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Nearpod: Foster a love of learning in every student

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Create active learning experiences students can’t wait to be a part of.

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Research Guides: Evidence Based Practice: 1. Ask: PICO(T) Question

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Use the PICOT format to break down your question into smaller parts and identify keywords: Who are the relevant patients? Think about age, sex, geographic location, or specific characteristics that would be important to your question. What is the management strategy, diagnostic test, or exposure that you are interested in?

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In the Fall of 2019, the American Psychological Association released the 7th edition of its popular citation format, often referred to as " style." This format is commonly used in science and research based courses and is one of the most popular citation styles available on EasyBib.com!

At EasyBib, we are working on making updates to our citation style offerings to make APA 7 available. In the meantime, you're probably wondering what's new in this edition. Read on for details on some of the most important changes made to APA format:
Paper formatting and word choice guideline changes:

The words "Running head" no longer need to be included on the title page. Instead, the title page only requires the page number and the abbreviated version of the paper title at the top.

The new style version endorses the use of the singular "they" as an option for a gender neutral pronoun.

Citation and reference page guideline changes:

The label "DOI:" is no longer required in online resource/website citations, and DOIs can now be represented as URLS (htttps://doi.org)

For an APA in-text citation for a work with three or more authors/contributors, only write the first author's name and then include the abbreviation "et al." for the rest.
Example: (Johnson et al., 2019)

You no longer need to include the location of a source's publisher.
Example: "Atlanta: Random House" would just become "Random House."

The format of an ebook (e.g., Kindle, Nook, etc.) is no longer needed in citations.

For more information of what has been updated in the 7th edition, check out the official announcement from the American Psychological Association .

Find EasyBib resources on more than just APA! Grab a plagiarism and grammar check , read up on what is MLA format , learn about irregular verbs , and more at EasyBib.com .

About the Author

Elise Barbeau is the Citation Specialist at Chegg. She has worked in digital marketing, libraries, and publishing. She graduated from the University of Delaware with a Bachelor's degree in History/Art History, and earned her Master's degree in Public History/Library Science from St. John's University. In her spare time, she enjoys reading, running, and cheering on the Yankees/Islanders/Jets. She lives and works in New York.

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In the Fall of 2019, the American Psychological Association released the 7th edition of its popular citation format, often referred to as " style." This format is commonly used in science and research based courses and is one of the most popular citation styles available on EasyBib.com!

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Darria Long: An ER doctor on triaging your "crazy busy" life

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How do doctors in the emergency room stay calm and focused amidst the chaos? Drawing on years of experience, ER doctor Darria Long shares a straightforward framework to help you take back control and feel less overwhelmed when life starts to get "crazy busy."

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This tutorial is designed for writers who are new to APA Style. It covers the basics of seventh edition APA Style, including paper elements, format, and organization; academic writing style; grammar and usage; bias-free language; mechanics of style; tables and figures; in-text citations, paraphrasing, and quotations; and reference list format and order.

This tutorial was adapted from the tutorial featured in Academic Writer ®, APA's tool for teaching and learning effective writing. Academic Writer is intended for use by undergraduate instructors with their students in courses that require papers to be written in APA Style. For information on or questions about Academic Writer, please contact APA Customer Engagement.

Webinars

Creating References Using Seventh Edition APA Style

The seventh edition of the Publication Manual of the American Psychological Association streamlines and simplifies the process of creating references.

In this webinar, members of the APA Style team provide an in-depth look at the simplified reference system, describing the rationale behind it, how to format references using it, and why references are easier because of it.

The panelists answer one of the most frequent questions: how to cite a work found online. They also use real-life examples to walk through creating references for works with missing information; found via a database; needing DOIs, URLs, and retrieval dates; and more.

Navigating the Transition to Seventh Edition APA Style

The release of the seventh edition of the Publication Manual of the American Psychological Association ushers in a new era of APA Style.

In this webinar, members of the APA Style team discuss the seventh edition of the Publication Manual, highlighting key updates in each of the manual's 12 chapters.

The panelists provide insights into the rationale behind many of the changes and advice for navigating the transition to seventh edition style. They also address how students, faculty, and librarians can incorporate APA Style into the classroom and promote the teaching and mastery of the skills of effective scholarly communication.

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This tutorial is designed for writers who are new to APA Style. It covers the basics of seventh edition APA Style, including paper elements, format, and organization; academic writing style; grammar and usage; bias-free language; mechanics of style; tables and figures; in-text citations, paraphrasing, and quotations; and reference list format and order.

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This page is brought to you by the OWL at Purdue University. When printing this page, you must include the entire legal notice.

Copyright ©1995-2018 by The Writing Lab & The OWL at Purdue and Purdue University. All rights reserved. This material may not be published, reproduced, broadcast, rewritten, or redistributed without permission. Use of this site constitutes acceptance of our terms and conditions of fair use.

These OWL resources will help you learn how to use the American Psychological Association (APA) citation and format style. This section contains resources on in-text citation and the References page, as well as APA sample papers, slide presentations, and the APA classroom poster.

This workshop provides an overview of APA (American Psychological Association) style and where to find help with different APA resources. It provides an annotated list of links to all of our APA materials and an APA overview. It is an excellent place to start to learn about APA format.

APA (American Psychological Association) style is most commonly used to cite sources within the social sciences. This resource, revised according to the 7 th edition of the APA manual, offers examples for the general format of APA research papers, in-text citations, endnotes/footnotes, and the reference page. For more information, please consult the Publication Manual of the American Psychological Association, (7 th ed.).

This poster summarizes APA style in a visual format. For more detailed information, please review the formatting and style guide linked above.

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This page is brought to you by the OWL at Purdue University. When printing this page, you must include the entire legal notice. Copyright ©1995-2018 by The Writing Lab & The OWL at Purdue and Purdue University. All rights reserved. This material may not be published, reproduced, broadcast, rewritten, or redistributed without permission.

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Back to school sale: 20% off all EndNote 21 single-user licenses for a limited time.

EndNote is a reference manager that helps you save time formatting citations, so you can focus on your research.

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With EndNote 21 you stay organized using features like tags that enhance productivity. You can enjoy peace of mind with data restoration functions that protect your work and improve your writing workflow with integrated document creation tools for Google Docs.

EndNote 21 key features

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In EndNote 21, you can restore your library and library structure with our new data restoration function, ensuring your research is not lost. With single reference restoration you can also compare and restore previous versions of individual references.

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Tags are customizable labels that let you organize your references however you'd like. You can add tags to references and customize the color and name of the tags.

You can add multiple tags to a reference and anyone who you share your library with can view a tag, making tags a great way to quickly and intuitively organize your references.

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EndNote is a reference manager that helps you save time formatting citations, so you can focus on your research

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Just need to create a quick bibliography?

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Zotero | Your personal research assistant

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Zotero is a free, easy-to-use tool to help you collect, organize, cite, and share research.

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Want to help bring out the best in people? Let these talks support you in guiding others to succeed.

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Want to help bring out the best in people? Let these talks support you in guiding others to succeed.

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Here are 156 free nursing games with some 6,000 questions designed to make your nurse learning / education more interesting, engaging and fun! In this section we have developed, and are experimenting with, different kinds of educational nursing games. Online games are very popular, so why not apply them to your nursing education?

The Super Nurse and Word Guess games have been developed in HTML5. Therefore, the latest browser versions of Internet Explorer (IE10/11), Firefox, Chrome or Safari need to be used. These games can also be played on most mobile devices.

We have enhanced the games software to produce a Report that you can print out and keep for your records, or to hand in for assignments. For statistical and research purposes, the game results are now being tracked and recorded.

Click on a Title below to open up a specific nursing educational game in a new window. If you find the audio annoying or distracting, click the Mute button on your computer. Enjoy!

1. Nursing Games - Super Nurse Series

1.27 Drug Dosage Calculations I - This game tests your knowledge of the metric system and how to accurately make conversions between the various units. ( 15 items selected from 50 questions).

1.28 Drug Dosage Calculations II - Test and refresh you knowledge and skills about how to calculate the correct tablet medication dosages. ( 15 items selected from 50 questions).

1.29 Drug Dosage Calculations III- This game is designed to assess and review your knowledge and skills in calculating the correct fluid medication dosages. ( 15 items selected from 50 questions).

1.30 Drug Dosage Calculations IV - Test and refresh your knowledge and skills in calculating the correct dosages for medication administration by injection. ( 15 items selected from 50 questions).

1.31 Drug Dosage Calculations V - This game assesses your knowledge and skills in calculating the correct intravenous (IV) dosages, flow rates and administration times. ( 15 items selected from 50 questions).

2. Nursing Games - Word Guess Series

2.45 Pediatric Disorders I - Test your knowledge of the names of disorders related to child development, vision, hearing, blood, respiratory system and nervous system in pediatric patients. (1 5 items drawn from a pool of 45 questions).

These Drag and Drop games were developed using Articulate's StoryLine 3 software. For best viewing of these SL3 games on Apple's iPhone and iPad, download and install the FREE Articulate from the iTunes Store. If you are using an Android tablet or phone, download and install the FREE Articulate Android Player App from Google Play.

3.2 Blood Tests I - See how well you know the indications / applications of 60 blood tests used to diagnose and monitor various body disorders and diseases. ( 15 questions selected from 60).

3.3 Blood Tests II - Test and refresh your knowledge of the indications / applications of another 60 blood tests used to diagnose and monitor various body disorders and diseases. ( 15 questions selected from 60).

3.4 Cancer Symptoms - Try this funky nursing game to see how well you know the signs and symptoms of 12 different types of common cancers. ( 24 questions).

3.5 Diagnostic Tests I - Try this game to see how well you know the indications / applications of 45 electrodiagnostic, endoscopic and nuclear diagnostic technologies, tools and procedures used to identify, monitor and evaluate body disorders and diseases. ( 15 questions from 45).

3.6 Diagnostic Tests II - Another game to see how well you know the indications / applications of 45 manometric, ultrasound and x-ray diagnostic technologies, tools and procedures used to identify, monitor and evaluate body disorders and diseases. ( 15 questions from 45).

3.10 Infectious Diseases - See how well you know the causes (bacteria, virus, fungi, parasites or protozoa) of these infectious diseases. ( 48 questions).

3.18 Oral Dosages - Another game about calculating the correct dosages for medications administered orally using solutions, suspensions, mixtures and syrups. ( 15 questions randomly selected from 35 items).

3.21 Pressure Ulcer Terms II - Another game to review the terminology used in the assessment, prevention and treatment of pressure ulcers / bedsores. ( 20 questions chosen from 70 items).

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Here are 156 free nursing games with some 6,000 questions designed to make your nurse learning / education more interesting, engaging and fun! In this section we have developed, and are experimenting with, different kinds of educational nursing games. Online games are very popular, so why not apply them to your nursing education?

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Create A Virtual Escape Room with Google Forms Tutorial

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The Importance Of Debriefing In Clinical Simulation

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The Importance Of Debriefing In Clinical Simulation

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An expert committee will extend the vision for the nursing profession into 2030 and chart a path for the nursing profession to help our nation create a culture of health, reduce health disparities, and improve the health and well-being of the U.S. population in the 21st century. The committee will consider newly emerging evidence related to the COVID-19 global pandemic and include recommendations regarding the role of nurses in responding to the crisis created by a pandemic.

The committee will examine the lessons learned from the Future of Nursing Campaign for Action as well as the current state of science and technology to inform their assessment of the capacity of the profession to meet the anticipated health and social care demands from 2020 to 2030.

In examining current and future challenges, the committee will take into account the dramatically changed context and the rapidly deployed changes in clinical care, nurse education, nursing leadership, and nursing-community partnerships as a result of the pandemic. The committee will consider:

The role of nurses in improving the health of individuals, families, and communities by addressing social determinants of health and providing effective, efficient, equitable, and accessible care for all across the care continuum, as well as identifying the system facilitators and barriers to achieving this goal.

The current and future deployment of all levels of nurses across the care continuum, including in collaborative practice models, to address the challenges of building a culture of health.

System facilitators and barriers to achieving a workforce that is diverse, including gender, race, and ethnicity, across all levels of nursing education.

The role of the nursing profession in assuring that the voice of individuals, families and communities are incorporated into design and operations of clinical and community health systems.

The training and competency-development needed to prepare nurses, including advanced practice nurses, to work outside of acute care settings and to lead efforts to build a culture of health and health equity, and the extent to which current curriculum meets these needs.

The ability of nurses to serve as change agents in creating systems that bridge the delivery of health care and social needs care in the community.

The research needed to identify or develop effective nursing practices for eliminating gaps and disparities in health care.

The importance of nurse well-being and resilience in ensuring the delivery of high quality care and improving community health.

The role of nurses in response to emergencies that arise due to natural and man-made disasters and the impact on health equity.

In developing its recommendations for the future decade of nursing in the United States, the committee will draw from domestic and global examples of evidence-based models of care that address social determinants of health and help build and sustain a culture of health. Join the conversation using #FutureofNursing2030 on Twitter!

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The Future of Nursing 2020-2030 - National Academy of Medicine

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An expert committee will extend the vision for the nursing profession into 2030 and chart a path for the nursing profession to help our nation create a culture of health, reduce health disparities, and improve the health and well-being of the U.S. population in the 21st century.

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Building a psychologically safe workplace | Amy Edmondson | TEDxHGSE

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Background

As a clinical skills educator I am involved in the delivery of simulation based education for UK trained doctors in their first year post qualifying (Foundation Year 1 [FY1]). I have an interest in the use of feedback and debrief as a tool to improve performance through reflection.

When relating simulation to Kolb's learning cycle it is evident that taking part in the simulated scenario only accounts for the concrete experience component. Debrief and feedback accounts for the reflective observation, abstract conceptualization and active experimentation components of the learning cycle by helping participants make sense of the simulation scenario and reflect on their practice to improve future performance.

Preparation for simulation

A simulation event took place in a hospital skills laboratory set up to resemble a patient bed space. All simulation scenarios involved the management of an acutely unwell patient. Each participant was an FY1 doctor and all participated in a simulation scenario followed by feedback from both faculty and the other participants attending the event.

Four participants attended the event in total. This small group size allowed for debate and discussion as well as helping students to feel relaxed and promoting interaction between the participants. All participants had completed their training in the UK so it was assumed they already had a threshold of knowledge and skills as documented by the General Medical Council (GMC).

Prior to the simulation event individualized scenarios were developed relevant to each participant's current placement as it is important for the simulation to be appropriate for students' needs., It could be argued that by only focusing on what it is felt students "need to know" they are not experiencing a full breadth of learning. However, I consider that the scenarios delivered to the students are common emergency scenarios that could potentially be experienced across all disciplines of medicine.

Learning outcomes that fulfilled the requirements of the GMC, were usedas a basis for developing the simulations. Clear outcomes were set for the event so participants knew what knowledge; skills, attitudes and behaviours needed to be demonstrated., The outcomes included both the technical and non-technical aspects of care delivery. Both of these aspects are imperative in delivering safe patient care ⁻ and are focused on critical thinking and problem solving. Discussing the learning outcomes at the beginning of the event enabled exploration of the importance of non-technical skills. In the future, I plan to ask the students what their objectives for the session are to increase participation, motivation and performance. The HEA recognizes that student centred learning increases student confidence and excitement about the subject.

Delivering the simulation

On the day of the simulation, students were given an overview of each of the faculty members' roles and information regarding the manikin's limitations and equipment being used. Identifying limitations before starting the scenarios improved fidelity as the faculty didn't have to interrupt the scenario to acknowledge constraints.

Providing a pre-brief at the beginning of the session was useful and helped to facilitate reflective practice by preparing students for the discussion at the end of their scenario and making them aware of how they would receive their feedback. It also alerted the students that they were equal partners in the feedback process and triggered internal feedback.,

Each student was allocated a scenario and acted as the team leader whilst faculty acted as other members of the healthcare team. During the scenario the faculty observed the students' so that feedback could be given. However,direct observation does not facilitate in-depth exploration of clinical reasoning or problem-solving abilities. In future sessions a member of the faculty will act as a medical student to question the participant and determine their underpinning knowledge.

Debrief and feedback

After completing the individual scenarios, oral feedback was given to students by the faculty and their peers. Group feedback and peer learning are all effective assessment for learning tools. Individuals can learn a lot through the experience alone but specific feedback will maximise learning.,

Waiting until completion of the scenario before giving feedback allowed the participants to self-reflect and make sense of what had just happened. Facilitators and peers were then able to discuss the strengths and weaknesses of the student's performance without interrupting the scenario and decreasing scenario fidelity and allows participants to discuss the consequences of their actions.

Feedback on the participant's performance is the most important feature of simulation education as it produces long lasting learning and allows the student to develop a deep insight and reflection about their performance as well as slowing the decay in knowledge.

During debrief students discussed any emotions that they had about the simulation scenario as well as reflecting on and exploring their decision making processes. Giving oral feedback to students enabled the faculty to be flexible with their questioning, allowed an immediate response from the student and permitted clarification of any misunderstandings. However, oral feedback does not allow the person giving feedback time to reflect on the student's performance.

A criticism from one of the participants was that they would have liked written feedback for portfolio evidence. One option would be for the faculty to meet after the event, discuss each student's performance and then email individual feedback. However, this option would be time consuming and may not be feasible.

When giving feedback, the first question the student was asked was: "How do you feel that went?" This facilitated self-evaluation which is essential to reducing the emotive impact of feedback. Facilitating self-evaluation will also promote the student to function in a reflective mode in their daily practice. However, we all hold biases in the way we judge our own performance. Self-evaluation relies on the student to be self-aware and effective at critiquing their own performance; a skill not always present. Self-evaluation alone is inadequate for performance improvement, it needs to be facilitated by skilled evaluators who can change their questioning strategy appropriately to ensure student understanding.

Overall participants evaluated the simulation event as a valuable learning experience that gave them a chance to apply their theoretical knowledge to simulated reality and made them aware of the national and local guidance available to them. However, feedback was identified as an area for faculty development. One student asked for "more strict feedback" This feedback itself is somewhat unhelpful due to its vagueness. Another student asked that the "feedback sandwich" be "more strictly enforced". I have never been a devotee to the feedback sandwich as I find it predictable, patronising and a wasted opportunity to discuss the meat of the issue and improve student performance. For feedback to be useful it needs to lead to action which will improve the student's performance.,,, Feedback can only do this if it identifies specific areas for development and supports the learner in identifying strategies to bridge the gap between current and desired performance.,

The simulation event presented valuable learning for the faculty. Most student errors were human factor errors. For example, guidelines were either not used or not followed correctly and communication was often poor leading to delays in patient treatment. In future sessions more emphasis will be put on human factor training and a structured model of debrief will be used.

