TRENDS
AND ISSUES IN CONTEMPORARY NURSING EDUCATION
The Influence of Contemporary Trends and
Issues on Jsfursing Education
CHAPTER OVERVIEW
Nursing education (and practice) is influenced by
a number of emerging trends in society, some of which are described in this
chapter; others also are important and are discussed elsewhere in this book.
The selected trends are presented with related issues for students and faculty
to provide a broader view of education. The American society is increasingly
diverse; thus each trend precipitates different issues and problems. Trends
result from issues in the past, just as these issues will lead to other trends
in the future; this is the never ending process of change. These trends are
complex and overlapping but are presented here as separate categories to
emphasize their importance; all of them influence nursing education. The
chapter is brief and should be considered as a guide to more in-depth
resources, including the print and Internet website references listed at the
end of the chapter; explore them as much as possible.
The most influential trend is the rapid
development of knowledge and information fueled by expanding communication
technology and the Internet. This in turn precipitates expectations for nearly
instant access and response to almost everything and results in multiple
problems for students and faculty. A related trend is the increasing urgency
for competence, focused on specified outcomes and validated through objective
performance assessment methods. Competency outcomes and performance-based
evaluation now are required and are more stringent to safeguard consumers,
nurses, and employers; therefore they are essential in nursing education. Other
trends focus on ethics and bioethical developments and personal choice.
Expanding scientific research and innovations have led to amazing new treatment
modalities, but also to a multitude of issues. Expectations of personal freedom
of choice raise ethical issues related to abortion, the right to die, and
lifestyle preferences. Several highly interrelated trends include the changing
characteristics of the population and the political and economic influences on
health and health care. Collectively they have influenced the trends of
community- and consumer-oriented health care, interdisciplinary health care,
use of alternative health practices, and increased collaboration among various
agencies and institutions. Two other trends that affect nursing education are
the increasing shortage of qualified nurses, faculty, and students and the
increasing stress related to personal and professional responsibilities.
These trends influence the number and types of
nursing programs for basic and experienced students. Students and the effective
contemporary practitioner need to understand these trends and issues to cope
with them and help change them into more positive trends (ANA, 1999). At the
end of the chapter, interactive learning activities are suggested under each
learning outcome.
TRENDS AND ISSUES IN
CONTEMPORARY NURSING EDUCATION
In many ways nursing education is the same as it
always has been: concerned with preparing nurses with enough knowledge and
skills to meet the health care needs of the community with compassion. How it
does this is shaped by a number of trends and issues in society, which change
continually and with increasing complexity. This chapter presents a concise
review of selected trends and related issues that influence the content,
expected outcomes, learning processes, and assessment methods of nursing
education today. Heller, Oros, and Durney-
These trends and issues illustrate nursing's
complex environment and help to explain how and why nursing education needs to
change and function in contemporary society. The final trend focuses on nursing
education itself and on its continuing and emerging issues. Although listed
separately, the trends actually should be viewed as a constellation of factors
that simultaneously influence nursing education and practice.
Knowledge Expansion and Use of
Technology and the Internet
With the ever-expanding developments in computer
technology, the volume of knowledge is expanding exponentially. From e-mails to
complex research documents and video images, nurses and students, like everyone
else, are communicating more frequently, with more contacts and with the speed
of light. This ability to access and disseminate unlimited information almost
instantly has enormous benefits but also presents major issues.
Computer-accessible knowledge has become the potential content for nursing and
other courses and the standards for practice. Textbooks and journal articles
are considered nearly obsolete by the time they are published, and an expanding
array of websites has become a major learning resource. Websites generally are
more interactive than texts and link to multitudes of other helpful resources (Nicoll, 2000; Skiba, 1997). Even
though updated frequently, they also become outdated quickly. Students easily
can become lost in the interesting web of links while they search for
assignments and communicate with others in class or around the world. Thus it
actually may take more time to find and learn content, although it provides
broader, more specific, and more accurate information.
