Nursing Education in the U.S.:Academic, Orientation, Staff development, & Continuing Education

Martha Highfield, PhD, RN, AOCN

Associate Professor Nursing

California State University, Northridge, USA

Presented at the invitation of the Guangzhou Municipal Health Bureau

Guangzhou, China

August 2001

mefh 8/01 3

•Basic nursing education in the U.S.•Clinical competence & quality care•How additional nursing competence is gained through

•Orientation•Staff development •Continuing education

•Assessing & monitoring the quality of nursing care

Topics of Discussion

4 mefh 8/01

U .S. B ackground: N ursing Education

High Sc hool (Grades 9-12)

BSN and/orGraduate Degree

RN L ic ense Exam

LV N to RN or BSNvariable years

State LV N Exam

L ic ensed V oc ational(LV N) T raining

18 months

1. Hospital-based Diploma OR2. Community College

A ssoc iate Degree3 years

Doc torate in Nurs ing3-6 years

(Researc h Degree)

Masters in Nurs ing1-2 years

RN to BSN2-3 yearsU nivers ity

(Generalis t P rofess ional)

RN L ic ense Exam

Doc torate in Nurs ing3-6 years

(Researc h Degree)

Masters in Nurs ing1-2 years

(Spec ialty P rac tic e, e.g.,M idw ife, NP , CNS)

RN L ic ense Exam

U ndergraduate Generic BSNU nivers ity level

4 years

E lementary (Grades 1-5)J unior H igh Sc hool (Grades 6-8)

mefh 8/01 5

U.S. Nursing Education & Practice Guided by

• Professional Standards: American Nurses Association & other professional nursing organizations

• Law: Nurse Practice Acts

mefh 8/01 6

Professional Standards: Education & Licensure• Knowledge base:

– Human experiences and responses to birth, health, illness, and death. Nurses focus on these phenomena within the context of individuals, families, groups, and communities

– Diagnosis, Interventions, Outcomes

• Scope of Practice: – Basic & Advanced

mefh 8/01 7

Professional Standards: Basic Nursing Practice

• Graduate of approved school of nursing

• Qualified by national exam to be RN

• Baccalaureate degree• Caregivers for

patients, families, groups, & communities

• Interventions based on desired outcomes

• Coordinators of care• Integrate patient

service delivery• Prepare for

tests/procedures• Monitor responses to

interventions

mefh 8/01 8

Law: Education & Licensure

• Establishes education & licensure criteria

– To protect public

– To hold those with licenses accountable for practice

mefh 8/01 9

Law: Education & Licensure• Activities of state Board of Registered

Nursing

– Approves all basic & advanced nursing education programs

– Issues RN license based on passing national exam

– Oversees those with RN license

mefh 8/01 10

Law: Education & Licensure

• Beyond basic education, requires: – Orientation & staff development related to

work setting– Continuing education related to professional

advances

mefh 8/01 11

Law: Program Director Qualifications

• Masters degree or higher

• One year's experience in administration

• Two years' experience teaching nursing

• One year providing direct patient care; or

• Equivalent experience and/or education

mefh 8/01 12

Law: Faculty Qualifications

• INSTRUCTOR Qualifications– Names to Board of Registered Nurses– Valid, active license – Masters degree or higher– One year providing direct patient care – One year's experience teaching courses related

to nursing or a course which includes practice in teaching nursing.

mefh 8/01 13

Law: Faculty Qualifications• ASSISTANT INSTRUCTOR Qualifications

– Baccalaureate including courses in nursing, or in sciences relevant to nursing practice;

– One year's continuous, full-time experience in direct patient care practice as a registered nurse.

• CLINICAL TEACHING ASSISTANT qualifications– One year's experience, within the previous five years,

as a registered nurse providing direct patient care.

mefh 8/01 14

Law: Faculty Clinical Competence

• “ Nursing faculty members whose teaching responsibilities include subject matter directly related to the practice of nursing shall be clinically competent in the areas to which they are assigned.”... ‘Clinically competent’ means that a nursing program faculty member possesses and exercises the degree of learning, skill, care and experience ordinarily possessed and exercised by staff level registered nurses of the clinical unit to which the instructor is assigned; “

mefh 8/01 15

Law: Faculty Responsibilities

• Instruction

• Evaluation of students

• Planning

• Implementing curriculum content.