Conflict of Interest

The author declares that she has no conflict of interest.

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Using debriefing and feedback in simulation to improve participant performance: an educator's perspective

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As a clinical skills educator I am involved in the delivery of simulation based education for UK trained doctors in their first year post qualifying (Foundation Year 1 [FY1]). I have an interest in the use of feedback and debrief as a tool to improve performance through reflection.

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Abstract

Keywords: Clinical conference, clinical education, clinical nursing round, students

Introduction

Recent changes in nursing performances have increased the requirement for nurses with high knowledge, managerial leadership skills, and power for committing to professional roles.[ 1] Therefore, the duty of planners and executors of nursing education for training more sufficient and empowered nurses is heavier than ever. Nursing education should provide appropriate context for the growth of critical thinking in students so that the students would be able to recognize nursing problems and present appropriate solutions for them. Hence, the students would be able to gain many opportunities for advancing and completing nursing skills within the appropriate educational context.[ 2] Creating opportunities require more serious investment in improvement of the clinical education quality. About 50% of nursing education courses are about clinical training.[ 3] Effective clinical training by increasing nursing students' learning, creating an opportunity for merging theoretical knowledge with clinical skills, development of clinical judgment skill, and gaining professional identity should prepare future nurses for having proper professional performance. Clinical environment is a dynamic environment which is filled with complicated variables for nursing students that could affect their learning.[ 4] Furthermore, clinical training is a dynamic process and a set of instructions and activities to facilitate learning in clinical environments which clinical instructors and students are involved in it equally.[ 5] The professor, students, and patients are the main three pillars if clinical training.[ 6] Used methods in clinical training should be in accordance with the goals, educational principles, individual differences in learning, interpersonal interactions, the capacity of the learner, available resources, and teacher's ability for effective and creative use of this method.[ 7] In other words, the training should be in a way to provide appropriate educational conditions and opportunities for entanglement and integration of theoretical and practical knowledge.[ 8] However, the employers mostly believe that nursing students do not have the required competencies for entering the labor market as a graduated nurse.[ 1] Various studies that have been conducted in Iran also have presented many challenges as the insufficiencies of clinical training including inappropriate physical environment, inappropriate mental atmosphere of the training environment, the duration of the training, and the number of the students.[ 9, 10] However, there are few studies conducted about the challenges of the methods of clinical training. Clinical round is one of the mostly used educational methods which would empower clinical reasoning and decision-making in students. Clinical conference, which means sharing experimental data in a group or asking students to represent a subject,[ 11] is one of the frequently used educational methods in clinical training of nursing students. Clinical rounds have been used as an appropriate solution for improving nursing training and performance in many situations.[ 12] The effectiveness of each of these two methods depends on the conformity of its execution stages with defined features of these methods. The present study was conducted to determine the level of conformity to the features of two methods of clinical conference and clinical rounds from nursing students' point of view.

Methods

This study was a descriptive-analytical study which was conducted to determine the level of conformity to the features of two methods of clinical conference and clinical rounds from the viewpoint of nursing students of Isfahan University of Medical Sciences in 2015. Students of the 4 th-6 th semester of nursing bachelor's degree were the study population for this research. Sampling was conducted through census method. The inclusion criteria were willingness to participate in the study, having passed at least two internship credits, and experiencing clinical round/clinical conference at least at one of the two internship credits. The 1 st semester students due to not having internship credits, the 2 nd semester students due to the nature of preliminary internship which is based on training practical skills, and the 7 th and 8 th semester students due to experiencing infield internship were not included in the study.

Data-gathering tool for this research was a researcher-made questionnaire which contained three parts of demographic characteristics (age, grade point average [GPA], semester, gender, marital status, and place of residence), clinical conference characteristics, and clinical round characteristics. The questionnaire for evaluating students' viewpoint of conformity to the characteristics of clinical conference included twenty items including three parts about evaluating students' viewpoints of planning for clinical conference, performing clinical conference, and satisfaction with clinical conference, respectively. The part of clinical round contained 25 items, respectively, about evaluating students' viewpoints of planning for clinical round, performing clinical round, and satisfaction with clinical round. Both parts of clinical conference and clinical round were scored with five-point Likert scale (always, mostly, sometimes, rarely, never).

The range of scoring for clinical conference and clinical round parts was from 0 to 100 that was divided into three equal groups of poor (0-33.3), medium (33.4-66.6), and good (66.7-100).

Content validity of the questionnaire was approved by sending it to ten nursing professors of the nursing and midwifery faculty of Isfahan University of Medical Sciences and modifying the items based on their recommendations. Reliability of the questionnaire was approved through pilot study. Fifteen nursing students completed the questionnaire and its validity was approved with a Cronbach's α of 0.78.

For gathering data, after taking necessary permissions from research council of the nursing and midwifery faculty and coordinating with the head of the education office of the faculty, the researcher coordinated with the professors who had classes with the 4 th-6 th semester nursing students and asked them to give a 15-min break to the students for filling the questionnaire (in the pilot study, the estimated time for filling the questionnaire was 10 min). After entering each class, the researcher explained the aims of the study for the students, and then, after taking verbal consent from the students and explaining the anonymity of the questionnaires and requesting them to answer the questionnaires independently, the questionnaires were distributed among the students. After gathering the data, it was analyzed using SPSS version 18 (IBM Company, Inc., Chicago, IL, USA), descriptive statistics (mean, standard deviation, and frequency distribution) and inferential statistics (independent t-test, ANOVA, Spearman correlation coefficient, and Pearson correlation coefficient).

Results

One hundred and thirty-four students participated in the study and the response rate was 82%. The age of the students was 21.9 ± 2.4 years and their mean of GPA was 15.95 ± 1.48 .

Table 1

Results of independent t-test showed a significant difference between the score of students' viewpoint of conformity to the features of clinical conference (34.89 ± 14.16) and clinical round (37.48 ± 15.97) ( P = 0.006, r = 2.78).

The viewpoints of 61 (45.5%), 71 (53%), and 2 (1.5%) of the students of conformity to the features of clinical conference were, respectively, poor, medium, and good. About conformity to the features of clinical round, 59 (44%), 69 (51.5%), and 6 (4.5%) students, respectively, had a poor, medium, and good viewpoint .

Table 2

The mean score of clinical conference in the field of planning was 34.65 ± 15.12, execution was 34.39 ± 17.21, and satisfaction with the method was 33.61 ± 15.3. For clinical round, the mean score of planning was 44.19 ± 22.22, execution was 37.72 ± 17.38, and satisfaction with the method was 33.19 ± 19.28 .

Table 3

Paired t-test showed a significant difference between the scores of students' viewpoint of clinical conference planning and clinical round planning ( P < 0.001, r = 4.8) and between the scores of execution of clinical conference and clinical round ( P = 0.006, r = 2.77).

Pearson correlation coefficient showed a significant relation between the scores of planning the method and execution of the method ( P < 0.001, r = 0.556), the scores of planning the method and satisfaction with the method ( P < 0.001, r = 0.651), and the scores of execution of the method and satisfaction with the method ( P < 0.001, r = 0.633) for clinical conference.

Pearson correlation coefficient showed a significant relation between the scores of planning the method and execution of the method ( P < 0.001, r = 0.622), the scores of planning the method and satisfaction with the method ( P < 0.001, r = 0.297), and the scores of execution of the method and satisfaction with the method ( P < 0.001, r = 0.295) for clinical round.

Pearson correlation coefficient showed no significant relation between students' age and GPA with their viewpoint of conformity to the features of clinical conference and clinical round ( P ≥ 0.05).

Independent t-test showed no significant difference between the scores of female and male students' viewpoint and also the scores of single and married students' viewpoint of conformity to the features of clinical conference and clinical round ( P = 0.05). However, this test showed a significant relation between students' gender and their viewpoint of conformity to the features of clinical round ( P = 0.04).

Spearman correlation coefficient showed a significant relation between students' semester and their viewpoint of conformity to the features of clinical conference ( P = 0.034, r = 0.18), but the relation between semester and clinical round was not significant ( P = 0.61, r = 0.04). Furthermore, one-way variance analysis revealed a significant relation between students' place of residence and their viewpoint of conformity to the features of clinical conference ( p 0.58) and clinical round ( P = 0.37).

Discussion

This study was conducted to evaluate the conformity to the features of clinical conference and clinical round from nursing students' viewpoint. Results showed weakness in conducting clinical conference and clinical round from students' viewpoint. In this regard, results of a study by Tod et al. which was aimed to find the facilitating factors of clinical evidence-based education showed that although clinical round has been recognized as an effective method for increasing students' empowerment, it is not conducted based on the standards.[ 13] Various reasons could justify this finding. Executing this educational method requires appropriate educational environment including a conference room in the ward or near the ward. Study of Mohebbi et al. (2012) revealed that one of the problems of clinical education was lack of a conference room in the wards (Mohebbi 2012). Abedini et al. (2009) also mentioned various factors such as the large number of students and lack of an appropriate educational environment as the problems of clinical education (Abedini 2009). Lack of experience of some of the clinical instructors could be another effective factor for lack of proper execution of clinical conference and round methods. Results of a study by Masoodi and Alhani (2007) showed that about 70% of the instructors with a working experience of <5 years believed that they did not have the required clinical skills and experiences for educating the students. Karimi et al. (2009) also believed that the most important obstacle for correct execution of clinical educational methods including clinical conference and round was lack of theoretical and practical knowledge of nursing professors in the field of clinical education. These researchers believed that occurrence unexpected events during the execution of clinical educational methods, especially clinical round, was another limiting factor of the mentioned clinical education methods.

Comparing the satisfaction with two methods of clinical conference and clinical round, students were more satisfied with clinical round than clinical conference. According to the results of Delaram, most of the students evaluated the aims and educational programs related to weekly conferences at an inappropriate level.[ 14, 15, 16, 17, 18]

Although results of the present study did not confirm any significant relation between students' semester and their viewpoint of conformity to the features of clinical round, the relation between students' semester and their viewpoint of conformity to the features of clinical conference was significant. In other words, students of higher semesters had more positive evolution of clinical conference. The reason could be due to the fact that students at clinical wards would more experience clinical conference than clinical round, and instructors mostly use the method of conference for clinical education of the students. Therefore, the possibility of mistake and error in clinical conference would be reduced compared to clinical round.

Conclusions

Clinical education is the heart of nursing education, and the most applicable clinical trainings depend on educational methods that could help students in gaining required clinical competencies. Based on the results of the present study about students' viewpoints, clinical training is facing serious challenges in the field of educational methods of clinical conference and clinical round. Since using these methods could be very helpful in clinical training of the students, it is necessary to conduct evaluations for determining the obstacles and providing operational guidelines for more appropriate execution of these methods.

Financial support and sponsorship

The present article was partially derived from a research project (no. 293314), approved by vice-chancellery for research in Isfahan University of Medical Sciences, Isfahan, Iran.

Conflicts of interest

There are no conflicts of interest.

Acknowledgments

The authors would like to thank the research chancellor of Isfahan University of Medical Sciences and the Education Development Office of the nursing and midwifery faculty of this university that made it possible to conduct this research. This article was adapted from the research project no. 293314 which was approved by the research council of Isfahan University of Medical Sciences, Isfahan, Iran.

References

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Nursing students' viewpoints toward two methods of clinical conference and clinical nursing round

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Keywords: Clinical conference, clinical education, clinical nursing round, students Recent changes in nursing performances have increased the requirement for nurses with high knowledge, managerial leadership skills, and power for committing to professional roles.[ 1] Therefore, the duty of planners and executors of nursing education for training more sufficient and empowered nurses is heavier than ever.

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Sharing critical judgments is an essential part of learning in simulation and debriefing. Instructors often avoid giving voice to critical thoughts and feelings because they do not want to appear confrontational and they worry that criticism might lead to hurt feelings or defensiveness on the part of the trainee. Voicing critical judgment poses a dilemma for many instructors: "How can I deliver a critical message and share my expertise while avoiding negative emotions, preserving social 'face' and maintaining my relationship with the trainee?" This paper offers an approach to debriefing that addresses this dilemma.

The existing debriefing literature provides little guidance on how to create an environment in which trainees feel simultaneously challenged and psychologically safe enough to engage in rigorous reflection. By "rigorous reflection," we mean a process that brings to the surface and helps resolve the clinical and behavioral dilemmas and areas of confusion raised by the simulation experience. Drawing on a 35-year research program on improving professional effectiveness in the business world through "reflective practice," this article articulates a model of debriefing for medical simulation exercises. The research program from which we adapted our approach has studied and helped thousands of practicing business executives and managers improve their personal and interpersonal effectiveness through the discipline of reflective practice. "Reflective practice" is a term coined by the late MIT professor Donald Schön to describe the discipline of examining the values, assumptions, and knowledge-base that drives one's own professional practice [see reference 12]. The debriefing model has three primary components: The first component is a conceptual model, drawn from research in cognitive science and on reflective practice, that guides the instructor on how to illuminate the mental models that were salient in guiding trainees' actions during the simulation. The second is an underlying debriefing "stance" that unites the apparently contradictory values of curiosity about and respect for the trainee and the value of clear evaluative judgments about trainee performance. The third component is a way of talking-combining advocacy and inquiry-that embodies the underlying stance.

The basis of this paper is the literature in the field of reflective practice and our experience with exercising the "debriefing with good judgment" approach. The four authors, who use this approach regularly, have together conducted approximately 2,000 debriefings using this method. Over the last 2 years, we have trained nearly 200 medical educators to use this approach. Most medical educators are able to reliably demonstrate competence after approximately 2 days of lecture and practice; expertise appears to require considerably longer to develop. Of the approximately 20 teaching faculty who regularly use simulation as an educational technique at our simulation center, approximately half use the "debriefing with good judgment" approach. The other half has not yet been trained in its use. Faculty who are comfortable with the technique find their skills quite stable and robust in the face of a great variety of trainees.

REFLECTIVE PRACTICE: METHOD AND THEORY

"Reflective practice" is a method used to scrutinize one's own taken-for-granted assumptions and professional work practices. It is often accomplished in a collaborative setting: in our case, the relevant setting is the simulation debriefing wherein we help colleagues and trainees develop crisis resource management, clinical, and reflective practice skills. Researchers at Harvard and the Massachusetts Institute of Technology developed the method as part of their investigation on how to support students in their professional schools and also to help experienced professionals to develop self-correcting versus "self-sealing" practice habits. They found that "reflective practitioners," who learned to scrutinize their taken-for-granted assumptions and mental routines, were able to self-correct and improve their professional skills. On the other hand, those without skill in this self-scrutiny tended to seal out or ignore disconfirming data and maintained ineffective habits of practice. 11,12,14,18,20

The theory underlying reflective practice draws on cognitive science, social psychology, and anthropology. The central idea is that people make sense of external stimuli through internal cognitive "frames," internal images of external reality. Terms for these images are myriad: "frames of reference," "schemata," and "mental models," to name a few. People don't passively perceive an objective reality, but engage in "sense-making" by which they actively filter, create, and apply meaning to their environment. For example, a diagnosis is a frame, as are the assumptions of "It's not a good idea to discuss mistakes here," or "I must have an bag-mask apparatus to ventilate this patient." Figure 1 shows the relationships among frames, actions, and simulation results.

These frames, in turn, shape the actions people take. A trauma physician facing a patient with a ventilation problem will, for example, take one set of actions if she frames the symptoms as a physical obstruction of the airway and another if her diagnosis is reactive airway disease. A nurse who holds the frame that reporting an error will lead to punishment will report errors at a very different rate than one who believes the report will be used to improve work processes. Or, in an example we will use throughout this article, consider an anesthesiologist who is called to manage an unresponsive patient in a setting where a bag-mask apparatus is not readily available. He holds the frame that he can only resuscitate using the device with which he is most familiar, a bag mask, and delays treatment while the patient descends into hypoxemia and arrest. The model suggests that people's actions, including those of this anesthesiologist, are an inevitable result of how they frame the situation they face.

Importantly, even mistakes are usually the result of "intentionally rational" actions. That is, the actions make perfect sense given how the person was framing the situation at that moment. Continuing the example of the anesthesiologist, the instructor may be surprised that instead of considering passive oxygenation or delivering a mouth-to-mask "rescue breath," the anesthesiologist trainee searched relentlessly for a bag-mask apparatus while the patient desaturated. These actions make perfect sense, however, when the instructor understands that the trainee held the belief that basic life support cannot be achieved without a bag-mask device, mouth-to-mask was out of the question, and passive oxygenation is something that he has never learned. It is the instructor's job during a debriefing to help the trainee bring these frames to the surface, analyze their impact on actions, and craft new frames (e.g., "If I don't find a bag-mask apparatus quickly, I have other options for ventilating") and actions (giving mouth-to-mask breaths, or apply oxygen and mechanically optimize the airway opening). In practice, the instructor asks questions during the debriefing to elicit these frames.

"Results" in the reflective practice model are seen, in turn, to be prompted by the actions the trainee takes. Results are states; for example, the patient's cardiac rhythm, whether the trainee ended up knowing the etiology of the clinical problem, or whether there was chaos or order in the clinical environment. The instructor and the trainee usually have an implicit idea of what the desired results were. For example, the patient remains stable and does not go into cardiac arrest, the trainee and others know why the patient arrested in the first place, or the resuscitation ran smoothly. The instructor explores with the trainee what frames and linked actions lead to the actual results and then, as depicted in the feedback arrows in Figure 1, collaborates with the trainee in developing alternative frames and actions for the future.

DEBRIEFING STANCE: MOVING FROM JUDGMENTAL DEBRIEFING TO DEBRIEFING WITH GOOD JUDGMENT

Although it may be obvious how discovering trainees' frames can enhance debriefing in medical simulation, the importance of identifying and revealing the instructor's frames is less obvious. Instructors' learning to identify and examine their own frames related to the simulation they observed is crucial to the process of a rigorous debriefing that is both nonthreatening and direct. Without an understanding of their own frames, instructors are handicapped in their ability to help illuminate a trainee's frames. The reasons for this are twofold. First, the instructors have to pull from experience about the frames and actions they themselves might have employed in a similar situation and be able to disclose these to the participant. Second, instructors have to be willing to test the validity of their own frames about the trainee's performance with trainees. To explain how this works, we start by describing and contrasting instructors' underlying frames when they are using judgmental, nonjudgmental and debriefing with good judgment approaches ( Table 1).

