EvidencedBased Nursing Education

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Evidenced-Based Nursing Education
NAPNES May 2007
Nancy Spector, PhD, RN Director of Education,
NCSBN
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Welcome!
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NCSBN Education Papers

• www.ncsbn.org
• Go to Programs and Services/ Education
• E-mail nspector_at_ncsbn.org

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Background

• Boards of Nursing need evidence for rules and
  regulations
• Legislators are asking for waivers on rules and
  regulations
• Promote more consistent nursing education rules
  and regulations
• Context of practice frenzy!
• Health care becoming more complex
• Nursing shortage
• Computerized NCLEX decreases transition times for
  new nurses

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Papers

• Approval of Nursing Programs
• PN Scope of Practice White Paper
• Systematic Review of Nursing Education Outcomes
• NCSBN Position Paper on Clinical Instruction
• Evidence-Based Nursing Education for Regulation

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Ongoing Systematic Review of Nursing Education

• Levels adapted from Polit and Hungler (2004)
  Gallagher (2003)
• Level I Properly conducted RCT, systematic
  review or meta-analysis
• Level II Other studies, such as
  quasi-experimental, correlational, descriptive,
  survey, evaluation, and qualitative
• Level III Expert opinion or consensus
  statements

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Systematic ReviewDatabases used

• CINAHL
• Medline
• ERIC
• Keywords
• Education, teaching, education research,
  learning methods, learning strategies,
  research-based education, outcomes of education

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Systematic ReviewCriteria

• Educational outcomes
• Identify a design
• Sample described
• Comparison being studied or objective of study
  (qualitative studies)
• Report of results
• Not limited to U.S., though must be written in
  English

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Systematic ReviewResults

• 25 usable studies
• 22 Level II
• 3 Level I

• Analysis
• Citation
• Sample
• Comparison
• Procedures
• Key Results
• Strengths and Weaknesses
• Implications for Boards

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Systematic ReviewFindings

• Deliberate practice
• Supervision by qualified faculty who provide
  feedback and opportunities for reflective
  practice
• Clinical experiences with actual patients
• Collaboration with interdisciplinary teams
• Opportunities to develop critical thinking
• Online and simulated strategies

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Systematic ReviewStudies with students and
faculty

• White (2003) qualitative design5 components of
  clinical decision-making
• Gaining confidence
• Gaining comfort in the role of a nurse
• Building relationships with staff
• Connecting with patients
• Understanding the clinical picture

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Systematic ReviewStudies with students and
faculty(cond)

• Angel, Duffey Belyea (2000) found that
  critical-thinking, measured objectively, improved
  after a semester of faculty supervised clinical
  experiences
• Bjørk Kirkvold (1999) supports qualified
  faculty providing feedback to students
• Platzer, Blake Ashford (2000) found the
  importance of immediate feedback and the
  opportunity to reflect

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Systematic ReviewSimulation(Issenberg,
McGaghie, Petrusa, Gordon Scalese, 2005)

• Feedback by qualified faculty
• Repetitive practice
• Integration with the curriculum
• Offering a range of difficulty
• Allowing multiple learning strategies
• Capturing clinical variation
• Controlled environment
• Defined outcomes
• Valid simulator

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Systematic ReviewConclusions

• There is available evidence on nursing education
  outcomes
• Actual clinical experiences improve learning
  outcomes
• Supervision by qualified faculty essential
• Feedback and reflection important
• Simulation techniques are beneficial
• Online learning most beneficial with traditional
  learning
• More research is necessary

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LiteratureProvidingTheoretical Background

• Benners work with the Dreyfus Modelnovice,
  advanced beginner, competent, proficiency,
  expertise.
• Linking Benners work with Ericcsons sentinel
  review of deliberate practice
• Linking Benner Ericcson to theory of situated
  cognition

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Past studies at NCSBN
Past studies at NCSBN

• Best Practices in Nursing Education Provide
  learning experiences where students can
• Make decisions
• Provide direct care to 2 clients
• Know when and how to call the physician
• Supervise care
• Work effectively with the health care team

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Other Evidence

• Surveys to nursing education organizations
• Position statement of AONE
• it is the position of AONE that all
  prelicensure nursing education programs must
  contain structured and supervised clinical
  instruction and that the clinical instruction
  must be provided by appropriately prepared
  registered nurses.

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Other Evidence, (cond)

• Surveys to boards of nursing
• 28/31 thought they should have direct patient
  contact
• 27/31 thought experiences should be across the
  lifespan
• Variable with requiring actual hours
• Issues for the future
• Technology
• Making the most of clinical and learning sites

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Other Evidence - PRE Committee

• Consulted with renowned expert in simulation, Dr.
  William McGaghie, from Northwestern University
  Feinberg School of Medicine
• Participated in simulation experience at the
  Patient Safety Simulator Center at Northwestern
  University Feinberg School of Medicine.
• Engaged in dialogue with a simulation facilitator
  at the Patient Safety Simulator Center

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NCSBN Evidence-BasedClinical Recommendations(app
roved by Delegate Assembly in August 2005)

• Prelicensure nursing education programs should be
  across the lifespan.
• Prelicensure nursing education programs shall
  include clinical experiences with actual
  patients they might also include innovative
  teaching strategies that complement clinical
  experiences for entry into practice competency.

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NCSBN Evidence-BasedClinical Recommendations(app
roved by Delegate Assembly in August 2005),
(contd)

• Prelicensure clinical education should be
  supervised by qualified faculty who provide
  feedback and facilitate reflection.
• Faculty members retain the responsibility to
  demonstrate that programs have clinical
  experiences with actual patients that are
  sufficient to meet program outcomes.
• Additional research needs to be conducted on
  prelicensure nursing education and the
  development of clinical competency.