Herein lies the conflict
and the issues: almost unlimited information is available, but it requires more
time and skill to navigate the web and learn, even though most students seem to
have less time for study (Focus, 1999; Mallow and Gilje,
1999). Learning from the Internet requires disciplined focus and clear
guidelines and expected outcomes related to assignments. It also develops
skills in analytic thinking, decision making, and reflective judgment, all of
which are essential competencies for nursing practice but are not easily
learned. Other issues relate to time management, the integration of all the
information available, keeping up with changes in technology, and meeting the
expectations for immediate responses to an everwidening
web of contacts.
Like students, faculty also
have similar issues related to knowledge and technology expansion, the
scope of information, and the time to use it. They have to make rational
decisions about what and how much students need to learn at a given level, and
they, too, can become entranced by and lost in the learning opportunities available
on the Internet. Teachers also have to learn and keep updated with content and
technology to be able to effectively help students stay ahead of the curve.
Unlike students, faculty also are constantly in the process of making
curriculum and course revisions and modifying teaching and evaluation
methods—all of which are time-consuming and greatly influenced by the knowledge
and technology explosion.
Practice-Based Competency Outcomes
Trends in business and commerce often find their
way into higher education and nursing education. The current emphasis on using
competency outcomes to set directions and goals related to real-world practice
is one of them. To focus on outcomes is to focus on results. In business the
outcome of spending time and resources based on actual needs is what counts in
determining financial success. The same is true for nursing practice and
nursing education. What really matters is that students (nurses) achieve the
competency outcomes that specify the skills actually needed in practice. They
are the measurable results of time and efforts spent in learning. Competence in
realistic practice-based outcomes is the target, the goal to be reached.
However, this outcomes approach is very different
for most teachers and students from the past ways of thinking, teaching
methods, and evaluation. It is not just changing words. For teachers it
requires considerable rethinking and time to revise course syllabi, reassess
and specify the competencies nurses actually need for practice in the changing
and complex contemporary health care environments, and design ways to help
students learn them. For students it means a change from memorizing class notes
and readings to learning to integrate knowledge, make decisions, and be
competent and confident in the abilities contained in course outcomes.
Practice-based competency outcomes specify the destination students need to
reach, the interactive learning strategies are the directions and guidelines
for getting there, and performance-based assessment confirms they have arrived
at the right place. The process is important, but achieving final competency
outcomes is the bottom line. These changes in the entire education process pose
threats and concerns to all the stakeholders that need to be resolved (Bargagliotti, Luttrell, and Lenburg,
1999).
Redefining practice-based competencies is a
complex issue, and, although many educators and organizations are engaged in
this process, no single method has emerged as predominant. Lenburg
(1999a, b) created the Competency Outcomes and
Performance Assessment (COPA) Model as a way to change and reorganize the
curriculum to emphasize competence and assessment. Using this framework, she
developed a master list of eight core practice competency categories under
which all of the skills nurses use in practice can be listed. They include
assessment and intervention, communication, critical thinking, caring
relationships, teaching, management, leadership, and knowledge integration.
Competency outcomes incorporate these practice-based
skills, as well as the course content. Learning strategies and performance
examination are based on outcomes and content. Several articles describe the
model, process, and related issues as used by others (Luttrell et al., 1999;
Redman, Lenburg, and Walker, 1999). Critical thinking
is perhaps the most pivotal competence, as seen in many resources (Critical
thinking, 2000; Rubenfeld and Scheffer,
1995).
Performance-Based Learning and
Assessment Methods
A change in methods used to promote learning and
evaluate competence is another trend closely linked to competency outcomes. In
the era of cost containment, finding the most effective and efficient ways for
students to become competent is paramount. Related issues include:
• Changes in roles of teachers and learners
• Refocusing responsibility and accountability
• Shifting the perception of students from
passive receivers of information to active learners responsible for being
competent in the array of specific practice-based skills
In actual clinical practice, nurses must be
competent in creative and effective problem solving, communication, teaching,
caring, and management. Rather than lectures and multiple-choice tests, these
skills are learned more effectively through activities such as problem-based
learning, case studies, and diverse projects in many community agencies. In
addition to hospitals and extended care agencies, settings include
congregational health, parish nursing, hospice care, homeless clinics, rural
migrant workers, schools, and prisons (Brendtro and Leuning, 2000; Mathews-Smith et al, 2001; Mundt, 1997; Palmer, 2001; Solari-Twadell
and McDermott, 1999).
