M. (1968) The Visible and the Invisible, A. Lingis (trans.), Evanston, IL: Northwestern University of Press