THE JUDGMENTAL APPROACH TO DEBRIEFING

Imagine or recall the instructor whose voice, dripping with disdain, inquires of a group of students, "Can anyone tell me what went wrong here?" or "Can anyone tell me Pat's big mistake?" The judgmental approach, whether laced with harsh criticism or more gently applied, places truth solely in the possession of the instructor, error in the hands of the trainee, and presumes that there is an essential failure in the thinking or actions of the trainee. In the last 15 years, the discourse in medical journals suggests that many clinicians concerned about reducing medical error and improving patient safety have sought to move healthcare away from the "shame-and-blame" approach captured in this style of questioning. A judgmental approach to debriefing, especially one that includes harsh criticism, can have serious costs: humiliation, dampened motivation, reluctance to raise questions about later areas of confusion, or exit of talented trainees from the specialty or clinical practice altogether. But the shame-and-blame approach has an important virtue: the trainee is rarely left in doubt about what the instructor feels are the salient issues.

THE "NONJUDGMENTAL" APPROACH TO DEBRIEFING

The central dilemma facing instructors who want to move away from this judgmental approach is how to deliver a critical message while avoiding negative emotions and defensiveness, preserving social "face," and maintaining trust and psychological safety. Psychological safety is a person's sense that the immediate environment is safe for interpersonal risk taking; that trying out new ways of talking or acting will not be ridiculed; that mistakes will be worked on together as a source of learning instead of being treated as a crime to be punished or covered up. 10,23 Instructors using a "nonjudgmental approach" often resolve the dilemma by employing protective social strategies such as sugar-coating errors; the "sandwich" approach in which a compliment is followed by a criticism, which is, in turn, followed by another compliment; filtering out too-critical insights; or by avoiding the problem topic altogether.

Many instructors (ourselves included) have used a Socratic approach in which we ask leading questions and use a kind tone-of-voice to lead the trainee to the critical insight we hold but are reluctant to state explicitly, a process Argyris has termed "easing in." To our surprise and dismay, we have found that when the instructor holds a critical judgment, open-ended or Socratic questions that camouflage the judgment may backfire when the trainee becomes confused about the nature of the question or suspicious about the instructor's unexplained motives.

Although the nonjudgmental approach has the advantage of being nonblaming, and therefore avoids some of the hurt and humiliation generated by the judgmental approach, it has serious weaknesses. In spite of a desire to appear nonjudgmental, hints of one's views often "leak" via subtle cues such as facial expression, tenor, cadence, and body language. Furthermore and most importantly, it is not nonjudgmental. Although the surface tone of nonjudgmental debriefing may be softer than the judgmental approach, as we illustrate in Table 1, the underlying assumptions are the same: I'm right; I have the complete picture; my job is to hand-off the correct knowledge or behavior to you, the trainee. Whereas the judgmental approach often humiliates directly, the nonjudgmental approach conveys nonverbally that mistakes are not discussible, or possibly shameful, undermining the very values-mistakes are puzzles to be learned from rather than crimes to be covered up-instructors aim to endorse with the nonjudgmental approach.

DEBRIEFING WITH GOOD JUDGMENT APPROACH

We offer a brief rationale of why we arrived at this framework. When our center started 12 years ago we relied on a nonjudgmental approach. To maintain a positive relationship with trainees, we thought it necessary to withhold judgment and use open-ended and leading questions in the hopes that the participants would arrive at the conclusions we were reluctant to say. We began to become uncomfortable with the approach when we realized that we weren't "walking our talk." That is, we were saying that mistakes were discussable and a source of learning, yet we found that we tended to cover them up or shy away from discussing them. This conflicted with our commitment and stated mission to make errors discussable and enhance patient safety. We thought to ourselves, "If we can't discuss errors here in a simulation center, how can we expect others in the medical world to do it?" We felt that if we were going to advocate for patient safety, then we had to find a way to openly discuss errors-and by the same token, we had to find a way to respectfully insert our clinical and behavioral expertise into our debriefings. We migrated to a position of "debriefing with good judgment," which allowed us, it seemed, the best of all worlds: it fit with educational theory; it allowed our participants to make mistakes and feel that they were still worthwhile and intelligent; it allowed us to use our clinical and behavioral expertise; and it fostered deep learning among both our participants and instructors.

The "debriefing with good judgment" approach shifts the focus of debriefing in several ways. First, it focuses on creating a context for adult learners (including the instructor) to learn important lessons that will help them move toward key objectives, determined either unilaterally by the instructor or collaboratively with the trainee. Second, the focus widens to include not only the trainees' actions, but also the meaning-making systems of the trainees such as their frames, assumptions, and knowledge. Third, the instructor's sense-making system about the simulation also becomes part of the debriefing terrain ( Table 1). The instructor has one view of the situation-and it may be an expert view-that is shared as a way to initiate dialogue with the trainee. Instructors' stating their main concerns in a debriefing is especially important in the domain of healthcare simulation where being indirect about crucial errors can perpetuate medical mistakes and undermine patient safety when the trainee returns to the real clinical environment. In this approach, in contrast to the nonjudgmental approach, the instructor shares critical or appreciative insights about the simulation explicitly. Then these insights are tested and explored with trainees step-by-step as illustrated in the next section and in Table 2.

This "good judgment" approach is one that values the expert opinion of the instructors, while at the same time valuing the unique perspective of the trainees. The idea is to learn what participant frames drive their behaviors so that both their "failures" and successes can be understood as an ingenious, inevitable and logical solution to the problem as perceived within their frames.

Cases where the instructor has significant concerns about the trainee's clinical judgment or motives-concerns that might merit remedial training, counseling, or discipline-are best treated in a follow up. That is, if the instructor needs to convey that certain clinical approaches or social behaviors will not be tolerated in the program, that important message is a good topic for a postdebriefing conversation.

"TRANSPARENT" TALK IN DEBRIEFING: ENACTING THE GOOD JUDGMENT APPROACH WITH ADVOCACY-INQUIRY

The "debriefing with good judgment" frames outlined in Table 1 are enacted via the style of speaking used by the instructor. Like all frames, mental models, or schemata, the values underlying the "good judgment" approach are invisible; the only way to see them is when they are transformed into actions-and speaking is a powerful action for instructors. One particularly effective style of debriefing speech is to pair advocacy with inquiry. An advocacy is an assertion, observation, or statement, whereas an inquiry is a question. When pairing the two together, the instructor acts as a conversational scientist, stating in the advocacy his or her hypothesis, and then testing the hypothesis with an inquiry. For example, an instructor might say, "So, Damon, I noticed that you stepped away from the patient to find the bag-mask apparatus as the vital signs were deteriorating. I was thinking there possibly were alternative means to oxygenate the patient (advocacy). So I'm curious: how were you seeing the situation at that time? (inquiry)" Here, the instructor is using advocacy plus inquiry to elicit the invisible frames that guided the trainee's actions. This is the generic approach that instructors can use in any scenario: notice a relevant result, observe what actions led to the result, and then use advocacy-inquiry to discover the frames that produced the results.

Compare this utterance with a judgmental version ("Damon, I can't believe it took you 90 seconds to notice that he was desaturating!") or a nonjudgmental ("Guess what I'm thinking") version: "So, Damon, what was this patient's saturation when you went to look for the bag-mask apparatus?" The judgmental version, although getting the instructor's point across, precludes the instructor learning what frames or assumptions set Damon on a particular path of action; it also may humiliate Damon. The nonjudgmental version leaves Damon uncertain about what the instructor is thinking or why he's is being asked this question; the result will likely be confusion and/or defensiveness. He may correctly detect that the instructor already knows the answer to the question and has a judgment that is lurking in the background. The advocacy-inquiry utterance clearly and directly stated the instructor's perspective and concerns, and set out to understand the meaning-making process that had Damon focused on finding missing equipment.

The advocacy-inquiry version also helps surface Damon's frames. For example, consider the debriefing between Damon and his instructor illustrated in Table 2. This example, taken from one of our actual debriefings, shows how advocacy-inquiry can be used in a simulation debriefing. When said with a true sense of curiosity, paired advocacy and inquiry not only helps trainees like Damon learn from simulations by digging deeper into the frames that drive their actions, but it also helps the instructor learn about the trainees' thought process and provides a lever for deeper teaching. To be clear, this technique isn't about "talking nicely." On the contrary, it places the instructors' thoughts, judgments, and feelings front-and-center. The difference is that by treating the instructor's views as also requiring public testing, the instructor increases mutuality by making himself or herself "vulnerable" to learning and opens their own views to challenge. Additionally, by pairing this advocacy with true inquiry, the instructor increases mutuality by respecting the trainee enough to value the trainee's perspective, and this, in turn, improves learning.

Table 3 provides an example of how to apply the debriefing with good judgment approach. The table shows how the frames-actions-results conceptual model, the instructor's judgments, and advocacy-inquiry fit together to discover the frames that led to a respiratory arrest and chaos in scenario requiring a cardiac resuscitation.

CONCLUSION

The "debriefing with good judgment" approach is designed to increase the chances that the trainee will be able to hear and process what the instructor is saying without being defensive or trying to guess what the instructor's critical judgment is. The "debriefing with good judgment" appellation is not meant to imply that the judgmental or nonjudgmental approach do not have good judgment as their basis. We believe that all three approaches often start with some important evaluative insight held by the instructor. We chose the salutary name, "debriefing with good judgment," to highlight the positive attributes of the approach. These are providing trainees with a clear signal about the instructor's point of view while reducing the potential "noise"-misunderstandings or defensiveness- that too often are associated with the judgmental and nonjudgmental approaches. The judgmental approach poses a substantial risk of embarrassing or humiliating the student and the nonjudgmental approach may send confusing and mixed messages to the learner. Both approaches can obfuscate or reduce the clarity of the instructor's message and the trainee's frames.

The debriefing with good judgment approach has two constraints of which we are aware. The most important is that the model presumes that the trainee is operating with good will and is trying to do the right thing. In those rare cases where the trainee is willfully negligent or malevolent, the model is unlikely to work. In those circumstances, other techniques are superior, such as counseling, goal setting, and discipline. Second, instructors may find difficulty with this approach when dealing with trainees who come from cultures in which deferring to authority and elders is of paramount importance and inhibits their disclosing views that may appear to contradict those of the instructor. To support the method in this context, explicit preparation regarding the goals and norms of the simulation environment is required-and sometimes that is not enough.

We conclude with the following insights. In debriefing the heat and drama of a high-fidelity clinical simulation, it is easy to focus primarily on trainees' actions. The debriefing with good judgment approach, however, highlights three additional areas of importance. First, it is vital that instructors ask questions that, like an anthropologist, help bring to the surface and clarify the invisible sense-making process, the cognitive frames and the emotions that governed the trainee's actions. Second, instructors work to become aware of, and explicitly narrate their own invisible judgments and concerns about crucial elements of the scenario. But instead of treating their own judgments or concerns as the single "truth," they test their views against the trainees' view of the same issue. This does not mean that instructors relinquish their expertise, or "sugar-coat" their judgments; rather, they state their view of the situation and use that as a springboard to legitimize and explore the trainees' view. The reward of this approach is that by understanding how trainee frames, assumptions, and beliefs drive the actions they take, the instructors can match their teaching objectives with problems that are deeply meaningful to the trainee. Finally, the debriefing with good judgment approach helps trainees and instructors learn of unintended consequences of common clinical and social frames and assumptions.

ACKNOWLEDGMENTS

We also wish to express our thanks to the participants in the Institute for Medical Simulation instructor workshops for giving us a forum and their patience to try out and refine these concepts. Peter Rivard's insights helped clarify a number of key points presented in this paper. Two anonymous reviewers provided extremely helpful feedback that improved the paper.

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There's No Such Thing as "Nonjudgmental" Debriefing: A... : Simulation in Healthcare

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he approach "debriefing with good judgment." The approach draws on theory and empirical findings from a 35-year research program in the behavioral sciences on how to improve professional effectiveness through "reflective practice." This approach specifies a rigorous self-reflection process that helps trainees recognize and resolve pressing clinical and behavioral dilemmas raised by the simulation and the judgment of the instructor.

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vSim for Nursing Fundamentals Online, Virtual Simulation

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Writing Good Multiple Choice Test Questions 

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Writing Good Multiple Choice Test Questions 

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Cite this guide: Brame, C. (2013) Writing good multiple choice test questions. Retrieved [todaysdate] from https://cft.vanderbilt.edu/guides-sub-pages/writing-good-multiple-choice-test-questions/.

Multiple choice test questions, also known as items, can be an effective and efficient way to assess learning outcomes. Multiple choice test items have several potential advantages:

Versatility: Multiple choice test items can be written to assess various levels of learning outcomes, from basic recall to application, analysis, and evaluation. Because students are choosing from a set of potential answers, however, there are obvious limits on what can be tested with multiple choice items. For example, they are not an effective way to test students' ability to organize thoughts or articulate explanations or creative ideas.

Reliability: Reliability is defined as the degree to which a test consistently measures a learning outcome. Multiple choice test items are less susceptible to guessing than true/false questions, making them a more reliable means of assessment. The reliability is enhanced when the number of MC items focused on a single learning objective is increased. In addition, the objective scoring associated with multiple choice test items frees them from problems with scorer inconsistency that can plague scoring of essay questions.

Validity: Validity is the degree to which a test measures the learning outcomes it purports to measure. Because students can typically answer a multiple choice item much more quickly than an essay question, tests based on multiple choice items can typically focus on a relatively broad representation of course material, thus increasing the validity of the assessment.

The key to taking advantage of these strengths, however, is construction of good multiple choice items.

A multiple choice item consists of a problem, known as the stem, and a list of suggested solutions, known as alternatives. The alternatives consist of one correct or best alternative, which is the answer, and incorrect or inferior alternatives, known as distractors.

Constructing an Effective Stem

1. The stem should be meaningful by itself and should present a definite problem. A stem that presents a definite problem allows a focus on the learning outcome. A stem that does not present a clear problem, however, may test students' ability to draw inferences from vague descriptions rather serving as a more direct test of students' achievement of the learning outcome.

2. The stem should not contain irrelevant material, which can decrease the reliability and the validity of the test scores (Haldyna and Downing 1989).

3. The stem should be negatively stated only when significant learning outcomes require it. Students often have difficulty understanding items with negative phrasing (Rodriguez 1997). If a significant learning outcome requires negative phrasing, such as identification of dangerous laboratory or clinical practices, the negative element should be emphasized with italics or capitalization.

4. The stem should be a question or a partial sentence. A question stem is preferable because it allows the student to focus on answering the question rather than holding the partial sentence in working memory and sequentially completing it with each alternative (Statman 1988). The cognitive load is increased when the stem is constructed with an initial or interior blank, so this construction should be avoided.

Constructing Effective Alternatives

1. All alternatives should be plausible. The function of the incorrect alternatives is to serve as distractors,which should be selected by students who did not achieve the learning outcome but ignored by students who did achieve the learning outcome. Alternatives that are implausible don't serve as functional distractors and thus should not be used. Common student errors provide the best source of distractors.

2. Alternatives should be stated clearly and concisely. Items that are excessively wordy assess students' reading ability rather than their attainment of the learning objective

3. Alternatives should be mutually exclusive. Alternatives with overlapping content may be considered "trick" items by test-takers, excessive use of which can erode trust and respect for the testing process.

4. Alternatives should be homogenous in content. Alternatives that are heterogeneous in content can provide cues to student about the correct answer.

5. Alternatives should be free from clues about which response is correct. Sophisticated test-takers are alert to inadvertent clues to the correct answer, such differences in grammar, length, formatting, and language choice in the alternatives. It's therefore important that alternatives

have grammar consistent with the stem.

are parallel in form.

are similar in length.

use similar language (e.g., all unlike textbook language or all like textbook language).

6. The alternatives "all of the above" and "none of the above" should not be used. When "all of the above" is used as an answer, test-takers who can identify more than one alternative as correct can select the correct answer even if unsure about other alternative(s). When "none of the above" is used as an alternative, test-takers who can eliminate a single option can thereby eliminate a second option. In either case, students can use partial knowledge to arrive at a correct answer.

7. The alternatives should be presented in a logical order (e.g., alphabetical or numerical) to avoid a bias toward certain positions.

8. The number of alternatives can vary among items as long as all alternatives are plausible. Plausible alternatives serve as functional distractors, which are those chosen by students that have not achieved the objective but ignored by students that have achieved the objective. There is little difference in difficulty, discrimination, and test score reliability among items containing two, three, and four distractors.

Additional Guidelines

1. Avoid complex multiple choice items , in which some or all of the alternatives consist of different combinations of options. As with "all of the above" answers, a sophisticated test-taker can use partial knowledge to achieve a correct answer.

2. Keep the specific content of items independent of one another. Savvy test-takers can use information in one question to answer another question, reducing the validity of the test.

Considerations for Writing Multiple Choice Items that Test Higher-order Thinking

When writing multiple choice items to test higher-order thinking, design questions that focus on higher levels of cognition as defined by Bloom's taxonomy. A stem that presents a problem that requires application of course principles, analysis of a problem, or evaluation of alternatives is focused on higher-order thinking and thus tests students' ability to do such thinking. In constructing multiple choice items to test higher order thinking, it can also be helpful to design problems that require multilogical thinking, where multilogical thinking is defined as "thinking that requires knowledge of more than one fact to logically and systematically apply concepts to a ...problem" (Morrison and Free, 2001, page 20). Finally, designing alternatives that require a high level of discrimination can also contribute to multiple choice items that test higher-order thinking.

Additional Resources

Burton, Steven J., Sudweeks, Richard R., Merrill, Paul F., and Wood, Bud. How to Prepare Better Multiple Choice Test Items: Guidelines for University Faculty, 1991.

Cheung, Derek and Bucat, Robert. How can we construct good multiple-choice items? Presented at the Science and Technology Education Conference, Hong Kong, June 20-21, 2002.

Haladyna, Thomas M. Developing and validating multiple-choice test items, 2nd edition. Lawrence Erlbaum Associates, 1999.

Haladyna, Thomas M. and Downing, S. M.. Validity of a taxonomy of multiple-choice item-writing rules. Applied Measurement in Education, 2(1), 51-78, 1989.

