My first read of the day... awesome! The Gap between Clinical Practice and Education CNA SEPTEMBER 2013 • FEATURE Nurse educators call for reform to better align the two — to “future proof” nurses and improve health outcomes When Dylan Brown began working as an operating room nurse, he was excited about using the knowledge he’d gained in nursing school. Brown, who graduated from St. Francis Xavier’s school of nursing in 2012, was particularly keen on evidence demonstrating that using forced-air warmers to warm patients in the operating room is the best way to prevent hypothermia, a common problem that can increase surgical site infections. But when Brown, 22, approached his colleagues about using the warmers — a change to their normal preoperative routine — he was instantly rebuffed. “It was frustrating and disenfranchising,” Brown says of trying to introduce an evidence-based change he knew would help patients. “There is more than a little resistance to any small change, particularly one that comes from a student or a very inexperienced nurse.” A hidden curriculum Brown’s experience is an example of what 15 nurse leaders in education, policy and service fields recently identified as barriers that are diluting the ability of undergraduate nursing education to “future proof” nurses by preparing them for the complex demands of the evolving health-care system. In some workplaces, new nurses, eager to put into practice the latest evidence-based research, are quickly deflated when they begin work and discover the workplace culture ignores their desire to transfer knowledge and rejects their attempts at change. “The biggest problem we have in nursing education is the disconnect between practice and education,” says Kathleen MacMillan, director of the Dalhousie University school of nursing and the organizer of a think-tank at the campus last November where the nurse leaders gathered to assess the current state of nursing education. “We should be leading practice change as partners. Instead, nursing is lagging.” By “lagging,” MacMillan means that much of nursing practice follows rigid procedures and has failed to adapt to the latest research that could improve outcomes, including patient safety, at the patient, provider and system level. The disconnect occurs because students are exposed to what has been termed a hidden curriculum during their clinical placements, MacMillan explains. Instead of treating them as partners on a health-care team, those supervising them during placements often silence them when they raise issues or questions about something they have observed in a patient’s care, she says. Students receive an unspoken message: their job is to follow orders and procedure, not try to change the status quo. “That’s a fundamental problem,” says MacMillan. Some educators reinforce that message, she adds, because they are desperate to obtain clinical placements, which they don’t want to jeopardize by questioning care at the institutions where their students are placed. “Together, what we (educators and provider agencies) are doing with these kinds of behaviours is that we’re maintaining the status quo and validating that evidence-based practice is voluntary. There’s no other health-care profession out there that believes that now.” The cultural pressure to simply stick with the tried and true rather than introduce something new is certainly what Brown felt when he tried to shift practice to prevent hypothermia. “Our practices are not consistent with the standards of the American Society of Anesthesiologists,” Brown says. “Pre-warming patients is a current evidence-based recommendation, but I never had a conversation about it with others that lasted more than five seconds. They just said, ‘That’s pretty inconvenient — I don’t think we’re going to do that.’” Widespread change required MacMillan and her colleagues at the think-tank believe Canada needs to undertake a comprehensive, national review of undergraduate nursing education that will better equip nurses like Brown to assume leadership roles in interprofessional teams and support them in providing high-quality patient-centred care. Included in the think-tank report is a recommendation for engaging champions to advocate for innovations in curriculum, new teaching methods and broad partnerships across the health-care professions. MacMillan is particularly critical of how adhering to traditional procedures blocks the spread of the knowledge new nurses like Brown could bring to bedside care. “Our front-line colleagues may not have grown and developed along with the system,” she says. “They are technically highly competent, but they have not yet bought into their role as change agents, patient advocates and leaders in adopting evidence-based practice.” MacMillan believes closer partnerships between practice and education are needed to support nurse educators and nurse managers in advancing practice. Intellectual capital being wasted Another reason for the disconnect is that not enough clinicians are teaching in nursing schools, says Judy Duchscher, an assistant professor at the University of Calgary’s faculty of nursing. She is also the executive director of Nursing the Future, an organization she founded to help bridge the transition from the ideals nurses learn in school to the realities they experience in practice. “We aren’t using enough of these highly competent direct-care practitioners — often just because they may not be academically prepared at the graduate level. I do not believe they have to be master’s prepared to teach students how to apply evidence-informed clinical knowledge. I would like to see these baccalaureate-prepared nurses helping us bridge theory and practice in our classrooms as well as in clinical placements,” she says. Although nurses are educated to read and reflect on the latest research related to patient care, most of them stop reading journals within a year of going into practice because the knowledge is not valued in their workplaces, says MacMillan. “Nursing has still not bought into the fact that you need an educated nurse. They still think you need a trained nurse,” she adds. Essentially, workplaces waste valuable intellectual capital by not utilizing nurses’ capacity to diagnose, to