The concept of evaluation also is changing to
focus on documenting actual competence in the most realistic circumstances.
This requires performance examinations that specify the critical elements, or
behaviors, that must be met according to the standard for practice (Lenburg, 1999b; Luttrell et al.,
1999; Scanlon, Care, and Gessler, 2001; Tracy et al.,
2000). Developing a structured portfolio is another method used to document
competence (Serembus, 2000; Trossman,
1999). The rapid expansion of knowledge and technology and related changes in
competency outcomes in education and practice require major changes in teaching-learning
methods and evaluation of performance.
These trends precipitate issues for students and
teachers. Both need to change ideas about learning. Sometimes students think it
is easier just to figure out "what the teacher wants" and "study
for the test" rather than engage in interactive group projects in and out
of class that require more decision making, group process, and time. It is
easier to take written tests than to demonstrate actual competence through
performance examinations that require 100% accuracy of specified critical
elements. Yet demonstration of competence is what employers expect, consumers
need, and practitioners must do. Memorization is not adequate; abilities to
assess, solve problems, and communicate effectively in diverse circumstances
require far more skill. The increase in reported medical-related errors also
vividly emphasizes the need for more effective performance validation (IOM,
1999; NCSBN, 1997-2001)
Issues for faculty also include creating
interactive learning strategies and making arrangements for them. This means
contracts with many agencies, working with preceptors and community leaders,
and having students in multiple settings simultaneously. Again, the issues are
time, creativity, and a very different way of thinking about learning. It also
means creating more complex performance examinations both in class and in
clinical settings to help students gain confidence and demonstrate achievement
of essential competencies (Fig. 4-1). No easy task, but one required in contemporary
education and practice.
Sociodemographic,
Cultural Diversity, and Economic and Political Changes
From rural to metropolitan areas throughout the
Some of the issues for students are the distinct
differences among patients in their responses to illness, treatments, and
caregivers, which are based on differences in age, culture, re ligion, and life experiences in family and community (Ryan
et al., 2000). Additional factors pertain to the heritage of their geographic
location. For example, issues related to nursing care may differ considerably
among those in areas that are rural or urban, mountains or plains, north,
south, east, or west. Ways of healing and caring may include many alternative,
nonmedical, natural remedies and embrace the benefits of religion, rituals, and
traditions (LaSala et al., 1997; Moylan, 2000). How
the nurse responds to these modalities may make all the difference in the
therapeutic relationship and outcome of care.
Effective and thoughtful nursing care is
individualized according to client characteristics and circumstances, which is
why students need to learn as much as possible from sociology, cultural
diversity, psychology, religion, economics, history, and literature, as well as
basic sciences. Moreover, learning the stories of diverse peoples, their
customs, life experiences, and expectations is interesting and expands human
understanding and creativity for personal and professional life.
Issues for faculty include the need to modify
curriculum and learning experiences to help students prepare for increasing
diversity in the population and healing modalities, in health care costs, and
in the consequences of inadequate insurance or resources to support health.
Teachers need time to learn about and establish trusting and caring
relationships among leaders in various communities and to create new learning
opportunities. Case studies (i.e., projects related to community health and
ethnic and lifestyle diversity) are essential.
Community-Focused Interdisciplinary
Approaches
These societal trends described in the preceding
paragraphs helped create the current focus on community-focused health
with an interdisciplinary emphasis. The large-scale economic and political
influences to reduce health care costs also played a part. For example, the
extraordinary expansion of knowledge and creative treatment technologies made
it common practice for complex surgery to be performed in ambulatory settings
on an outpatient basis or for drugs to be used instead of surgery. In addition,
diverse health-conscious groups slowly made progress to change the national
orientation from "illness care" to promoting health more efficiently
and effectively. Another contributing factor is the increasing emphasis on
health of the family as a whole and on entire communities and populations (Kiehl and Wink, 2000; Lutz, Herrick, and Lehman, 2001). The
concept of community now is perceived as groups of individuals who share
particular characteristics that shape their collective relationships,
regardless of where they are located. Some examples are religious communities,
ethnic communities, and homeless communities. The concept of community agencies
also is redefined; acute hospitals are viewed as one of many community
resources rather than in a totally different category. These changes require a
radically different philosophy of care, one that creates a culture of
interdisciplinary collaboration. This health care culture incorporates concepts
of shared responsibility for health promotion among individuals, family,
community, and multiple care providers. More than ever, family and neighbors
need to become competent caregivers and members of the health care team.