Morrison, Susan and Free, Kathleen. Writing multiple-choice test items that promote and measure critical thinking. Journal of Nursing Education 40: 17-24, 2001.

This teaching guide is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

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Writing Good Multiple Choice Test Questions

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by Cynthia J. Brame Print Version Cite this guide: Brame, C. (2013) Writing good multiple choice test questions. Retrieved [todaysdate] from https://cft.vanderbilt.edu/guides-sub-pages/writing-good-multiple-choice-test-questions/. Constructing an Effective Stem Constructing Effective Alternatives Additional Guidelines for Multiple Choice Questions Considerations for Writing Multiple Choice Items that Test Higher-order Thinking Additional Resources Multiple choice test questions, also known as items,...

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Creating A Group Presentation In Voice Thread

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Creating a Group Presentation in VoiceThread

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Based on the CNE ® examination blueprint, Certified Nurse Educator Review Book: The Official NLN Guide to the CNE® Exam, Second Edition delivers a comprehensive review to prepare you to take the Certified Nurse Educator examination. Each chapter provides an overview of the content included on the exam blueprint and practice test items, complete with rationales for correct and incorrect answers, reflecting the types of items you will encounter on the exam.

This revised edition streamlines and enhances your exam preparation with updated content, additional bulleted lists and tables, additional practice questions, and example scenarios that demonstrate the practical application of chapter concepts.
"This CNE® review book provides real-world examples of important concepts relevant to each of the competencies of the nurse educator role. As a quick review or a means to identify areas for more in-depth study, this official NLN guide is an invaluable resource to faculty seeking CNE® certification."
Lynne P. Lewallen, PhD, RN, CNE, ANEF
Associate Dean for Academic Affairs
Professor, UNC-Greensboro School of Nursing
Greensboro, North Carolina

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Based on the CNE® examination blueprint, Certified Nurse Educator Review Book: The Official NLN Guide to the CNE® Exam, Second Edition delivers a comprehensive review to prepare you to take the Certified Nurse Educator examination.

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Preparing for the Certified Nurse EducatorCM Examination

Before you begin to study for the Certified Nurse Educator examination, please make sure that you meet the eligibility requirements. The Certified Nurse Educator examination is designed to assess the knowledge one has acquired as a result of engaging in the full scope of the faculty role. To that end, it is recommended that in preparing for this examination, you begin by reviewing the following:

1. The detailed test blueprint (PDF) to identify the content areas that will be on the exam and to determine which areas you should focus your study.

2. The test blueprint (PDF) to understand how each content area is weighted, and to review the percentage of questions that pertain to each area.

3. The recommended reference list (PDF), which provides references specific to each of the content areas. The recommended reference list is provided to serve as a guide and is not intended to be all-inclusive.

4. Sample questions, which can be found on pages 12-13 of the Candidate Handbook. These sample questions are similar to those found on the examination, but do not represent the full range of content or levels of difficulty.

In addition, we have the following resources available for purchase:

1. The Scope of Practice for Academic Nurse Educators developed in 2005 by the National League for Nursing's Certification Governance Committee, and revised in 2012. This document describes academic nursing education as a specialty area and an advanced nursing practice role within professional nursing. The description includes: definition, historical perspective, values and beliefs, theoretical framework, scope of practice, and competencies or standards of practice. To order your copy of The Scope of Practice for Academic Nurse Educators, visit NLN Bookstore.

2. A Self-Assessment Examination (SAE) is an internet-based, 65-item, multiple- choice practice examination and can be considered a learning tool and assessment instrument that is parallel in form to the actual CNE® examination. The CNE SAE is a half-length examination that will meet the examination specifications including content outline coverage, percentage of items in each of the content categories and the cognitive complexity item distribution. By taking the SAE, candidates will be able to practice taking CNE-type questions, experience computer based testing, review rationales for correct and incorrect answers and receive a score report to assess strengths and areas for additional study. Note: those who purchase the SAE will be provided online access to this product for 60 days from the date of purchase. Additional Information "

Please make certain that you carefully review the Candidate Handbook for complete information about the Certified Nurse Educator examination.

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Before you begin to study for the Certified Nurse Educator examination, please make sure that you meet the eligibility requirements. The Certified Nurse Educator examination is designed to assess the knowledge one has acquired as a result of engaging in the full scope of the faculty role.

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The Academic Clinical Nurse Educator Certification Exam was created for academic clinical nurse educators to demonstrate expertise in this role. The academic clinical nurse educator facilitates the learning of nursing students throughout clinical components of an academic nursing program. This educator is guided in this role by faculty of the nursing program and is accountable to that nursing program for providing fair evaluations of learners' performance in meeting expected learning outcomes. The academic clinical nurse educator may have a variety of titles depending on the classification used by the specific nursing education program (e.g., clinical faculty, part-time faulty, adjunct faculty, clinical instructor, or preceptor).

The certification test plan for this role is based on the identified competencies of the Academic Clinical Nurse Educator and can be found within the Academic Clinical Nurse Educator Candidate Handbook.

Exam Registration is NOW OPEN "

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The Academic Clinical Nurse Educator Certification Exam was created for academic clinical nurse educators to demonstrate expertise in this role. The academic clinical nurse educator facilitates the learning of nursing students throughout clinical components of an academic nursing program.

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Self-Assessment Examination (SAE)

A Self-Assessment Examination (SAE) is available to help prepare candidates for success in obtaining the Certified Nurse Educator (CNE) credential. With the assistance of our testing partner, Applied Measurement Professionals, Inc., we are able to offer this internet-based, 65-item, multiple-choice practice exam. The SAE can be considered a learning tool and assessment instrument that is parallel in form to the actual CNE examination. The CNE SAE is a half-length examination that will meet the examination specifications including content outline coverage, percentage of items in each of the content categories and the cognitive complexity item distribution. The CNE SAE may be accessed as many times as you like, 24 hours a day, for 60 days from the time of purchase. Please note that once you choose to submit your responses and receive a final score report, you will no longer have online access to the examination.

By taking this Self-Assessment Examination, you will be able to:

practice taking CNE-type questions

experience computer-based testing

review rationales for correct and incorrect answers

receive two score reports to assess strengths and areas for additional study:

1. a score report providing the number of correct responses you provided in each of the six content areas

2. a mastery report providing the number of correct responses you provided in each of the six content areas and the calculated percentage of correct answers.

Become a member and save "
Purchase the Certified Nurse Educator (CNE) Self-Assessment Examination (SAE) "

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A Self-Assessment Examination (SAE) is available to help prepare candidates for success in obtaining the Certified Nurse Educator (CNE) credential. With the assistance of our testing partner, Applied Measurement Professionals, Inc., we are able to offer this internet-based, 65-item, multiple-choice practice exam.

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Formative assessment has never been faster. Plickers is the free card activity your students will love. Join millions and play in your next lesson. Sign up for free Used by K-12 teachers in over 100 countries

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The European Union General Data Protection Regulation (GDPR) replaces the Data Protection Directive 95/46/EC and was designed to harmonize data privacy laws across Europe, to protect and empower all EU citizens data privacy and to reshape the way organizations across the region approach data privacy. These EU GDPR in higher education resources geared to help any organization processing personal data about people in Europe.

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Lessons from Nursing to the World | Kathleen Bartholomew | TEDxSanJuanIsland

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Competencies for the Academic Nurse Educators
These competencies promote excellence in the advanced specialty role of the academic nurse educator. They establish nursing education as a specialty area of practice and create a means for faculty to more fully demonstrate the richness and complexity of the faculty role.

NLN Core Competencies
Note: The task statements that accompany each competency can be found in NLN Core Competencies for Nurse Educators: A Decade of Influence (2019) and The Scope of Practice for Academic Nurse Educators & Academic Clinical Nurse Educators (2020).

Competency I: Facilitate Learning
Nurse educators are responsible for creating an environment in classroom, laboratory, and clinical settings that facilitates student learning and the achievement of desired cognitive, affective, and psychomotor outcomes.

Competency II: Facilitate Learner Development and Socialization
Nurse educators recognize their responsibility for helping students develop as nurses and integrate the values and behaviors expected of those who fulfill that role.

Competency III: Use Assessment and Evaluation Strategies
Nurse educators use a variety of strategies to asses and evaluate student learning in classroom, laboratory and clinical settings, as well as in all domains of learning.

Competency IV: Participate in Curriculum Design and Evaluation of Program Outcomes
Nurse educators are responsible for formulating program outcomes and designing curricula that reflect contemporary health care trends and prepare graduates to function effectively in the health care environment.

Competency V: Function as a Change Agent and Leader
Nurse educators function as change agents and leaders to create a preferred future for nursing education and nursing practice.

Competency VI: Pursue Continuous Quality Improvements in the Nurse Educator Role
Nurse educators recognize that their role is multidimensional and that an ongoing commitment to develop and maintain competence in the role is essential.

Competency VII: Engage in Scholarship
Nurse educators acknowledge that scholarship is an integral component of the faculty role, and that teaching itself is a scholarly activity.

Competency VIII: Function Within the Educational Environment
Nurse educators are knowledgeable about the educational environment within which they practice and recognize how political, institutional, social, and economic forces impact their role.

​ Certification for Nurse Educators (CNE)

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Competencies for the Academic Nurse Educators These competencies promote excellence in the advanced specialty role of the academic nurse educator. They establish nursing education as a specialty area of practice and create a means for faculty to more fully demonstrate the richness and complexity of the faculty role.

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Evaluating portfolio use as a tool for assessment and professional development in graduate nursing education.

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Students in a Bachelor of Science in Nursing (BSN) degree program may be familiar with the term nursing portfolio. Both new and experienced nurses should have a portfolio ready to share when they are searching for a job. A portfolio allows prospective employers to view your credentials beyond the contents of your resume. If you don't already have a portfolio, it might be time to put one together.

A nursing portfolio is a collection of documents that demonstrates your professional goals, accomplishments, competencies and skills.

You can think of your nursing portfolio as a sourcebook for future employers. A portfolio serves to validate the information listed on your resume. Your portfolio should show the progression of your nursing career as well as clinical competence, continuing education and professional development. A portfolio is also helpful for keeping your license, records, certifications, degrees and other materials related to nursing in one place so they are easily available when you need them.

A nursing portfolio is confirmation of your nursing preparation, licensure and employment history. You also need to offer supporting documents, which provide proof of your achievements. If you recently graduated from nursing school or completed an advanced degree program, you may want to provide your transcripts. You should include the following in your portfolio:

Title page.

Table of contents.

Cover letter.

Resume.

Name, address, contact info, health records.

Level of preparation and type of degrees.

Professional licensure and specialty certifications.

Certification cards such as Cardio Pulmonary Resuscitation (CPR), Advanced Cardiovascular Life Support (ACLS), Basic Life Support (BLS), Pediatric Advanced Life Support (PALS), and Neonatal Advanced Life Support (NALS).

Continuing Education Unit (CEU) certificates.

Brief description of nursing roles and responsibilities throughout your career.

In-service training.

Performance evaluation and goals.

Professional development.

List of committees and volunteer projects.

Examples of professional or scholarly work such as articles or research.

Memberships in professional organizations.

Letters of recommendation and appreciation.

You should have both a hard copy of your portfolio and an electronic version. How you submit your portfolio for review depends on the interviewer's preference. Some employers may request that you send your portfolio in a digital format.

You can organize your portfolio any way you choose because there is no right or wrong way. Just remember that your portfolio should look professional and not like a scrapbook. Most importantly, it should be easy for the reader to comprehend.

Consider organizing your portfolio using a three-ring binder. By inserting documentation in chronological order, you can develop a timeline of your career. You can add sections with tabs to further categorize your information.

You'll use your nursing portfolio to market yourself when applying for jobs. The portfolio showcases your clinical expertise and skills so employers can understand your nursing abilities. A nursing portfolio helps them determine if you are a good candidate for the open position in their healthcare facility.

A nursing portfolio showcases all of the critical information that represents your career. A well-maintained portfolio provides employers with insight into your experience, preparation, accolades and scope of practice. A professional portfolio is an additional way to authenticate your qualifications as a nurse.

Every nurse needs a portfolio to move forward in the nursing profession. Are you a nurse seeking employment? Do you have a nursing portfolio? Nurses who do not have a portfolio should start building one to be ready for future opportunities in nursing.
Learn more about The University of Alabama in Huntsville's online RN to BSN program.
Sources:
Nursing Made Incredibly Easy: Developing a Professional Nursing Portfolio Daily Nurse: How to Create a Nursing Portfolio RegisteredNurseRN.com: Nursing Portfolio | How to Create, Examples, and What Is It?
RN.com: Building a Professional Nursing Portfolio
Have a question or concern about this article? Please contact us.

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Students in a BSN degree program may be familiar with the term nursing portfolio. Both new and experienced nurses should have a portfolio ready to share when they are searching for a job. A portfolio allows prospective employers to view your credentials beyond the contents of your resume.

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NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

Adam MP, Ardinger HH, Pagon RA, et al., editors. GeneReviews® [Internet]. Seattle (WA): University of Washington, Seattle; 1993-2020.

From: Malignant Hyperthermia Susceptibility

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NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health. Adam MP, Ardinger HH, Pagon RA, et al., editors. GeneReviews® [Internet]. Seattle (WA): University of Washington, Seattle; 1993-2020. From: Malignant Hyperthermia Susceptibility Copyright © 1993-2020, University of Washington, Seattle. GeneReviews is a registered trademark of the University of Washington, Seattle.

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Signs and Symptoms of an M.I. by Joanne Serembus

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The Flipped Classroom: Where Interactive Learning Meets Technology

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Presented By

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Exam Development, Exam Operations, NCLEX Exam, NCSBN Products/Services

Audience

Board Members, Board Staff, Executive Officers, Nursing Educators, Nursing Students

Knowledge Network

NCLEX Examinations

Description

To ensure public protection, each jurisdiction requires candidates for registered nurse licensure to meet set requirements that include passing an examination that measures the competencies needed to perform safely and effectively as a newly licensed, entry-level registered nurse. Triennially, NCSBN conducts a practice analysis to analyze entry-level RN practice. Using the data collected from the practice analysis, the NCLEX Test Plan is developed, which guides the selection of content and behaviors to be tested during NCLEX administration. This webinar will provide an overview of the 2019 NCLEX-RN Test Plan, including new information effective with the test plan revision.

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NCLEX Examinations Webinar Series: 2019 NCLEX-RN Test Plan Overview | NCSBN

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The National Council of State Boards of Nursing (NCSBN) is a not-for-profit organization whose purpose is to provide an organization through which boards of nursing act and counsel together on matters of common interest and concern affecting the public health, safety and welfare, including the development of licensing examinations in nursing.

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RN Mentor

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RN students can now prepare for the NCLEX® on-the-go, anywhere, anytime with the ATI RN Mentor™. Based on the 2013 NCLEX-RN Test Plan, this quiz app now includes over 800+ unique questions developed by ATI Nurse Educators specifically for this app only. Questions are organized by NCLEX area, body function and clinical area.

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Preparing Nurses For The Future-By Johnson & Johnson 

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Preparing Nurses For The Future-By Johnson & Johnson 

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Katie Hungarter is a registered nurse (RN) who was introduced to the nursing profession as a child watching her mom, an emergency room nurse, at work. "At first I was nervous about having so much responsibility for another person," says Katie. "But I am so glad I decided to become a nurse."

For the past two years, Katie has been caring for patients before and after their surgical procedures at Hunterdon Medical Center in Flemington, N.J. Although she attended a thorough orientation program at the hospital, making the transition from being a student and nurse intern to a registered nurse, "was intimidating," Katie recalls. "When I started working I was suddenly responsible for patients and had to interact with doctors for the first time."

As the U.S. faces the most profound shortage of nurses in its history, new nurses are vital to the nursing profession and the health care system. A shortfall of nearly half a million registered nurses threatens to disrupt the quality and availability of health care services.

Supporting Nurses in the Transition from Classroom to Patient Room
The Johnson & Johnson Campaign for Nursing's Future, a public-awareness campaign launched by Johnson & Johnson in 2002, is working to address the nursing shortage in the U.S. by recruiting new nurses and nurse faculty and helping to retain nurses currently in the profession.

To prepare soon-to-be nurses for the challenges of the workplace, Johnson & Johnson recently developed Your Future in Nursing, a training program that combines the interactivity of video computer gaming with real-life nursing scenarios. New and future nurses can practice responding to scenarios in a risk-free and relaxed virtual environment while developing the communication skills that are such a critical part of the transition from classroom to bedside.

"Understanding the needs and challenges of new nurses and supplying them with supportive tools and resources is key to keeping them in practice," says Andrea Higham, Director, Johnson & Johnson Campaign for Nursing's Future. "This learning tool represents a novel approach to education and development in health care, and our hope is that the software will engage and prepare future nurses for the real experience they'll face in today's nursing environment."

Your Future in Nursing was developed with insight from a diverse team of nurses, including Katie. They worked to identify common challenges that may face new nurses of all ages, such as feeling overwhelmed by patient care responsibilities to working with difficult co-workers.

"We worked hard to get at the heart of the issues that affect nurses during the transition from school to the workforce and then strategized the best ways for nurses to manage those issues," says Barbara Tofani, RN, Director, Hunterdon Regional Cancer Center and a consultant in the development of Your Future in Nursing.

The interactive training tool allows nurses to navigate a personalized 3-D nurse character through rooms of a virtual hospital. "The game is great because everywhere you turn you are encountering a different situation with doctors, nurses and patients. That is the real life of a nurse-you don't know what you'll run into on any given day," says Katie.

With experience comes confidence in caring for patients. "What I like about nursing is being with patients and the conversations that I have with them," says Katie, who is now working towards her Bachelor's degree in nursing. "You really feel like you are making a big difference."

Read more on how the Campaign for Nursing's Future was honored by the National League of Nurses

Learn more:
Your Future in Nursing
The Campaign for Nursing's Future
Discover Nursing
Follow Nursing Notes by Johnson & Johnson on Facebook

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Katie Hungarter is a registered nurse (RN) who was introduced to the nursing profession as a child watching her mom, an emergency room nurse, at work. "At first I was nervous about having so much responsibility for another person," says Katie. "But I am so glad I decided to become a nurse."