lead and to move practice forward, MacMillan believes. Learning to work in a team Another recommendation in the think-tank report is that nursing schools develop models that educate nurses to practise more effectively within interprofessional teams, whether those are in primary care settings or specialized units. Heather Walker is an obstetrical nurse at a hospital in Yellowknife. Although some nursing schools facilitate opportunities during clinical placements for nursing students to work with students from other health-care professions, Walker did not get that chance at the University of Prince Edward Island’s school of nursing. Ensuring students have those opportunities, she says, would make a difference. “The second we graduate, we’re all working together so closely, and if you don’t know what the person working beside you does and is actually responsible for, it’s tricky,” Walker says. “It can slow things down.” And ideally, she adds, new nurses should spend more time shadowing other members of the health-care teams they will end up working with. “It’s unrealistic to expect them to work well with physicians if they haven’t had much previous contact working with them.” Interprofessional education is still relatively new, and it will require time to assess the most effective models for teaching health-care professionals to work together, says Cynthia Baker, executive director of the Canadian Association of Schools of Nursing (CASN). (The use of high-fidelity simulation shows promise as a way of teaching teamwork among interprofessional groups, Baker notes.) She is concerned about the increasing pressure on schools to secure clinical placements to ensure their students get the practice experience they need. The overall rise in the number of students in all health-care professions has made it difficult for clinical agencies to accommodate them, she says. To specialize or generalize? Another aspect of the discussion about how to educate nurses appropriately concerns whether they should be taught to be generalists or if there is a need for more specialization. Teaching all nurses a foundation of general knowledge is important to ensure workforce flexibility, says MacMillan. But the reality is that many full-time jobs are now in specialty areas, from oncology to critical care to gerontology. At Dalhousie University, students can earn a certificate in oncology nursing in addition to a BScN degree, if they take three identified courses and focus their later clinical placements in oncology. Dalhousie, in collaboration with its clinical partners, is considering expanding this model into other specialty areas, MacMillan says. Duchscher would like to see nursing residency programs instituted: “A residency in the first year of a nurse’s practice would allow clinical institutions to impart knowledge specific to the graduate’s chosen area of practice while gradually increasing the complexity of the care assignments. It simply isn’t best practice to throw a person who has just learned to swim into the deep end of the pool; you have to expect they are going to take in water. And when that person is responsible for the health and quality of life of our society, we have to ask ourselves what we are accomplishing in the end?” Both Brown and Walker say they would welcome a residency year. “Obviously, that would be fantastic,” says Brown. “I would love to do it.” Residencies are an idea the think-tank participants discussed but did not go as far as recommending, citing the challenge of balancing emerging needs for specialty knowledge in mental health and aging, for example, with the generalist knowledge base all nurses require. Sioban Nelson, vice-provost, academic programs at the University of Toronto, agrees a residency year would benefit new grads but she is worried about where the funding would come from and has doubts it would be possible for all graduates. Nelson, who attended the think-tank and served on the National Expert Commission, is the former dean of the Lawrence S. Bloomberg Faculty of Nursing. She believes the discussions about greater disconnect between education and clinical practice miss the point and only lead to increased finger pointing from both sides. “The problem has always been there. We would make better use of our time if we stopped blaming each other and chose to focus on how to align education, service delivery and health outcomes. We need to develop a national framework for nursing education across undergraduate and graduate education that reflects the skill sets new grads require now and in the future and prepares them for roles they may take on to meet the health-care needs of Canadians.” The think-tank report did not conclude with a long menu of recommendations, but CNA and CASN were urged to work together to create an alliance of partners that can drive “solutions, change and action.” An education summit for nurse leaders and educators, organizational representatives and others is planned for later this fall. -------------------------------------------------------------------------------- “A new system needs new service providers” Think-tank participants and presenters were unified in their agreement with the National Expert Commission’s call for education reform: Turning around health and health-care systems the way we envision will require radical change in health-care education. New topics, teaching methods, science and research are all needed to prepare health professionals for a very different health system. Nothing is more fundamental to transforming health care than the way professionals are educated, but curricula are out of date and out of step with the transformations ahead. Because it takes a number of years to graduate nurses, doctors and other professionals, action must begin now, in 2012, so by 2017 we have a workforce in step with our goals and targets for system transformation. It is important for nursing leaders to prepare nurses to meet the demands of a new health system, including roles as navigators, case managers, and coordinators of care to support patient- and family-centred care. – From A Nursing Call to Action, the final report of CNA’s independent National Expert Commission
Posted on: Wed, 11 Sep 2013 12:04:10 +0000