• Clinical supervision only of enrolled students

mefh 8/01 16

Law: Curriculum

• Minimum 58 semester units (about 2 years)• 36 of units (62% of total) in nursing courses

– 1/2 (18 units) theory– 1/2 ( 18 units) clinical– Theory & clinical taught at the same time for

medical-surgical, maternal/child, mental health, psychiatric nursing, and geriatrics

• 6 units communication• 16 units natural, behavioral, social sciences

mefh 8/01 17

Law: Curriculum must include:

• Personal hygiene• Human sexuality• Client abuse• Cultural diversity• Nutrition (including therapeutic aspects)• Pharmacology• Legal, social and ethical aspects of nursing

• Nursing leadership and management.

mefh 8/01 18

Law: Curriculum must include:

Integrated concepts• Nursing process• Basic nursing skills• Human development • Interdisciplinary skills • Communication • Natural sciences• Related behavioral and social sciences

mefh 8/01 19

Competence is KEY to Quality Practice

• Competence = knowledge & skills to do job

• Basic competence from nursing program

• Job-related competence established during employment & orientation

• Maintained by monitoring performance & ongoing education

mefh 8/01 20

Law: Education After Licensure

• Continuing education within profession

• Orientation to workplace

• Staff development within workplace

mefh 8/01 21

Law: Continuing Education

• Relevant to RN practice & consumer needs

• Content above that required for licensure.

• Course must meet educational standards set by a State Board or Professional Association.

• Required in many states

mefh 8/01 22

Examples of CE Content• Academic courses in nursing

• Other examples Physical sciences Social science Behavioral sciences Professional educational meetings Patient education skills Nursing administration skills

NOT included: basic knowledge like CPR

23 mefh 8/01

Nurs ing Orientation to Hospital

J ob Spec ific Orientationup to 12 months

(tasks & ac tivities in role)P rec eptorship may be inc luded

Nurs ing Orientation1-4 w eeks

(Information that applies to NU RSING employees)

General Hospital Orientation1-2 days

(Information that applies to AL L employees)

Bas ic Educ ation+

RN L ic ense

mefh 8/01 24

Orientation Requirements

• RN must be qualified by experience, education, licensure, and credentials for specific job

• Oriented to job & role

• Assessed as competent

mefh 8/01 25

Orientation Requirements (cont.)

• Cross-training

• Transfer training

mefh 8/01 26

Orientation & Competence

• Establishing new competence beyond basic education through:– Classes & assessment of knowledge– Clinical orientation & assessment of skills

• Validating prior education (knowledge) & experience (skills)

mefh 8/01 27

Orientation for Competence

• Includes information about particular – Healthcare agency – Nursing department– Clinical specialty area– Job role

• It is NOT a repeat of basic nursing education.

mefh 8/01 28

Experts Guide Orientation

• Hospital/Healthcare agency

• Department

• Job-Specific– Classes– Preceptors

mefh 8/01 29

General Hospital Orientation• The Mission, Vision, Values, & Goals of Agency• General Personnel Policies• Overview of Orientation & Competency Assessment• Safety• Sexual Harassment• Equal Employment Opportunity (EEO) process• Customer Service• Patient Rights, Confidentiality, Ethics, etc.• Performance Improvement (QA)

• Basic Infection Control for Non Clinical Staff, etc.

mefh 8/01 30

Nursing Orientation

• Organization of Nursing• Safety & Emergencies: CPR, codes, fire, etc.• Communications & documentation

– Paper & electronic – With other departments & disciplines

• Nursing specific role: provider, educator, administrator, researcher

mefh 8/01 31

Job Specific Orientation• RN Direct care provider

Age specific characteristics & needs Medications Equipment Role in quality of care Admission & discharge Ongoing assessment and documentation Rounds & Shift reports Preceptor Other duties: check crash cart, returning & obtaining equipment

mefh 8/01 32

Job Specific Orientation for Competence

• RN Educator: Role in supporting competence of staff– Collaboration– Curriculum expertise– Orientation responsibilities– Staff development responsibilities– CE responsibilities

mefh 8/01 33

Job Specific Orientation for Competence

• RN Administrator: Leadership role– Managing staff & budget– Monitoring quality of care– Monitoring & maintaining staff competence– Procedure & policy development

mefh 8/01 34

Job Specific Orientation for Competence

• RN Researcher: Advance knowledge – Conduct research – Role in staff education– Collaboration with administration & education– Evaluate programs

mefh 8/01 35

Orientation Outcome: Assessing Competence

• Competence statements – Specific, measurable, objective, behavioral

– Equipment & practice

– Example: “RN will correctly hang & monitor IV fluids”

• Competency checklists– Used to assess & document competence

– Example: “1. Obtains correct equipment. 2. Uses aseptic technique. 3. Checks fluid against MD orders. 4. Explains procedure to patient,” etc….

mefh 8/01 36

Education for Clinical Specialty:Example of Critical Care

• Basic RN education outcomes– Communication skills– Therapeutic intervention skills– Critical thinking skills