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Always a Nurse: The Nurse Educator

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Key Message #2 Major changes in the U.S. health care system and practice environ ments will require equally profound changes in the education of nurses both before and after they receive their licenses. Nursing education at all levels needs to provide a better understanding of and experience in care management, quality improvement methods, systems-level change management, and the reconceptualized roles of nurses in a reformed health care system. Nursing education should serve as a platform for continued lifelong learning and include opportunities for seamless tran sition to higher degree programs. Accrediting, licensing, and certifying organizations need to mandate demonstrated mastery of core skills and competencies to complement the completion of degree programs and written board examinations. To respond to the underrepresentation of racial and ethnic minority groups and men in the nursing workforce, the nursing student body must become more diverse. Finally, nurses should be educated with physicians and other health professionals as students and throughout their careers. : Nurses should achieve higher lev els of education and training through an improved education system that promotes seamless academic progression.
Major changes in the U.S. health care system and practice environments will require equally profound changes in the education of nurses both before and after they receive their licenses. In Chapter 1, the committee set forth a vision of health care that depends on a transformation of the roles and responsibilities of nurses. This chapter outlines the fundamental transformation of nurse education that must occur if this vision is to be realized.

The primary goals of nursing education remain the same: nurses must be prepared to meet diverse patients' needs; function as leaders; and advance science that benefits patients and the capacity of health professionals to deliver safe, quality patient care. At the same time, nursing education needs to be transformed in a number of ways to prepare nursing graduates to work collaboratively and effectively with other health professionals in a complex and evolving health care system in a variety of settings (see Chapter 3). Entry-level nurses, for example, need to be able to transition smoothly from their academic preparation to a range of practice environments, with an increased emphasis on community and public health settings. And advanced practice registered nurses (APRNs) need graduate programs that can prepare them to assume their roles in primary care, acute care, long-term care, and other settings, as well as specialty practices.

This chapter addresses key message #2 set forth in Chapter 1: Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression. The chapter begins by focusing on nurses' undergraduate education, emphasizing the need for a greater number of nurses to enter the workforce with a baccalaureate degree or to progress to this degree early in their career. This section also outlines some of the challenges to meeting undergraduate educational needs. The chapter then turns to graduate nursing education, stressing the need to increase significantly the numbers and preparation of nurse faculty and researchers at the doctoral level. The third section explores the need to establish, maintain, and expand new competencies throughout a nurse's education and career. The chapter next addresses the challenge of underrepresentation of racial and ethnic minority groups and men in the nursing profession and argues that meeting this challenge will require increasing the diversity of the nursing student body. The fifth section describes some creative solutions that have been devised for addressing concerns about educational capacity and the need to transform nursing curricula. The final section presents the committee's conclusions regarding the improvements needed to transform nursing education.

The committee could have devoted this entire report to the topic of nursing education-the subject is rich and widely debated. However, the committee's statement of task required that it examine a range of issues in the field, rather than delving deeply into the many challenges involved in and solutions required to advance the nursing education system. Several comprehensive reports and analyses addressing nursing education have recently been published. They include a 2009 report from the Carnegie Foundation that calls for a "radical transforma tion" of nursing education (Benner et al., 2009); a 2010 report from a conference sponsored by the Macy Foundation that charts a course for "life-long learning" that is assessed by the "demonstration of competency [as opposed to written assessment] in both academic programs and in continuing education" (AACN and AAMC, 2010); two consensus reports from the Institute of Medicine (IOM) that call for greater interprofessional education of physicians, nurses, and other health professionals, as well as new methods of improving and demonstrating competency throughout one's career (IOM, 2003b, 2009); and other articles and reports on necessary curriculum changes, faculty development, and new partnerships in education (Erickson, 2002; Lasater and Nielsen, 2009; Mitchell et al., 2006; Orsolini-Hain and Waters, 2009; Tanner et al., 2008). Additionally, in February 2009, the committee hosted a forum on the future of nursing in Houston, Texas, that focused on nursing education. Discussion during that forum informed the committee's deliberations and this chapter; a summary of that forum is included on the CD-ROM in the back of this report. Finally, Appendix A highlights other recent reports relevant to the nursing profession. The committee refers readers wishing to explore the subject of nursing education in greater depth to these publications.

UNDERGRADUATE EDUCATION

This section begins with an overview of current undergraduate nursing education, including educational pathways, the distribution of undergraduate degrees, the licensing exam, and costs (see Appendix E for additional background information on undergraduate education). The discussion then focuses on the need for more nurses prepared at the baccalaureate level. Finally, barriers to meeting undergraduate educational needs are reviewed.

Overview of Current Undergraduate Education

Educational Pathways

Nursing is unique among the health care professions in the United States in that it has multiple educational pathways leading to an entry-level license to practice (see the annexes to Chapter 1 and Appendix E). For the past four decades, nursing students have been able to pursue three different educational pathways to become registered nurses (RNs): the bachelor's of science in nursing (BSN), the associate's degree in nursing (ADN), and the diploma in nursing. More recently, an accelerated, second-degree bachelor's program for students who possess a baccalaureate degree in another field has become a popular option. This multiplicity of options has fragmented the nursing community and has created confusion among the public and other health professionals about the expectations for these educational options. However, these pathways also provide numerous opportunities for women and men of modest means and diverse backgrounds to access careers in an economically stable field.

In addition to the BSN, ADN, or diploma received by RNs, another undergraduate-level program available is the licensed practical/vocational diploma in nursing. Licensed practical/vocational nurses (LPNs/LVNs) are especially important because of their contributions to care in long-term care facilities and nursing homes. LPNs/LVNs receive a diploma after completion of a 12-month program. They are not educated or licensed for independent decision making for complex care, but obtain basic training in anatomy and physiology, nutrition, and nursing techniques. Some LPNs/LVNs continue their education to become RNs; in fact, approximately 17.9 percent of RNs were once licensed as LPNs/LVNs (HRSA, 2010b). While most LPNs/LVNs have an interest in advancing their education, a number of barriers to their doing so have been cited, including financial concerns, lack of capacity and difficulty getting into ADN and BSN programs, and family commitments (HRSA, 2004). Although this chapter focuses primarily on the education of RNs and APRNs, the committee recognizes the contributions of LPNs/LVNs in improving the quality of health care. The committee also recognizes the opportunity the LPN/LVN diploma creates as a possible pathway toward further education along the RN and APRN tracks for the diverse individuals who hold that diploma.

Distribution of Undergraduate Degrees

At present, the most common way to become an RN is to pursue an ADN at a community college. Associate's degree programs in nursing were launched in the mid-20th century in response to the nursing shortage that followed World War II (Lynaugh, 2008; Lynaugh and Brush, 1996). The next most common undergraduate nursing degree is the BSN, a 4-year degree typically offered at a university. Baccalaureate nursing programs emphasize liberal arts, advanced sciences, and nursing coursework across a wider range of settings than are addressed by ADN programs, along with formal coursework that emphasizes both the acquisition of leadership development and the exposure to community and public health competencies. The least common route to becoming an RN currently is the diploma program, which is offered at a hospital-based school and generally lasts 3 years. During the 20th century, as nursing gained a stronger theoretical foundation and other types of nursing programs increased in number, the number of diploma programs declined remarkably except in a few states, such as New Jersey, Ohio, and Pennsylvania. Figure 4-1 gives an overview of trends in the distribution of nursing graduates by initial nursing degree.

Entry into Practice: The Licensing Exam

Regardless of which educational pathway nursing students pursue, those working toward an RN must ultimately pass the National Council Licensure Examination for Registered Nurses (NCLEX-RN), which is administered by the National Council of State Boards of Nursing (NCSBN), before they are granted a license to practice. Rates of success on the NCLEX-RN are often used for rating schools or for marketing to potential students. As with many entry-level licensing exams, however, the NCLEX-RN uses multiple-choice, computer-based methods to test the minimum competency required to practice nursing safely. The exam is administered on a pass/fail basis and, although rigorous, is not meant to be a test of optimal performance. Following passage of the exam, individual state boards of nursing grant nurses their license to practice.

The content of the NCLEX-RN is based on surveys of what new nurses need to know to begin their practice. As with most entry-level licensing exams, the content of the NCLEX-RN directly influences the curricula used to educate nursing students. Currently, the exam is skewed toward acute care settings because this is where the majority of nurses are first employed and where most work throughout their careers. To keep pace with the changing demands of the health care system and patient populations, including the shift toward increasing care in community settings (see Chapter 2), the focus of the exam will need to shift as well. Greater emphasis must be placed on competencies related to community health, public health, primary care, geriatrics, disease prevention, health promotion, and other topics beyond the provision of nursing care in acute care settings to ensure that nurses are ready to practice in an evolving health care system.

Costs of Nursing Education

Although a limited number of educational grants and scholarships are available, most of individuals seeking nursing education must finance their own education at any level of preparation. Costs vary based on the pathway selected for basic preparation and through to doctoral preparation. The LPN degree is the least expensive to attain, followed by the ADN, BSN (accelerated program), BSN, master's of science in nursing (MSN), and PhD/doctor of nursing practice (DNP) degrees. It is no surprise that educational costs and living expenses play a major role in determining which degree is pursued and the numbers of nurses who seek advanced degrees.

To better understand the costs of nursing education, the committee asked the Robert Wood Johnson Foundation (RWJF) Nursing Research Network to estimate the various costs associated with pursuing nursing education, specifically at the advanced practice level, in comparison with those for a medical doctor (MD) or doctor of osteopathy (DO). The RWJF Nursing Research Network produced several comparison charts in an attempt to convey accurately the differences in costs between alternative nursing degrees and the MD or DO degree. This task required making assumptions about public versus private and proprietary/for-profit education options, prerequisites for entry, and years required to complete each degree. An area of particular difficulty arose in assessing costs associated with obtaining an ADN degree. In most non-health care disciplines, the associates degree takes 2 years to complete. In nursing, however, surveys have found that it takes students 3 to 4 years to complete an ADN program because of the need to fulfill prerequisites necessary to prepare students for entry into degree programs and the lack of adequate faculty, which lead to long waiting lists for many programs and classes (Orsolini-Hain, 2008). Box 4-1 illustrates the challenges of this task by outlining the difficulty of comparing the cost of becoming a physician with the cost of becoming an APRN. The task of comparing the increasing "sticker costs" of nursing and medical education was complicated further because much of the data needed to compute those costs is either missing or drawn from incomparable years. In the end, the committee decided not to include detailed discussion of the costs of nursing education in this report.

Why More BSN-Prepared Nurses Are Needed

The qualifications and level of education required for entry into the nursing profession have been widely debated by nurses, nursing organizations, academics, and a host of other stakeholders for more than 40 years (NLN, 2007). The causal relationship between the academic degree obtained by RNs and patient outcomes is not conclusive in the research literature. However, several studies support a significant association between the educational level of RNs and outcomes for patients in the acute care setting, including mortality rates (Aiken et al., 2003; Estabrooks et al., 2005; Friese et al., 2008; Tourangeau et al., 2007; Van den Heede et al., 2009). Other studies argue that clinical experience, qualifications before entering a nursing program (e.g., SAT scores), and the number of BSN-prepared RNs that received an earlier degree confound the value added through the 4-year educational program. One study found that the level of experience of nurses was more important than their education level in mitigating medication errors in hospitals (Blegen et al., 2001). Another study performed within the Department of Veterans Affairs (VA) system found no significant association between the proportion of RNs with a baccalaureate degree and patient outcomes at the hospital level (Sales et al., 2008).

This debate aside, an all-BSN workforce at the entry level would provide a more uniform foundation for the reconceptualized roles for nurses and new models of care that are envisioned in Chapters 1 and 2. Although a BSN education is not a panacea for all that is expected of nurses in the future, it does, relative to other educational pathways, introduce students to a wider range of competencies in such arenas as health policy and health care financing, leadership, quality improvement, and systems thinking. One study found that new BSN graduates reported significantly higher levels of preparation in evidence-based practice, research skills, and assessment of gaps in areas such as teamwork, collaboration, and practice (Kovner et al., 2010)-other important competencies for a future nursing workforce. Moreover, as more nurses are being called on to lead care coordination efforts, they should have the competencies requisite for this task, many of which are included in the American Association of Colleges of Nursing's (AACN's) Essentials of Baccalaureate Education for Professional Nursing Practice.

Care within the hospital setting continues to grow more complex, and nurses must make critical decisions associated with care for sicker, frailer patients. Care in this setting depends on sophisticated, life-saving technology coupled with complex information management systems that require skills in analysis and synthesis. Care outside the hospital is becoming more complex as well. Nurses are being called upon to coordinate care among a variety of clinicians and community agencies; to help patients manage chronic illnesses, thereby preventing acute care episodes and disease progression; and to use a variety of technological tools to improve the quality and effectiveness of care. A more educated nursing workforce would be better equipped to meet these demands.

An all-BSN workforce would also be poised to achieve higher levels of education at the master's and doctoral levels, required for nurses to serve as primary care providers, nurse researchers, and nurse faculty-positions currently in great demand as discussed later in this chapter. Shortages of nurses in these positions continue to be a barrier to advancing the profession and improving the delivery of care to patients.

Some health care organizations in the United States are already leading the way by requiring more BSN-prepared nurses for entry-level positions. A growing number of hospitals, particularly teaching and children's hospitals and those that have been recognized by the American Nurses Credentialing Center Magnet Recognition Program (see Chapter 5), favor the BSN for employment (Aiken, 2010). Depending on the type of hospital, the goal for the proportion of BSN-prepared nurses varies; for example, teaching hospitals aim for 90 percent, whereas community hospitals seek at least 50 percent (Goode et al., 2001). Absent a nursing shortage, then, nurses holding a baccalaureate degree are usually the preferred new-graduate hires in acute care settings (Cronenwett, 2010). Likewise, in a recent survey of 100 physician members of Sermo.com (see Chapter 3 for more information on this online community), conducted by the RWJF Nursing Research Network, 76 percent of physicians strongly or somewhat agreed that nurses with a BSN are more competent than those with an ADN. Seventy percent of the physicians surveyed also either strongly or somewhat agreed that all nurses who provide care in a hospital should hold a BSN, although when asked about the characteristics they most value in nurses they work with, the physicians placed a significantly higher value on compassion, efficiency, and experience than on years of nursing education and caliber of nursing school (RWJF, 2010c).

In community and public health settings, the BSN has long been the preferred minimum requirement for nurses, given the competencies, knowledge of community-based interventions, and skills that are needed in these settings (ACHNE, 2009; ASTDN, 2003). The U.S. military and the VA also are taking steps to ensure that the nurses making up their respective workforces are more highly educated. The U.S. Army, Navy, and Air Force require all active duty RNs to have a baccalaureate degree to practice, and the U.S. Public Health Service has the same requirement for its Commissioned Officers. Additionally, as the largest employer of RNs in the country, the VA has established a requirement that nurses must have a BSN to be considered for promotion beyond entry level (AACN, 2010c). As Table 4-1 shows, however, the average earnings of BSN-prepared nurses are not substantially higher than those of ADN- or diploma-prepared nurses.

Decades of "blue ribbon panels" and reports to Congress on the health care workforce have found that there is a significant shortage of nurses with baccalaureate and higher degrees to respond to the nation's health needs (Aiken, 2010). Almost 15 years ago, the National Advisory Council on Nurse Education and Practice, which advises Congress and the secretary of Health and Human Services on areas relevant to nursing, called for the development of policy actions that would ensure a minimum of 66 percent of RNs who work as nurses would have a BSN or higher degree by 2010 (Aiken et al., 2009). The result of policy efforts of the past decade has been a workforce in which approximately 50 percent of RNs hold a BSN degree or higher, a figure that includes ADN- and diploma-educated RNs who have gone on to obtain a BSN (HRSA, 2010b). Of significant note, the Tri-Council for Nursing, which consists of the American Nurses Association, American Organization of Nurse Executives, National League for Nursing (NLN), and AACN, recently released a consensus policy statement calling for a more highly educated nursing workforce, citing the need to increase the number of BSN-prepared nurses to deliver safer and more effective care (AACN, 2010a).

In sum, an increase in the percentage of nurses with a BSN is imperative as the scope of what the public needs from nurses grows, expectations surrounding quality heighten, and the settings where nurses are needed proliferate and become more complex. The formal education associated with obtaining the BSN is desirable for a variety of reasons, including ensuring that the next generation of nurses will master more than basic knowledge of patient care, providing a stronger foundation for the expansion of nursing science, and imparting the tools nurses need to be effective change agents and to adapt to evolving models of care. As discussed later in this chapter, the committee's recommendation for a more highly educated nursing workforce must be paired with overall improvements to the education system and must include competencies in such areas as leadership, basic health policy, evidence-based care, quality improvement, and systems thinking. Moreover, even as the breadth and depth of content increase within prelicensure curricula, the caring essence and human connectedness nurses bring to patient care must be preserved. Nurses need to continue to provide holistic, patient-centered care that goes beyond physical health needs to recognize and respond to the social, mental, and spiritual needs of patients and their families. Other fundamental elements of nursing education, such as ethics and integrity, need to remain intact as well.

The Goal and a Plan for Achieving It

In the committee's view, increasing the percentage of the current nursing workforce holding a BSN from 50 to 100 percent in the near term is neither practical nor achievable. Setting a goal of increasing the percentage to 80 percent by 2020 is, however, bold, achievable, and necessary to move the nursing workforce to an expanded set of competencies, especially in the domains of community and public health, leadership, systems improvement and change, research, and health policy.

The committee believes achieving the goal of 80 percent of the nursing workforce having a BSN is possible in part because much of the educational capacity needed to meet this goal exists. RNs with an ADN or diploma degree have a number of options for completing the BSN, as presented below. The combination of these options and others yet to be developed will be needed to meet the 80 percent goal-no one strategy will provide a universal solution. Technologies, such as the use of simulation and distance learning through online courses, will have to play a key role as well. Above all, what is needed to achieve this goal is the will of nurses to return to higher education, support from nursing employers and others to help fund nursing education, the elevation of educational standards, an education system that recognizes the experience and previous learning of returning students, and regional collaboratives of schools of nursing and employers to share financial and human resources.

While there are challenges associated with shortages of nurse faculty and clinical education sites (discussed below), these challenges are less problematic for licensed RNs pursuing a BSN than for prelicensure students, who require more intense oversight and monitoring by faculty. Additionally, most of what ADN-prepared nurses need to move on to a baccalaureate degree can be taught in a classroom or online, with additional tailored clinical experience. Online education creates flexibility and provides an additional skill set to students who will use technology into the future to retrieve and manage information.