The issues for teachers and students flow from
these changes in philosophy, from "nursing as illness care in
hospitals" to "nursing as health promotion and care management for
individuals in the context of family, and family within the community."
This requires a different perception and integration of core practice
competencies (see
This new reality poses a bipolar dilemma: how to
prepare nurses who will be competent to manage illness and health care to diverse
clients dispersed throughout the community and at the same time able to provide
critical care to patients in hospitals who are sicker and stay for shorter
periods of time. These changes require reorganization of the curriculum so that
multiple aspects of community health and illness care are emphasized in courses
throughout the program rather than in one course in community public health.
Students need very different clinical experiences dispersed throughout the
community and under the supervision of preceptors and nursing staff (Kiehl and Wink, 2000; Bringing healthcare, 1996). Like a
row of dominoes falling, these changes pose yet more issues.
Some issues for students include changing their
image of where they will work, the kinds of patients
they will care for, and the skills they will use. Although many will work in
acute care hospitals, others will provide care in diverse community settings to
those who are culturally diverse or elderly and have multiple chronic and/or
acute conditions that require long-term nursing management. This requires skill
in all core practice competencies, especially creative problem solving,
interdisciplinary collaboration, and ability to use computers and communication
technology effectively and independently (Engelke and
Britton, 2000). The Nightingale Tracker system is an example of such technology
currently being tested by the Fuld Institute for
Technology in Nursing Education (FITNE); access its website and reports through
www.fitne.net.
Other issues include working with preceptors and
staff in multiple locations with less one-on-one instructor interaction. This
requires planning, time, and resources for travel to diverse clinical locations
and out-of-class peer group work and projects. But it provides opportunities
for students to learn collaboration and diverse approaches to care in multiple
settings and to develop confidence and competence. Useful experiences may
include projects in congregational health, parish nursing, rural health care,
and alternative health practices (Brendtro and Leuning, 2000; Palmer, 2001). Service-learning projects
also are relevant parts of community health (Green and Adderley-Kelly,
1999; White and Henry, 1999). Explore websites in Table 4-2.
Consumer-Oriented Society
As consumers have become more knowledgeable about
illness care, health promotion, and the consequences of errors in care, they
also have become more assertive about their rights to competent and prudent
care. The economics and politics of health care and access to comprehensive
information via the Internet have promoted more consumer involvement in setting
health care standards and policies (Lewis, 2000; see Table 4-2 for multiple
websites). Consumers are more active on health-related boards and committees
and consumer advocacy groups. Their involvement has helped bring attention to
needed revisions and also has precipitated some issues that influence nursing
education.
For example, nurses need to change their approach
from "giving care" to the patient, to "working with" the
patient as a member of the health care team. This involves a different emphasis
on interpersonal communication and making decisions for outcomes. A more
informed and engaged patient is better able to make effective decisions, and
thus patient teaching is a core practice competence. Interactive learning and
service-learning projects are valuable ways for students to learn to work with
consumers in planning projects to promote safety and health and community
responsibility for health (Hurst and Osban, 2000;
White and Henry, 1999).
Other issues pertain to the increasing number and
consequences of serious medical errors made by health care professionals. These
errors have led to an increased number of lawsuits with high associated costs,
which further increase the cost of health care and tarnish the belief in the
quality of health care in this country. The
Ethics and Bioethical Concerns
Another trend closely connected to those in the
preceding paragraphs is patients who have different ways of responding to
illness, care providers, and therapies, which raises ethical issues of who is
right and who has the right to prevail. This is particularly relevant regarding
end-oflife issues (Rushton and Sabatier, 2001).