• Orientation content (3 parts): General Hospital, Nursing Department, Specific Job Role

mefh 8/01 37

Education for Clinical Specialty:Example of Critical Care Job Role

• Basic critical care specialty knowledge– Validated through BKAT– OR Taught through critical care classes &

validated by examination

THEN• Basic critical care specialty skills are taught

and/or validated through preceptorship using competence checklists

mefh 8/01 38

Competence Statements & Checklists

• Multiple checklists– One for each skill

• Preceptor uses checklists– Giving time for development of each skill– Developing simple skills to complex skills

• Let’s look at example of developing a checklist

mefh 8/01 39

American Association of Critical Care Nurses (AACCN)

Standards of Care for Critical Care Nursing

EXAMPLE

Standard of Care 1: Assessment

• The nurse caring for acute and critically ill patients collects relevant patient health data

mefh 8/01 40

AACN Standard I: Assessment (cont.)• Measurement Criteria

1. Data collection involves the patient, family, and other healthcare providers as appropriate to develop a holistic picture of the patient's needs.

2. The priority of data collection activities is driven by the patient's needs.

3. Pertinent data are collected using appropriate assessment techniques and instruments.

4. Data are documented in a retrievable form.

5. Data collection process is systematic and ongoing.

41 mefh 8/01

Practice Standards: The nurse caring for acuteand critically ill patients collects relevantpatient health dataRating:

1=Below standards2=Meets standards3=Exceed standards

Criteria: Weeks 1 2 31. Collects data frompatient, family, providers2. Priorities are based onpatient needsEtc.

mefh 8/01 42

Example of Checklist Use• “We have developed 2 competency checklists.

One for removing femoral arterial/venous sheaths using manual compression and one for the Femostop. All ICU nurses are required to watch a video on the procedure, observe the skill being performed by a "competent RN", and then performs skill herself supervised by an instructor throughout the procedure. The learner must perform the skill according to the competency standard at least 3 times to perform the skill alone.”

mefh 8/01 43

Education for Clinical Specialty:Example of Oncology Nursing

• Scope of oncology nursing practice includes clinical practice, education, consultation, research, & administration

• Oncology nursing is directed toward care of – individuals, – families, – groups, & communities

with potential or actual diagnoses of cancer

mefh 8/01 44

Oncology Nursing Society (ONS) Standards

• Oncology Nursing Practice

• Advanced Oncology Nursing Practice

• Oncology Nursing Education

mefh 8/01 45

ONS Oncology Nursing Practice StandardsEXAMPLE

Standard 1: Assessment

• The oncology nurse systematically and continually collects data regarding the health status of the client

mefh 8/01 46

ONS Oncology Nursing Practice Standards (cont.)

Measurement Criteria

1. Collects pertinent objective & subjective data in timely, ongoing, systematic, & culturally competent manner

2. Collects data from multiple sources, including patient , family, healthcare team, community using appropriate techniques

mefh 8/01 47

3-5. Collects, communicates to healthcare team, & documents data in the following eleven high-incidence problem areas:

– Prevention & early detection

– Information– Coping– Comfort– Nutrition

– Protective mechanisms

– Mobility– Elimination– Sexuality– Ventilation– Circulation

mefh 8/01 48

Developing Competence Checklistse.g., Prevention & early detection

– Assesses environmental risk factors– Documents environmental risk factors– Communicates environmental risk factors to healthcare

team as needed– Assesses personal risk factors– Documents personal risk factors– Communicates personal risk factors to team prn– Assesses early detection practice, etc.– Assesses cultural & social factors, etc.

49 mefh 8/01

Practice Standards: Collects pertinentobjective & subjective data in timely,ongoing, systematic, & culturally competentmannerRating:

1=Below standards2=Meets standards3=Exceed standards

Criteria: Weeks 1 2 31. Assesses environmentalrisk factors2. Documentsenvironmental risk factorsEtc.

mefh 8/01 50

Future of Nursing Education:10 Trends

1. Changing demographics and increasing diversity

2. Technological explosion

3. Globalization of the World's Economy & Society

mefh 8/01 51

Future of Nursing Education (cont.)

4. The Era of the Educated Consumer, Alternative Therapies and Genomics, and Palliative Care

5. Shift to Population-based care and the increasing complexity of patient care

6. Cost of health Care and Challenge of Managed Care

mefh 8/01 52

Future of Nursing Education (cont.)

7. Impact of Health Policy & Regulation

8. Growing need for interdisciplinary education for collaborative practice

9. Current nursing shortage/opportunities for lifelong learning and workforce development

10. Significant advances in nursing sciences & research