Over the course of its deliberations and during the forum on education held in Houston, the committee learned about several pathways that are available to achieve the goal of 80 percent of the nursing workforce having a BSN (additional innovations discussed at the forum on education can be found in the forum summary on the CD-ROM in the back of this report). For RNs returning to obtain their BSN, a number of options are possible, including traditional RN-to-BSN programs. Many hospitals also have joint arrangements with local universities and colleges to offer onsite classes. Hospitals generally provide stipends to employees as an incentive to continue their education. Online education programs make courses available to all students regardless of where they live. For prospective nursing students, there are traditional 4-year BSN programs at a university, but there are also community colleges now offering 4-year baccalaureate degrees in some states (see the next section). Educational collaboratives between universities and community colleges, such as the Oregon Consortium for Nursing Education (described in Box 4-2), allow for automatic and seamless transition from an ADN to a BSN program, with all schools sharing curriculum, simulation facilities, and faculty. As described below, this type of model is goes beyond the conventional articulation agreement between community colleges and universities. Beyond traditional nursing schools, new providers of nursing education are entering the market, such as proprietary/for-profit schools. These programs are offering new models and alternatives for delivering curriculum and reaching RNs and prospective students, although each of these schools should be evaluated for its ability to meet nursing accreditation standards, including the provision of clinical experiences required to advance the profession.

Two other important programs designed to facilitate academic progression to higher levels of education are the LPN-to-BSN and ADN-to-MSN programs. The ADN-to-MSN program, in particular, is establishing a significant pathway to advanced practice and faculty positions, especially at the community college level. Financial support to help build capacity for these programs will be important, including funding for grants and scholarships for nurses wishing to pursue these pathways. By the same token, the committee believes that diploma programs should be phased out over the next 10 years and should consolidate their resources with those of community college or preferably university programs offering the baccalaureate degree. Additionally, there are federal resources currently being used to support diploma schools that could better be used to expand baccalaureate and higher education programs.

The committee anticipates that it will take a few years to build the educational capacity needed to achieve the goal of 80 percent of the nursing workforce being BSN-prepared by 2020, but also emphasizes that existing BSN completion programs have capacity that is far from exhausted. Regional networks of schools working together, along with health care organizations, may best facilitate reaching this goal. Moreover, the committee believes this clearly defined goal will stimulate stakeholders to take action. Examples of such action include academic and health care organizations/employers partnering to achieve strategic alignment around workforce development; government and foundations introducing funding opportunities for scholarships to build faculty and provide tuition relief; state boards of nursing increasing the use of earmarks on licensure fees to offset the cost of education; and states developing statewide policy agendas and political action plans with identified leaders in nursing, government, and business to adopt measures to meet the goal.

The Role of Community Colleges

Community colleges play a key role in attracting students to the nursing education pipeline. Specifically, they provide an opportunity for students who may not have access to traditional university baccalaureate programs because of those programs' lack of enrollment capacity, distance, or cost.

Community colleges have an important role to play in ensuring that more BSN-prepared nurses are available in all regions of the United States and that nursing education at the associate level is high quality and affordable and prepares ADN nurses to move on to higher levels of education. Currently, ADN- and BSN-prepared nurses are not evenly distributed nationwide. BSN-prepared RNs are found more commonly in urban areas, while many rural and other medically underserved communities depend heavily on nurses with associate's degrees to staff their hospitals, clinics, and long-term care facilities (Cronenwett, 2010). Figure 4-2 shows the highest nursing or nursing-related education by urban/rural residence. According to a study by the Urban Institute, "medical personnel, including nurses, tend to work near where they were trained" (Bovjberg, 2009; see Figure 4-3). This suggests that state and community investments in nursing education (e.g., building nursing school capacity, building infrastructure to support that capacity, funding the purchase of technology, and offering scholarships) may be an effective way to reduce local and regional shortages. Community colleges are the predominant educational institutions in rural and medically underserved areas. Therefore, they must either join educational collaboratives or develop innovative and easily accessible programs that seamlessly connect students to schools offering the BSN and higher degrees, or they must develop their own BSN programs (if feasible within state laws and regulations). Community colleges must foster a culture that promotes and values academic progression and should encourage their students to continue their education through strategies that include making them aware of the full range of educational pathways and opportunities available to them (e.g., ADN-to-MSN and online RN-to-BSN programs). Box 4-3 describes a community college in Florida where nursing students can take advantage of lower costs and online classes to receive a BSN degree.

Barriers to Meeting Undergraduate Educational Needs

Although the committee believes the capacity needed to ensure a nursing workforce that is 80 percent BSN-prepared by 2020 can be attained using the approaches outlined above, getting there will not be easy. Nursing schools across the United States collectively turn away tens of thousands of qualified applicants each year because of a lack of capacity (Kovner and Djukic, 2009)-a situation that makes filling projected needs for more and different types of nurses difficult. Figure 4-4 shows the breakdown of numbers of qualified applicants who are turned away from ADN and BSN programs.

An examination of the root causes of the education system's insufficient capacity to meet undergraduate educational needs reveals four major barriers: (1) the aging and shortage of nursing faculty; (2) insufficient clinical placement opportunities of the right kind or duration for prelicensure nurses to learn their profession; (3) nursing education curricula that fail to impart relevant competencies needed to meet the future needs of patients and to prepare nurses adequately for academic progression to higher degrees; and (4) inadequate workforce planning, which stems from a lack of the communications, data sources, and information systems needed to align educational capacity with market demands. This final root cause-inadequate workforce planning-affects all levels of nursing education and is the subject of Chapter 6.

Aging and Shortage of Nursing Faculty

There are not enough nursing faculty to teach the current number of nursing students, let alone the number of qualified applicants who wish to pursue nursing. The same forces that are leading to deficits in the numbers and competencies of bedside nurses affect the capacity of nursing faculty as well (Allan and Aldebron, 2008). According to a survey by the NLN, 84 percent of U.S. nursing schools tried to hire new faculty in the 2007-2008 academic year; of those, four out of five found it "difficult" to recruit faculty, and one out of three found it "very difficult." The principal difficulties included "not enough qualified candidates" (cited by 46 percent) and the inability to offer competitive salaries (cited by 38 percent). The survey concluded that "post-licensure programs were much more likely to cite a shortage of faculty, whereas pre-licensure programs reported that lack of clinical placement settings were [sic] the biggest impediment to admitting more students. Specifically, almost two thirds (64 percent) of doctoral programs and one half of RN-BSN and master's programs identified an insufficient faculty pool to draw from as the major constraint to expansion, in contrast to one third of prelicensure programs" (NLN, 2010a).

Age is also a contributing factor to faculty shortages. Nursing faculty tend to be older than clinical nurses because they must meet requirements for an advanced degree in order to teach. Figure 4-5 shows that the average age of nurses who work as faculty as their principal nursing position-the position in which a nurse spends the majority of his or her working hours-is 50 to 54. By contrast, the median age of the total RN workforce is 46. More than 19 percent of RNs whose principal position is faculty are aged 60 or older, while only 8.7 percent of nurses who have a secondary position as faculty-those who hold a nonfaculty (e.g., clinical) principal position-are aged 60 or older. Nurses who work as faculty as their secondary position tend to be younger; among nurses under age 50, more work as faculty as their secondary than as their principal position (HRSA, 2010b). Moreover, the average retirement age for nursing faculty is 62.5 (Berlin and Sechrist, 2002); as a result, many full-time faculty will be ready to retire soon. Given the landscape of the health care system and the fragmented nursing education system, the current pipeline cannot easily replenish this loss, let alone meet the potential demand for more educators. In addition to the innovative strategies of the Veterans Affairs Nursing Academy (VANA) and Gulf Coast Health Services Steering Committee for responding to faculty shortages (discussed later in this chapter), a potential opportunity to relieve faculty shortages could involve the creation of programs that would allow MSN, DNP, and PhD students to teach as nursing faculty interns, with mentoring by full-time faculty. Box 4-4 presents a nurse profile of one assistant professor and her experience moving into an academic career.

Effects of the first degree at entry into the profession Nurses who enter the profession with an associate's degree are less likely than those who enter with a bachelor's degree to advance to the graduate level over the course of their career (Cleary et al., 2009). Figure 4-6 gives an overview of the highest educational degree obtained by women and men who hold the RN license. It includes RNs who are working as nurses and those who have retired, have changed professions, or are no longer working. According to an analysis by Aiken and colleagues (2009), nurses whose initial degree is the ADN are just as likely as BSN-prepared nurses to seek another degree. Approximately 80 percent of the time, however, ADN graduates fail to move beyond a BSN. Therefore, the greatest number of nurses with a master's or doctorate, a prerequisite for serving as faculty, received a BSN as their initial degree. Since two-thirds of current RNs received the ADN as their initial degree, Aiken's analysis suggests that currently "having enough faculty (and other master's prepared nurses) to enable nursing schools to expand enrollment is a mathematical improbability" (Aiken et al., 2009). A separate analysis of North Carolina nurses led to a similar conclusion (Bevill et al., 2007). Table 4-2 shows the length of time it takes those nurses who do move on to higher levels of education to progress from completing initial nursing education to completing the highest nursing degree achieved.

Salary disparities Another factor that contributes to the current nursing faculty shortage is salary disparities between nurses working in education and those working in clinical service (Gilliss, 2010). As shown in Table 4-3, the average annual earnings of nurses who work full time as faculty (most with either a master's or doctoral degree) total $63,949. By contrast, nurse practitioners (NPs) (with either a master's or doctoral degree) average just over $85,000 (see Table 4-4). Section 5311 of the Affordable Care Act (ACA) offers an incentive designed to offset lower faculty salaries by providing up to $35,000 in loan repayments and scholarships for eligible nurses who complete an advanced nursing degree and serve "as a full-time member of the faculty of an accredited school of nursing, for a total period, in the aggregate, of at least 4 years." However, the ACA does not provide incentives for nurses to develop the specific educational and clinical competencies required to teach.

Projections of future faculty demand To establish a better understanding of future needs, the committee asked the RWJF Nursing Research Network to proj ect faculty demand for the next 15 years. After reviewing data from the AACN and the NLN (Kovner et al., 2006), the network estimated that between 5,000 and 5,500 faculty positions will remain unfilled in associate's, baccalaureate, and higher degree programs. This projection is based on historical nurse faculty retirement rates and on graduation trends in research-focused nursing PhD programs. Although a doctoral degree is often required or preferred for all current faculty vacancies, some of these positions can be filled with faculty holding DNP or master's degrees.

If faculty retirement rates decrease and/or new faculty positions are created to meet future demands (resulting, for example, from provisions for loan repayment in the ACA), these factors will affect the shortage estimates. Additionally, the faculty supply may be affected positively by growing numbers of graduates with a DNP degree (discussed later in this chapter) who, as noted above, may be eligible for faculty positions in some academic institutions.

Insufficient Clinical Placement Opportunities

As nursing education has moved out of hospital-based programs and into mainstream colleges and universities, integrating opportunities for clinical experience into coursework has become more difficult (Cronenwett, 2010). Nursing leaders continue to confront challenges associated with the separation of the academic and practice worlds in ensuring that nursing students develop the competencies required to enter the workforce and function effectively in health care settings (Cronenwett and Redman, 2003; Fagin, 1986). While efforts are being made to expand placements in the community and more care is being delivered in community settings, the bulk of clinical education for students still occurs in acute care settings.

The required number of clinical hours varies widely from one program to another, and most state boards of nursing do not specify a minimum number of clinical hours in prelicensure programs (NCSBN, 2008). It is likely, moreover, that many of the clinical hours fail to result in productive learning. Students spend much of their clinical time performing routine care tasks repeatedly, which may not contribute significantly to increased learning. Faculty report spending most of their time supervising students in hands-on procedures, leaving little time focused on fostering the development of clinical reasoning skills (McNelis and Ironside, 2009).

Some advances in clinical education have been made through strong academic-service partnerships. An example of such partnerships in community settings is nurse-managed health centers (discussed in Chapter 3), which serve a dual role as safety net practices and clinical education sites. Another, commonly used model is having skilled and experienced practitioners in the field oversee student clinical experiences. According to a recent integrative review, using these skilled practitioners, called preceptors, in a clinical setting is at least as effective as traditional approaches while conserving scarce faculty resources (Udlis, 2006). A variety of other clinical partnerships have been designed to increase capacity in the face of nursing faculty shortages (Baxter, 2007; DeLunas and Rooda, 2009; Kowalski et al., 2007; Kreulen et al., 2008; Kruger et al., 2010).

In addition to academic-service partnerships and preceptor models, the use of high-fidelity simulation offers a potential solution to the problem of limited opportunities for clinical experience, with early studies suggesting the effectiveness of this approach (Harder, 2010). The NLN, for example, has established an online community called the Simulation Innovation Resource Center, where nurse faculty can learn how to "design, implement, and evaluate the use of simulation" in their curriculum. However, there is little evidence that simulation expands faculty capacity, and no data exist to define what portion of clinical experience it can replace. To establish uniform guidelines for educators, accreditation requirements should be evaluated and revised to allow simulation to fulfill the requirement for a standard number of clinical hours. The use of simulation in relationship to the promotion of interprofessional education is discussed below.

Increased attention is being focused on the dedicated education unit (DEU) as a viable alternative for expanding clinical education capacity (Moscato et al., 2007). In this model, health care units are dedicated to the instruction of students from one program. Staff nurses who want to serve as clinical instructors are prepared to do so, and faculty expertise is used to support their development and comfort in this role. DEUs were developed in Australia and launched in the United States at the University of Portland in Oregon in 2003. Since then, the University of Portland has helped at least a dozen other U.S. nursing schools establish DEUs. In programs that offer DEUs, students perform two 6-week rotations per semester, each instructor/staff nurse teaches no more than two students at a time, and a university faculty member oversees the instruction. Early results suggest the DEU can dramatically increase capacity and have a positive effect on satisfaction among students and nursing staff. A multisite study funded by RWJF is currently under way to evaluate outcomes of the DEU model.

DEUs offer benefits for the nursing schools, the hospitals, the faculty, and the students. Because the hospital employs the clinical instructors, the nursing school can increase its enrollment without increasing costs. The hospital benefits by training students it can hire after their graduation and licensure. Students benefit by having consistent clinical instructors each day, something not guaranteed under the traditional preceptorship model. As the case study in Box 4-5 shows, the benefits of DEUs extend beyond the academic environment to the practice setting as well.

Need for Updated and Adaptive Curricula

A look at the way nursing students are educated at the prelicensure level shows that most schools are not providing enough nurses with the required competencies in such areas as geriatrics and culturally relevant care to meet the changing health needs of the U.S. population (as outlined in Chapter 2) (AACN and Hartford, 2000). The majority of nursing schools still educate students primarily for acute care rather than community settings, including public health and long-term care. Most curricula are organized around traditional medical specialties (e.g., maternal-child, pediatrics, medical-surgical, or adult health) (McNelis and Ironside, 2009). The intricacies of care coordination are not adequately addressed in most prelicensure programs. Nursing students may gain exposure to leading health care disciplines and know something about basic health policy and available health and social service programs, such as Medicaid. However, their education often does not promote the skills needed to negotiate with the health care team, navigate the regulatory and access stipulations that determine patients' eligibility for enrollment in health and social service programs, or understand how these programs and health policies impact health outcomes. Nursing curricula need to be reexamined and updated. They need to be adaptive enough to undergo continuous evaluation and improvement based on new evidence and a changing science base, changes and advances in technology, and changes in the needs of patients and the health care system.

Many nursing schools have dealt with the rapid growth of health research and knowledge by adding layers of content that require more instruction (Ironside, 2004). A wide range of new competencies also are being incorporated into requirements for accreditation (CCNE, 2009; NLNAC, 2008). For example, new competencies have been promulgated to address quality and patient safety goals (Cronenwett et al., 2007; IOM, 2003a). Greater emphasis on prevention, wellness, and improved health outcomes has led to new competency requirements as well (Allan et al., 2005). New models of care being promulgated as a result of health care reform will need to be introduced into students' experiences and will require competencies in such areas as care coordination. These models, many of which could be focused in alternative settings such as schools and workplaces, will create new student placement options that will need to be tested for scalability and compared for effectiveness with more traditional care settings. (See also the discussion of competencies later in the chapter.)

The explosion of knowledge and decision-science technology also is changing the way health professionals access, process, and use information. No longer is rote memorization an option. There simply are not enough hours in the day or years in an undergraduate program to continue compressing all available information into the curriculum. New approaches must be developed for evaluating curricula and presenting fundamental concepts that can be applied in many different situations rather than requiring students to memorize different lists of facts and information for each situation.

funding to support nursing education research, potentially via mechanisms through the Health Resources and Services Administration;

multidisciplinary research training programs, including postdoctoral training to prepare a cadre of nurses dedicated to developing the science of nursing education; and

efforts to foster the development of PhD programs that have faculty expertise to mentor a new generation of nursing education researchers.

Just as curricula must be assessed and rethought, so, too, must teaching-learning strategies. Most nurse faculty initially learned to be nurses through highly structured curricula that were laden with content (NLN Board of Governors, 2003), and too few have received advanced formal preparation in curriculum development, instructional design, or performance assessment. Faculty, tending to teach as they were taught, focus on covering content (Benner et al., 2009; Duchscher, 2003). They also see curriculum-related requirements as a barrier to the creation of learning environments that are both engaging and student-centered (Schaefer and Zygmont, 2003; Tanner, 2007).

GRADUATE NURSING EDUCATION

Even absent passage of the ACA, the need for APRNs, nurse faculty, and nurse researchers would have increased dramatically under any scenario (Cronenwett, 2010). Not only must schools of nursing build their capacity to prepare more students at the graduate level, but they must do so in a way that fosters a unified, competency-based approach with the highest possible standards. Therefore, building the science of nursing education research, or how best to teach students, is an important emphasis for the field of nursing education. For APRNs, graduate education should ensure that they can contribute to primary care and help respond to shortages, especially for those populations who are most underserved. For nurse researchers, a focus on fundamental improvements in the delivery of nursing care to improve patient safety and quality is key.