Issues for students include the separation of
professional practice behaviors from personal beliefs and preferences and
acceptance of the concept of "a gray continuum" instead of simplistic
black-and-white interpretations. Diversity of backgrounds also conveys
diversity in interpretation of behaviors, events, and language. Some of the
most controversial issues include the right of individual choice regarding
abortion, organ transplant, preference in sexual partners, and euthanasia or
right to die a dignified death. Other issues may include the use of alternative
remedies that may not be in the mainstream, even among those who engage in
complementary health practices.
Teachers have similar issues related to which content
to include in courses and clinical experiences and how to help students become
more respectful of diversity in life practices. One part of the solution is to
teach ethical concepts and to use case studies, guided learning experiences,
and focused discussions to explore ways of interacting with patients/clients
who present behaviors or responses that are very different from the expected
norm. The need to explore these ethical issues will become even more essential
as the characteristics of the population change further (Riley and Fry, 2000).
Increasing Shortage of Nurses,
Students, and Faculty
A recurring trend over many decades is the
shortage of qualified staff nurses, teachers, and students. In addition to
Chapter
The shortage and aging of nurses have serious
consequences and issues for students, teachers, and the profession. Inadequate clinical staff results in lower quality of care and
fewer preceptors with enough time to work with students. More nurses
work part time and for agencies, which means that some students may be in
clinical settings without adequate supervision or may have fewer opportunities
for specific learning experiences. They also may be exposed to nurses with
inadequate educational background to help them integrate content and practice
and thus precipitate undesirable practices. Therefore students must take more
individual responsibility for competence.
Similarly, staff shortage has consequences for
teachers as they arrange for supervised learning experiences for students in
multiple and diverse clinical settings throughout the community. These conditions
may lead to frustration and disappointments, as well as limited competence in
the very abilities required for contemporary professional practice. These
circumstances present special concerns for students in distance learning and
Internet-based programs who are more dependent on qualified nurses to be
preceptors.
The number of qualified student applicants is
declining, and many of those who enroll are older and/or have prior education
in nursing or in other fields (Frik, Speed, and
Pollock, 1996). They often seek kinds of learning experiences that are
different from those of young students, and they may find course offerings and
experiences frustrating. Nursing programs also are faced with shortage of
qualified teachers because of the declining number of master of science in
nursing and doctoral graduates prepared in education, which in turn, may lead
to higher student-teacher ratios at a time when the complexity of clinical
learning requires even more one-on-one supervision. These issues require multilateral
planning by teachers, students, the profession, and the broader community.
Increasing Professional and Personal
Responsibilities
In the context of all these trends, another one
with multiple related issues has become increasingly evident. Students,
teachers, and nurses confront increasing life responsibilities and associated
stressful demands on time and resources. In summary, they simultaneously must
cope with the explosion of new information and technology; changing health care
systems; more precise expectations for learning outcomes; more interactive and
out-of-class methods of learning; different expectations for competent
performance; shortage of nurse preceptors and teachers; and multiple cultural,
ethical, and legal aspects of an ever-changing society. In addition, most also
have the responsibility of caring for dependent children, as well as aging
parents.
At the same time, the profession requires its
members to keep current and pursue planned professional development.
Complexities in practice increase the need for nurses, teachers, and
administrators to document continuing competence for relicensure
and recertification. Changes in multistate regulations also draw attention to
the need for initial and continuing competence (Gaffney, 1999). In many states
continuing education is mandatory, and state boards of nursing have changed or
are in the process of changing requirements to validate continuing competence
(see websites for NCSBN and specific states, such as
The related issues are almost universal, and
solutions are difficult and multifaceted. The high stress levels associated
with both professional and personal demands have consequences for one's own
health and that of those around them. These issues illustrate how important it
is for all of those involved in the educational process to be more caring,
understanding, respectful, and helpful to each other. Teachers, students,
administrators, staff nurses, employers, family, and friends need to learn anew
the meaning of "caring community" in the context of rapid change.