Numbers and Distribution of Graduate-Level Nurses

As of 2008, more than 375,000 women and men in the workforce had received a master's degree in nursing or a nursing-related field, and more than 28,000 had gone on to receive either a doctorate in nursing or a nursing-related doctoral degree in a field such as public health, public administration, sociology, or education (see Table 4-5) (HRSA, 2010b). Master's degrees prepare RNs for roles in nursing administration and clinical leadership or for work in advanced practice roles (discussed below) (AARP, 2010 [see Annex 1-1]). Many nursing faculty, particularly clinical instructors, are prepared at the master's level. Doctoral degrees include the DNP and PhD. A PhD in nursing is a research-oriented degree designed to educate nurses in a wide range of scientific areas that may include clinical science, social science, policy, and education. Traditionally, PhD-educated nurses teach in university settings and conduct research to expand knowledge and improve care, although they can also work in clinical settings and assume leadership and administrative roles in health care systems and academic settings.

The DNP is the complement to other practice doctorates, such as the MD, PharmD, doctorate of physical therapy, and others that require highly rigorous clinical training. Nurses with DNPs are clinical scholars who have the capacity to translate research, shape systems of care, potentiate individual care into care needed to serve populations, and ask the clinical questions that influence organizational-level research to improve performance using informatics and quality improvement models. The DNP is a relatively new degree that offers nurses an opportunity to become practice scholars in such areas as clinical practice, leadership, quality improvement, and health policy. The core curriculum for DNPs is guided by the AACN's Essentials of Doctoral Education for Advanced Nursing Practice.

Schools of nursing have been developing DNP programs since 2002, but only in the last 5 years have the numbers of graduates approached a substantial level (Raines, 2010). Between 2004 and 2008 the number of programs offering the degree increased by nearly 40 percent, as is shown in Figure 4-7. At this point, more evidence is needed to examine the impact DNP nurses will have on patient outcomes, costs, quality of care, and access in clinical settings. It is also difficult to discern how DNP nurses could affect the provision of nursing education and whether they will play a significant role in easing faculty shortages. While the DNP provides a promising opportunity to advance the nursing profession, and some nursing organizations are promoting this degree as the next step for APRNs, the committee cannot comment directly on the potential role of DNP nurses because of the current lack of evidence on outcomes.

Although 13 percent of nurses hold a graduate degree, fewer than 1 percent (28,369 nurses) have a doctoral degree in nursing or a nursing-related field, the qualification needed to conduct independent research (HRSA, 2010b). In fact, only 555 students graduated with a PhD in nursing in 2009, a number that has remained constant for the past decade (AACN, 2009a). As noted, key roles for PhD nurses include teaching future generations of nurses and conducting research that becomes the basis for improvements in nursing practice. As the need for nursing education and research and for nurses to engage with interprofessional research teams has grown, the numbers of nurses with a PhD in nursing or a related field have not kept pace (see Figure 4-7 for trends in the various nursing programs). The main reasons for this lag are (1) an inadequate pool of nurses with advanced nursing degrees to draw upon, (2) faculty salaries and benefits that are not comparable to those of nurses with advanced nursing degrees working in clinical settings, and (3) a culture that promotes obtaining clinical experience prior to continuing graduate education.

Preparation of Advanced Practice Registered Nurses

Nurses prepared at the graduate level to provide advanced practice services include those with master's and doctoral degrees. APRNs serve as NPs, certified nurse midwives (CNMs), clinical nurse specialists (CNSs), and certified registered nurse anesthetists (CRNAs). To gain certification in one of these advanced practice areas, nurses must take specialized courses in addition to a basic core curriculum. Credit requirements vary from program to program and from specialty to specialty, but typically range from a minimum of 40 credits for a master's to more than 80 credits for a DNP. Upon completion of required coursework and clinical hours, students must take a certification exam that is administered by a credentialing organization relevant to the specific specialization, such as the American Nursing Credentialing Center (for NPs and CNSs), the American Midwifery Certification Board (for CNMs), or the National Board on Certification and Recertification of Nurse Anesthetists (for CRNAs).

Nurses who receive certification, including those serving in all advanced practice roles, provide added assurance to the public that they have acquired the specialized professional development, training, and competencies required to provide safe, quality care for specific patient populations. For example, NPs and CNSs may qualify for certification after completing a master's degree, post-master's coursework, or doctoral degree through an accredited nursing program, with specific advanced coursework in areas such as health assessment, pharmacology, and pathophysiology; additional content in health promotion, disease prevention, differential diagnosis, and disease management; and at least 500 hours of faculty-supervised clinical training within a program of study (ANCC, 2010a, 2010c).

Certification is time-limited, and maintenance of certification requires ongoing acquisition of both knowledge and experience in practice. For example, most advanced practice certification must be renewed every 5 years (NPs, CNSs); requirements include a minimum of 1,000 practice hours in the specific certification role and population/specialty. These requirements must be fulfilled within the 5 years preceding submission of the renewal application (ANCC, 2010b). CRNAs are recertified every 2 years and must be substantially engaged in the practice of nurse anesthesia during those years, in addition to completing continuing education credits (NBCRNA, 2009). Recertification for CNMs is shifting from 8 to 5 years and also involves a continuing education requirement (AMCB, 2009).

As the health care system grows in complexity, expectations are that APRNs will have competence in expanding areas such as technology, genetics, quality improvement, and geriatrics. Coursework and clinical experience requirements are increasing to keep pace with these changes. Jean Johnson, Dean of the School of Nursing at The George Washington University, notes that in terms of education, this is a time of major transition for APRNs. With the DNP, some nursing education institutions are now able to offer professional parity with other health disciplines that are shifting, or have already shifted, to require doctorates in their areas of practice, such as pharmacy, occupational and physical therapy, and speech pathology. As discussed above, DNP programs allow nurses to hone their expertise in roles related to nurse executive practice, health policy, informatics, and other practice specialties. (It should be noted, however, that throughout this report, the discussion of APRNs does not distinguish between those with master's and DNP degrees who have graduated from an accredited program.)

Research Roles

Graduate-level education produces nurses who can assume roles in advanced practice, leadership, teaching, and research. For the latter role, a doctoral degree is required, yet as noted above, fewer than 1 percent of nurses have achieved this level of education. This number is insufficient to meet the crucial need for research in two key areas: nursing education and nursing science.

Research on Nursing Education

At no time in recent history has there been a greater need for research on nursing education. As health care reform progresses, basic and advanced nursing practices are being defined by the new competencies alluded to above and discussed in the next section, yet virtually no evidence exists to support the teaching approaches used in nursing education.

Additionally, little research has focused on clinical education models or clinical experiences that can help students achieve these competencies, even though clinical education constitutes the largest portion of nurses' educational costs. Likewise, little evidence supports appropriate student/faculty ratios. Yet current clinical education models and student/faculty ratios are limiting capacity at a time when the need for new nurses is projected to increase. The paucity of evidence in nursing education and pedagogy calls for additional research and funding to ascertain the efficiency and effectiveness of approaches to nursing education, advancing evidence-based teaching and interprofessional knowledge. Chapter 7 outlines specific research priorities that could shape improvements to nursing education.

In a recent editorial, Broome (2009) highlighted the need for three critical changes required to "systematically build a ... science that could guide nurse educators to develop high quality, relevant, and cost-effective models of education that produce graduates who can make a difference in the health system":

Research on Nursing Science

The expansion of knowledge about the science of nursing is key to providing better patient care, improving health, and evaluating outcomes. Along with an adequate supply of qualified nurses, meeting the nation's growing health care needs requires continued growth in the science of delivering effective care for people and populations and designing health systems. Nurse scientists are a critical link in the discovery and translation of knowledge that can be generated by nurses and other health scientists. To carry out this crucial work, a sustainable supply of and support for nurse scientists will be necessary (IOM, 2010).

The research conducted by nurse scientists has led to many fundamental improvements in the provision of care. Advances have been realized, for example, in the prevention of pressure ulcers; the reduction of high blood pressure among African American males; and the models described elsewhere in this report for providing transitional care after hospital discharge and for promoting health and well-being among young, disadvantaged mothers and their newborns. Yet nursing's research capacity has been largely overlooked in the development of strategies for responding to the shortage of nurses or effecting the necessary transformation of the nursing profession. The result has been a serious mismatch between the urgent need for knowledge and innovation to improve care and the nursing profession's ability to respond to that need, as well as a limitation on what nursing schools can include in their curricula and what is disseminated in the clinical settings where nurses engage.

A chapter of the National Research Council's 2005 report, Advancing the Nation's Health Needs: NIH's Research Training Program, focuses on nursing research; it identified factors that would likely influence its future, for example: an aging cadre of nursing science researchers, longer times required to complete doctoral degrees, increasing demands on nursing faculty to also meet workforce demands, and the emergence of clinical doctoral programs (NRC, 2005). Evaluating these and other factors will be essential to achieving the transformation of the nursing profession that this report argues is essential to a transformed health care system.

COMPETENCY-BASED EDUCATION

Competencies that are well known to the nursing profession, such as care management and coordination, patient education, public health intervention, and transitional care, are likely to dominate in a reformed health care system. As Edward O'Neil, Director, Center for the Health Professions at the University of California, San Francisco, pointed out however, "these traditional competencies must be reinterpreted for students into the settings of the emergent care system, not the one that is being left behind. This will require faculty to not only teach to these competencies but also creatively apply them to health environments that are only now emerging" (O'Neil, 2009). Emerging new competencies in decision making, quality improvement, systems thinking, and team leadership must become part of every nurse's professional formation from the prelicensure through the doctoral level.

A review of medical school education found that evidence in favor of competency-based education is limited but growing (Carraccio et al., 2002). Nursing schools also have embraced the notion of competency-based education, as noted earlier in the chapter in the case study on the Oregon Consortium for Nursing Education ( Box 4-2). In addition, Western Governors University uses competency-based education exclusively, allowing nursing students to move through their program of study at their own pace. Mastery of the competency is achieved to the satisfaction of the faculty without the normal time-bound semester structure (IOM, 2010).

Defining Core Competencies

The value of competency-based education in nursing is that it can be strongly linked to clinically based performance expectations. It should be noted that "competencies" here denotes not task-based proficiencies but higher-level competencies that represent the ability to demonstrate mastery over care management knowledge domains and that provide a foundation for decision-making skills under variety of clinical situations across all care settings.

Numerous sets of core competencies for nursing education are available from a variety of sources. It has proven difficult to establish a single set of competencies that cover all clinical situations, across all settings, for all levels of students. However, there is significant overlap among the core competencies that exist because many of them are derived from such landmark reports as Recreating Health Professional Practice for a New Century (O'Neil and Pew Health Professions Commission, 1998) and Health Professions Education: A Bridge to Quality (IOM, 2003b). The competencies in these reports focus on aspects of professional behavior (e.g., ethical standards, cultural competency) and emphasize areas of care (e.g., prevention, primary care), with overarching goals of (1) providing patient-centered care, (2) applying quality improvement principles, (3) working in interprofessional teams, (4) using evidence-based practices, and (5) using health information technologies.

Two examples of sets of core competencies come from the Oregon Consortium for Nursing Education and the AACN. The former set features competencies that promote nurses' abilities in such areas as clinical judgment and critical thinking; evidence-based practice; relationship-centered care; interprofessional collaboration; leadership; assistance to individuals and families in self-care practices for promotion of health and management of chronic illness; and teaching, delegation, and supervision of caregivers. The AACN's set of competencies is outlined in Essentials for Baccalaureate Education and highlights such areas as "patient-centered care, interprofessional teams, evidence-based practice, quality improvement, patient safety, informatics, clinical reasoning/critical thinking, genetics and genomics, cultural sensitivity, professionalism, practice across the lifespan, and end-of-life care" (AACN, 2008b). While students appear to gradu ate with ample factual knowledge of these types of core competencies, however, they often appear to have little sense of how the competencies can be applied or integrated into real-world practice situations (Benner et al., 2009).

Imparting emerging competencies, such as quality improvement and systems thinking, is also key to developing a more highly educated workforce. Doing so will require performing a thorough evaluation and redesign of educational content, not just adding content to existing curricula. An exploration of the educational changes required to teach all the emerging competencies required to meet the needs of diverse patient populations is beyond the scope of this report.

Defining an agreed-upon set of core competencies across health professions could lead to better communication and coordination among disciplines (see the discussion of the Interprofessional Education Collaborative below for an example of one such effort). Additionally, the committee supports the development of a unified set of core competencies across the nursing profession and believes it would help provide direction for standards across nursing education. Defining these core competencies must be a collaborative effort among nurse educators, professional organizations, and health care organizations and providers. This effort should be ongoing and should inform regular updates of nursing curricula to ensure that graduates at all levels are prepared to meet the current and future health needs of the population.

Assessing Competencies

Changes in the way competencies are assessed are also needed. In 2003, the IOM's Health Professions Education: A Bridge to Quality called for systemwide changes in the education of health professionals, including a move on the part of accrediting and certifying organizations for all health professionals toward mandating a competency-based approach to education (IOM, 2003a). Steps are already being taken to establish competency-based assessments in medical education. In its 2009 report to Congress on Improving Incentives in the Medicare Program, the Medicare Payment Advisory Commission highlighted an initiative of the Accreditation Council for Graduate Medical Education to require greater competency-based assessment of all residency programs that train physicians in the United States (MedPAC, 2009). The NCSBN has considered various challenges related to competency assessment and is considering approaches to ensure that RNs can demonstrate competence in the full range of areas that are required for the practice of nursing.

A competency-based approach to education strives to make the competencies for a particular course explicit to students and requires them to demonstrate mastery of those competencies (Harden, 2002). Performance-based assessment then shows whether students have both a theoretical grasp of what they have learned and the ability to apply that knowledge in a real-world or realistically simulated situation. The transition-to-practice or nurse residency programs discussed in Chapter 3 could offer an extended opportunity to reinforce and test core competencies in real-world settings that are both safe and monitored.

Lifelong Learning and Continuing Competence

Many professions, such as nursing, that depend heavily on knowledge are becoming increasingly technical and complex (The Lewin Group, 2009). No individual can know all there is to know about providing safe and effective care, which is why nurses must be integral members of teams that include other health professionals. Nor can a single initial degree provide a nurse with all she or he will need to know over an entire career. Creating an expectation and culture of lifelong learning for nurses is therefore essential.

From Continuing Education to Continuing Competence

Nurses, physicians, and other health professionals have long depended on continuing education programs to maintain and develop new competencies over the course of their careers. Yet the 2009 IOM study Redesigning Continuing Education in the Health Professions cites "major flaws in the way [continuing education] is conducted, financed, regulated, and evaluated" and states that the evidence base underlying current continuing education programs is "fragmented and undeveloped." These shortcomings, the report suggests, have hindered the identification of effective educational methods and their integration into coordinated, comprehensive programs that meet the needs of all health professionals (IOM, 2009). Likewise, the NCSBN has found that there is no clear link between continuing education requirements and continued competency. A new vision of professional development is needed that enables learning both individually and from a collaborative, team perspective and ensures that "all health professionals engage effectively in a process of lifelong learning aimed squarely at improving patient care and population health" (IOM, 2009).

This new comprehensive vision is often termed "continuing competence." The practice setting, like the academic setting, is challenged by the need to integrate traditional and emerging competencies. Therefore, building the capacity for lifelong learning-which encompasses both continuing competence and advanced degrees-requires ingenuity on the part of employers, businesses, schools, community and government leaders, and philanthropies. The case study in Box 4-6 describes a program that extends the careers of nurses by training them to transition from the acute care to the community setting.

Interprofessional Education

The importance of interprofessional collaboration and education has been recognized since the 1970s (Alberto and Herth, 2009). What is new is the introduction of simulation and web-based learning-solutions that can be used to can break down traditional barriers to learning together, such as the conflicting schedules of medical and APRN students or their lack of joint clinical learning opportunities. Simulation technology offers a safe environment in which to learn (and make mistakes), while web-based learning makes schedule conflicts more manageable and content more repeatable. If all nursing and medical students are educated in aspects of interprofessional collaboration, such as knowledge of professional roles and responsibilities, effective communication, conflict resolution, and shared decision making, and are exposed to working with other health professional students through simulation and web-based training, they may be more likely to engage in collaboration in future work settings. Further, national quality and safety agendas, including requirements set by the Joint Commission, the Commission on Collegiate Nursing Education, the NLN, and the Association of American Medical Colleges (AAMC), along with studies that link disruptive behavior between RNs and MDs to negative patient and worker outcomes (Rosenstein and O'Daniel, 2005, 2008), create a strong incentive to not just talk about but actually work on implementing interprofessional collaboration.

England, Canada, and the United States have made strides to improve interprofessional education by bringing students together from academic health science universities and medical centers (e.g., students of nursing, medicine, pharmacy, social work, physical therapy, and public health, among others) in shared learning environments (Tilden, 2010). Defined as "occasions when two or more professions learn with, from, and about each other to improve collaboration and the quality of care" (Barr et al., 2005), such education is based on the premise that students' greater familiarity with each other's roles, competencies, nomenclatures, and scopes of practice will result in more collaborative graduates. It is expected that graduates of programs with interprofessional education will be ready to work effectively in patient-centered teams where miscommunication and undermining behaviors are minimized or eliminated, resulting in safer, more effective care and greater clinician and patient satisfaction. Interprofessional education is thought to foster collaboration in implementing policies and improving services, prepare students to solve problems that exceed the capacity of any one profession, improve future job satisfaction, create a more flexible workforce, modify negative attitudes and perceptions, and remedy failures of trust and communication (Barr, 2002).

The AAMC, the American of Association of Colleges of Osteopathic Medicine, the American Dental Education Association, the American Association of Colleges of Pharmacy, the Association of Schools of Public Health, and the AACN recently formed a partnership called the Interprofessional Education Collaborative. This collaborative is committed to the development of models of collaboration that will provide the members' individual communities with the standards and tools needed to achieve productive interprofessional education practices. These organizations are committed to fulfilling the social contract that every nursing, pharmacy, dental, public health, and medical graduate is proficient in the core competencies required for interprofessional, team-based care, including preventive, acute, chronic, and catastrophic care. The collaborative is also committed to facilitating the identification, development, and deployment of the resources essential to achieving this vision. As a first step, the collaborative is developing a shared and mutually endorsed set of core competencies that will frame the education of the six represented health professions.

Efforts have been made to evaluate the effectiveness of interprofessional education in improving outcomes, including increased student satisfaction, modified negative stereotypes of other disciplines, increased collaborative behavior, and improved patient outcomes. However, the effect of interprofessional education is not easily verified since control group designs are expensive, reliable measures are few, and time lapses can be long between interprofessional education and the behavior of graduates. Barr and colleagues (2005) reviewed 107 evaluations of interprofessional education in published reports and found support for three outcomes: interprofessional education creates positive interaction among students and faculty; encourages collaboration between professions; and results in improvements in aspects of patient care, such as more targeted health promotion advice, higher immunization rates, and reduced blood pressure for patients with chronic heart disease. Reeves and colleagues (2008) reviewed six later studies of varying designs. Four of the studies found that interprofessional education improved aspects of how clinicians worked together, while the remaining two found that it had no effect (Reeves et al., 2008). Although empirical evidence is mixed, widespread theoretical agreement and anecdotal evidence suggest that students who demonstrate teamwork skills in the simulation laboratory or in a clinical education environment with patients will apply those skills beyond the confines of their academic programs.

THE NEED TO INCREASE THE DIVERSITY OF THE NURSING WORKFORCE

Chapter 3 highlighted a variety of challenges facing the nursing profession in meeting the changing needs of patients and the health care system. A major challenge for the nursing workforce is the underrepresentation of racial and ethnic minority groups and men in the profession. To better meet the current and future health needs of the public and to provide more culturally relevant care, the nursing workforce will need to grow more diverse. And to meet this need, efforts to increase nurses' levels of educational attainment must emphasize increasing the diversity of the student body. This is a crucial concern that needs to be addressed across all levels of nursing education.

Racial and Ethnic Diversity

Although the composition of the nursing student body is more racially and ethnically diverse than that of the current workforce, diversity continues to be a challenge. Figure 4-8 shows the distribution of minority students enrolled in nursing programs by race/ethnicity and by program type. Their underrepresentation is greatest for pathways associated with higher levels of education. In academic year 2008-2009, for example, ethnic minority groups made up 28.2 percent of ADN, 23.6 percent of BSN, 24.4 percent of master's, and 20.3 percent of doctoral students (NLN, 2009). Even less evidence of diversity is present among nurses in faculty positions (AACN, 2010b).

In 2003, the Sullivan Commission on Diversity in the Healthcare Workforce was established to develop recommendations that would "bring about systemic change ... [to] address the scarcity of minorities in our health professions." The commission's report, Missing Persons: Minorities in the Health Professions (Sullivan Commission on Diversity in the Healthcare Workforce, 2004), offered strategies to increase the diversity of the medical, nursing, and dentistry professions and included recommendations designed to remove barriers to health professions education for underrepresented minority students. The commission's 37 recommendations called for leadership, commitment, and accountability among a wide range of stakeholders-from institutions responsible for educating health professionals, to professional organizations and health systems, to state and federal agencies and Congress. The recommendations focused on expediting strategies to increase the number of minorities in health professions, improving the education pipeline for health professionals, financing education for minority students, and establishing leadership and accountability to realize the commission's vision of increasing the diversity of health professionals. The committee believes the implementation of these recommendations holds promise for ensuring a more diverse health care workforce in the future.

In the nursing profession, creating bridge programs and educational pathways between undergraduate and graduate programs-specifically programs such as LPN to BSN, ADN to BSN, and ADN to MSN-appears to be one way of increasing the overall diversity of the student body and nurse faculty with respect to not only race/ethnicity, but also geography, background, and personal experience. Mentoring programs that support minority nursing students are another promising approach. One example of such a program is the National Coalition of Ethnic Minority Nursing Associations, a group made up of five ethnic minority nursing associations that aims to build the cadre and preparation of ethnic minority nurses and promote equity in health care across ethnic minority populations (NCEMNA, 2010). This program is described at greater length in Chapter 5. Another example of a successful program that has promoted racial and ethnic diversity is the ANA Minority Fellowship Program, started in 1974 under the leadership of Dr. Hattie Bessent. This program has played a crucial role in supporting minority nurses with predoctoral and postdoctoral fellowships to advance research and clinical practice (Minority Fellowship Program, 2010). Programs to recruit and retain more individuals from racial and ethnic minority groups in nursing education programs are needed. A necessary first step toward accomplishing this goal is to create policies that increase the overall educational attainment of ethnic minorities (Coffman et al., 2001).

Gender Diversity

As noted in Chapter 3, the nursing workforce historically has been composed predominantly of women. While the number of men who become nurses has grown dramatically in the last two decades, men still make up just 7 percent of all RNs (HRSA, 2010b). While most disciplines within the health professional workforce have become more gender balanced, the same has not been true for nursing. For example, in 2009 nearly half of medical school graduates were female (The Kaiser Family Foundation- statehealthfacts.org, 2010), a significant achievement of gender parity in a traditionally male-dominated profession. Stereotypes, academic acceptance, and role support are challenges for men entering the nursing profession. These barriers must be overcome if men are to be recruited in larger numbers to help offset the shortage of nurses and fill advanced and expanded nursing roles. Compounding the gender diversity problem of the nursing profession is the fact that fewer men in general are enrolling in higher education programs (Mather and Adams, 2007). While more men are being drawn to nursing, especially as a second career, the profession needs to continue efforts to recruit men; their unique perspectives and skills are important to the profession and will help contribute additional diversity to the workforce.

One professional organization that works to encourage men to join the nursing profession and supports men who do so is the American Assembly for Men in Nursing (AAMN). To increase opportunities for men interested in joining the profession, the AAMN Foundation, in partnership with Johnson & Johnson, has awarded more than $50,000 in scholarships to undergraduate and graduate male nursing students since 2004 (AAMN, 2010b). Additionally, each year the AAMN recognizes the best school or college of nursing for men; in 2009, the honor was given to Monterey Peninsula College in Monterey, California, and Excelsior College in Albany, New York, for their "efforts in recruiting and retaining men in nursing, in providing men a supportive educational environment, and in educating faculty, students and the community about the contributions men have and do make to the nursing profession" (AAMN, 2010a).

SOLUTIONS FROM THE FIELD

This chapter has outlined a number of challenges facing nursing education. These challenges have been the subject of much documentation, analysis, and debate (Benner et al., 2009; Erickson, 2002; IOM, 2003a, 2009; Lasater and Nielsen, 2009; Mitchell et al., 2006; Orsolini-Hain and Waters, 2009; Tanner et al., 2008). Various approaches to responding to these challenges and transforming curricula have been proposed, and several are being tested. The committee reviewed the literature on educational capacity and redesign, heard testimony about various challenges and potential solutions at the public forum in Houston, and chose a number of exemplars for closer examination. Three of these models are described in this section. The committee found that each of these models provided important insight into creative approaches to maximizing faculty resources, encouraging the establishment and funding of new faculty positions, maximizing the effectiveness of clinical education, and redesigning nursing curricula.

AACN and Hartford (The John A. Hartford Foundation Institute for Geriatric Nursing). 2000. Older adults: Recommended baccalaureate competencies and curricular guidelines for geriatric nursing care . Washington, DC and New York: AACN and The John A. Hartford Foundation Institute for Geriatric Nursing.

Alberto, J., and K. Herth. 2009. Interprofessional collaboration within faculty roles: Teaching, service, and research. OJIN: The Online Journal of Issues in Nursing 14(2).

Gilliss, C. L. 2010. Nursing education: Leading into the future . Cronenwett, L. R. 2010. The future of nursing education. Paper commissioned by the Committee on the RWJF Initiative on the Future of Nursing, at the IOM (see Appendix I on CD-ROM).

Gonyea, M. A. 1998. Assessing resource requirements and financing for health professions education. In Mission management: A new synthesis, edited by E. R. Rubin, editor. . Washington, DC: Association of Academic Health Centers. Pp.217-233.

IOM. 2010. A summary of the February 2010 Forum on the Future of Nursing: Education . Washington, DC: The National Academies Press. [ PubMed: 25032390 ]

Kreulen, G. J., P. K. Bednarz, T. Wehrwein, and J. Davis. 2008. Clinical education partnership: A model for school district and college of nursing collaboration. 24(6):360-369. [ PubMed: 19114466 ]

Manno, B. V. 1998. Vocabulary lesson: Cost, price, and subsidy in American higher education. 31(10):22-25.

McNelis, A. M., and P. M. Ironside. 2009. National survey on clinical education in prelicensure nursing education programs. In Clinical nursing education: Current reflections , edited by N. Ard, editor; and T. M. Valiga, editor. . New York: National League for Nursing.

Orsolini-Hain, L. 2008. An interpretive phenomenological study on the influences on associate degree prepared nurses to return to school to earn a higher degree in nursing, Department of Nursing, University of California, San Francisco.

Sullivan Commission on Diversity in the Healthcare Workforce. 2004. Missing persons: Minorities in the health professions: A report of the Sullivan Commission on Diversity in the Healthcare Workforce . Washington, DC: The Sullivan Commission.

Veterans Affairs Nursing Academy

In 2007, the VA launched the VANA-a 5-year, $40 million pilot program-with the primary goals of developing partnerships with academic nursing institutes; expanding the number of faculty for baccalaureate programs; establishing partnerships to enhance faculty development; and increasing baccalaureate enrollment to increase the supply of nurses, not solely for the VA, but for the country at large. VANA also was aimed at encouraging interprofessional programs and increasing the retention and recruitment of VA nurses.

Since the program's inception, three cycles of requests for proposals have been sent to more than 600 colleges and schools of nursing, as well as to institutions within the VA system. Fifteen geographically and demographically diverse pilot sites were selected to participate in VANA based on the strength of their proposals.

Each funded VANA partnership is required to have a rigorous evaluation plan to measure outcomes. Outcomes are expected to include increased staff, patient, student, and faculty satisfaction; greater scholarly output; enhanced professional development; better continuity and coordination of care; more reliance on evidence-based practice; and enhanced interprofessional learning. Each selected school is also expected to increase enrollment by at least 20 students a year.

The program has already resulted in 2,700 new students, with 620 receiving the majority of their clinical rotation experiences at the VA. The graduates of this program may include students who have pursued a traditional prelicensure BSN, a BSN through a second-degree program, or a BSN through an RN-to-BSN program. The number of nursing school faculty has increased by 176 and the number of VA faculty by 264.

In addition to the new nurses and faculty, educational innovations have encompassed curriculum revision, including quality and safety standards; DEUs (described earlier in Box 4-4); and a postgraduate baccalaureate nurse residency (see Chapter 3). Other changes include interprofessional simulation training and the development of evidence-based practice committees and programs. Beyond these specific changes and accomplishments, the VANA faculty has worked to develop the program into a single community of learning and to prepare students in a genuinely collaborative practice environment with clinically proficient staff and educators.

Carondolet Health Network

The Carondolet Health Network of Tucson, Arizona, is an example of how employers can offer educational benefits that improve both patient outcomes and the bottom line. Carondelet, which includes four hospitals and other facilities and employs approximately 1,650 nurses, is featured as one of seven cases studies in the Lewin Group's 2009 report Wisdom at Work: Retaining Experienced RNs and Their Knowledge-Case Studies of Top Performing Organizations.

After Carondelet became part of Ascension Health in 2002, the Tucson organization embarked on a strategic plan to recruit and retain more nurses. Arizona faces some of the severest nursing shortages in the nation, and most nurses prefer to live and work in higher-paying markets, such as Phoenix or southern California. When Carondelet instituted an on-site BSN program, which it subsidized in exchange for a 2-year work commitment, the response was dramatic. Instead of an anticipated class size of 20 nurses in the first semester of the program, it enrolled 104. Of interest, it was the business case-the opportunity to decrease the amount of money the organization was spending on costly temporary nurses-that tipped the balance in favor of action (The Lewin Group, 2009).

Hospital Employee Education and Training

The Hospital Employee Education and Training (HEET) program was developed through a joint effort of the 1199NW local affiliate of the Service Employees International Union and the Washington State Hospital Association Work Force Institute to help address shortages in nursing and nursing-related positions through education and upgrading of incumbent workers. The program is administered through the Washington State Board for Community and Technical Colleges. Across the state, HEET-funded programs support industry-based reform of the education system and include preparation and completion of nursing career ladder programs. HEET seeks to develop educational opportunities that support both employer needs and the career aspirations of health care workers. It features cohort-based programs, distance learning, worksite classes, use of a simulation laboratory for nursing prerequisites, case management, tutoring support for those reentering academia, and nontraditional scheduling of classes to enable working adults to attend and address employee barriers to education.

The findings for this union-inspired initiative demonstrate its potential to increase racial/ethnic diversity in the nursing population. HEET participants represent a pool of potential nurses who are more diverse than the current nursing workforce. Providing on-site classes at hospitals appears to support the participation of working adults who are enrolled in nursing school while continuing to work at least part time. Workers participating in the HEET program have had lower attrition rates and higher rates of course completion compared with community college students in nursing career tracks. The curriculum also blends academic preparation with health care career education, thereby opening the doors of college to workers who might not otherwise enroll or succeed (Moss and Weinstein, 2009).

CONCLUSION

The future of access to basic primary care and nursing education will depend on increasing the number of BSN-prepared nurses. Unless this goal is met, the committee's recommendations for greater access to primary care; enhanced, expanded, and reconceptualized roles for nurses; and updated nursing scopes of practice (see Chapter 7) cannot be achieved. The committee believes that increasing the proportion of the nursing workforce with a BSN from the current 50 percent to 80 percent by 2020 is bold but achievable. Achieving this target will help meet future demand for nurses qualified for advanced practice positions and possessing competencies in such areas as community care, public health, health policy, evidence-based practice, research, and leadership. The committee concludes further that the number of nurses holding a doctorate must be increased to produce a greater pool of nurses prepared to assume faculty and research positions. The committee believes a target of doubling the number of nurses with a doctorate by 2020 would meet this need and is achievable.

To achieve these targets, however, will require overcoming a number of barriers. The numbers of educators and clinical placements are insufficient for all the qualified applicants who wish to enter nursing school. There also is a shortage of faculty to teach nurses at all levels. Incentives for nurses at any level to pursue further education are few, and there are active disincentives against advanced education. Nurses and physicians-not to mention pharmacists and social workers-typically are not educated together and yet are increasingly required to cooperate and collaborate more closely in the delivery of care.

To address these barriers, innovative new programs to attract nursing faculty and provide a wider range of clinical education placements must clear long-stand ing bottlenecks. To this end, market-based salary adjustments must be made for faculty, and more scholarships must be provided to help nursing students advance their education. Accrediting and certifying organizations must mandate demonstrated mastery of clinical skills, managerial competencies, and professional development at all levels. Mandated skills, competencies, and professional development milestones must be updated on a more timely basis to keep pace with the rapidly changing demands of health care. All health professionals should receive more of their education in concert with students from other disciplines. Efforts also must be made to increase the diversity of the nursing workforce.

The nursing profession must adopt a framework of continuous lifelong learning that includes basic education, academic progression, and continuing competencies. More nurses must receive a solid education in how to manage complex conditions and coordinate care with multiple health professionals. They must demonstrate new competencies in systems thinking, quality improvement, and care management and a basic understanding of health care policy. Graduate-level nurses must develop an even deeper understanding of care coordination, quality improvement, systems thinking, and policy.

The committee emphasizes further that, as discussed in Chapter 2, the ACA is likely to accelerate the shift in care from the hospital to the community setting. This transition will have a particularly strong impact on nurses, more than 60 percent of whom are currently employed in hospitals (HRSA, 2010b). Nurses may turn to already available positions in primary or chronic care or in public or community health, or they may pursue entirely new careers in emerging fields that they help create. Continuing and graduate education programs must support the transition to a future that rewards flexibility. In addition, the curriculum at many nursing schools, which places heavy emphasis on preparing students for employment in the acute care setting, will need to be rethought (Benner et al., 2009).

REFERENCES

1

2

While titles for LPNs and LVNs vary from state to state, their responsibilities and education are relatively consistent. LPNs/LVNs are required to pass the National Council Licensure Examination for Practical Nurses (NCLEX-PN) to secure a license to practice.

3

4

5

"Difficult" is the sum of schools responding either "somewhat difficult" or "very difficult." Personal communication, Kathy A. Kaufman, Senior Research Scientist, Public Policy, National League for Nursing, September 8, 2010.

6

Personal communication, Joanne Spetz, Professor, Community Health Systems, University of California, San Francisco, September 2, 2010.

7

Patient Protection and Affordable Care Act, HR 3590 § 5311, 111th Congress.

8

Personal communication, Di Fang, Director of Research and Data Services, AACN, March 3, 2010.

9

This paragraph, and the three that follow, were adapted from a paper commissioned by the committee on "Transforming Pre-Licensure Nursing Education: Preparing the New Nurse to Meet Emerging Health Care Needs," prepared by Christine A. Tanner, Oregon Health & Science University School of Nursing (see Appendix I on CD-ROM).

10

11

Available evidence is based on evaluation of BSN programs and curricula. Evidence was not available for ADN or diploma programs.

12

Nursing-related doctoral degrees are defined by the National Sample Survey of Registered Nurses as non-nursing degrees that are directly related to a nurse's career in the nursing profession. "Nursing-related degrees include public health, health administration, social work, education, and other fields" (HRSA, 2010b).

13

14

Personal communication, Jean Johnson, Dean, School of Nursing, George Washington University, September 3, 2010.

15

Some faculty development programs and training opportunities are offered through universities and professional organizations, such as the AACN and the NLN. Additionally, the NLN offers a certification program for nurse educators, who can publically confirm knowledge in the areas of pedagogy, learning, and the complex encounter between educator and student. This certification program can provide a basis for innovation and the continuous quality improvement of nursing education.

16

17

Personal communication, Kathy Apple, CEO, NCSBN, May 30, 2010.

18

Personal communication, Kathy Apple, CEO, NCSBN, May 30, 2010.

19

This paragraph draws upon a paper commissioned by the committee on "The Future of Nursing Education," prepared by Virginia Tilden, University of Nebraska Medical Center College of Nursing (see Appendix I on CD-ROM).

20

Personal communication, Geraldine Bednash, CEO, AACN, August 12, 2010.

21

This paragraph draws upon a paper commissioned by the committee on "The Future of Nursing Education," prepared by Virginia Tilden, University of Nebraska Medical Center College of Nursing (see Appendix I on CD-ROM).

22

23

24

This paragraph, and the three that follow, draw upon a presentation made by Cathy Rick, chief nursing officer for the VA, at the Forum on the Future of Nursing: Education, held in Houston, TX on February 22, 2010 (see Appendix C) and published in A Summary of the February 2010 Forum on the Future of Nursing: Education (IOM, 2010).

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Major changes in the U.S. health care system and practice environments will require equally profound changes in the education of nurses both before and after they receive their licenses. In Chapter 1, the committee set forth a vision of health care that depends on a transformation of the roles and responsibilities of nurses.

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