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NCSBNs Elements Study
NCSBNs Elements Study
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Design
Design

• Two Rounds of Survey
• Nursing Programs
• Graduates of those programs

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Study Participants
Study Participants
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Design
Indicators of the Constructs in the Theoretical
Model

• Faculty
• Education preparation of faculty
• Percentage of faculty in practice
• Percentage of faculty with joint appointments
• Faculty-student interactions
• Availability of faculty to students (graduate
  perception)

• Graduate attributes
• Gender
• Age
• Ethnicity
• Type of education completed

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Design
Indicators of the Constructs in the Theoretical
Model, (cond)

• Curriculum
• Clinical hours
• Direct care experience
• Clinical learning activities allowed
• Types of clinical sites used
• Student-faculty ratio for clinical teaching
• Percentage of faculty that teaches both didactic
  clinical components of curriculum

• Use of preceptors and/or clinical adjuncts
• Didactic content taught
• Modes of delivery of didactic content
• Interdisciplinary opportunities
• Link between didactic clinical elements
• Distance education

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Design
Indicators of the Constructs in the Theoretical
Model, (cond)

• Characteristics of Practice
• Employing facility
• Specialty areas
• Length of employment after receiving license
• Regular working hours in a week
• Non-Nonmandatory overtime
• Mandatory overtime
• Types of shift

• Program characteristics
• Geographic location
• Size of the program
• Faculty shortage
• Number of faculty

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Design
Indicators of the Constructs in the Theoretical
Model, (cond)

• Outcomes measures
• Perceived adequacy of preparation
• Perceived difficulty with client assignments

• Transition Program
• Types
• Duration
• Timing
• Paid or pay for
• Preceptor/mentor involvement
• Focus of the transition program

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Instrument
Instrument

• Reliability
• 12 clinical components Cronbach Alpha 0.87
• 11 classroom components Cronbach Alpah 0.91
• Internal consistency of each of the items
  0.87-0.91

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Instrument
Instrument

• Validity
• Content
• Advisory Panel of nurses around country
• Practice, Regulation and Education Committee
• Education consultants from boards of nursing
• Concurrent
• Relationship between perceived adequacy of
  preparation and difficulty in client assignments
  plt.0001

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Characteristics of Nurses
Characteristics of PNs

• 91.5 PNs are female with average age of 34.2
• 67.2 White 22.1 Black 5.2 Hispanic 2.3
  Asian 3.3 other

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Interesting Practice Characteristics
Interesting Practice Characteristics

• Surveyed 10.4 months after receiving license
• Average hours per week 35.2
• Work mandatory overtime 9.9
• Types of shifts 63.4 are 8-hour
• Employed by Longterm care 51.8
• Hospital 25.8
• Community/Ambulatory 17.5

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Important Practice Findings
Important Practice Findings

• Areas PNs Reported Being Adequately Prepared
• Administer medications (82.3)
• Provide care to 2 clients (77.7)
• Work effectively within a team (74.2)
• Perform psychomotor skills (71.3)
• Teach clients (61.5)
• Document (63.6)
• Make data-based decisions (49.7)

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Important Practice Findings
Important Practice Findings

• Areas PNs Reported Being Adequately Prepared by
  Classroom
• Understand pathophysiology (64)
• Teach clients (62.9)
• Use IT to enhance patient care (64.6)
• Recognized medicine side effects (64.6)
• Meet clients emotional needs (63.8)
• Analyze multiple types of data (53.2)
• Understand clients cultural needs (59.2)
• Utilize research findings (52.6)

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Inadequacy of Preparation
Inadequacy of Preparation

• Areas Nurses Reported Not Being Adequately
  Prepared
• Provide direct care to 6 clients (35.3)
• Administer medicine to groups (27.5)
• Delegate tasks to other nurses (28.2)
• Supervise care by others (26.5)
• Know when and how to call a physician (20.4)

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Inadequacy of Preparation
Difficulty with Assignment

• 17.7 PNs reported typical assignments were too
  challenging

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Significant Practice Relationships with Outcome
Measures
Significant Practice Relationships with
Difficulty with Assignments Logistic Regression
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Interesting Clinical Findings
Curriculum Characteristics Interesting
Clinical Findings For PNs

• Activities allowed
• Call physician only 19.4
• Delegate tasks 58.6
• Start IVs 43
• Clinical sites used
• 100 used medical-surgical units in hospitals
• 97.7 used longterm care settings
• Preceptors/Adjuncts
• 50.8 used adjuncts/preceptors
• 20 of clinicals were supervised by
  adjuncts/preceptors

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Interesting Clinical Findings
Curriculum Characteristics
Mean of student/faculty ratios across settings
varied from 6.3 9.4
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Interesting Didactic Findings
Curriculum Characteristics Interesting
Didactic Findings

• Content Not Taught
• Use of IT 12.4
• Evidence-based practice 45.7
• Critical care 53.9
• Care Management/Supervision 17.8

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Interdisciplinary Elements
Interdisciplinary Elements

• Clinical activities with other health care
  professionals 60
• Didactic course work with other health care
  professionals 23.9
• NOT available 30.8

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Relationship Between Curricular Elements and
Preparation
Relationship Between Curricular Elementsand
Preparation

• The graduates were significantly (using multiple
  regression) more likely to report being
  adequately prepared when
• Higher of faculty teach didactic and supervise
  clinical
• When use of information technology and
  evidence-based practice were taught
• When pathophysiology, critical thinking were
  integrated throughout curriculum
• When population content, such as pediatrics,
  womens health, psychiatric and mental health,
  and medical-surgical nursing were taught
  independently

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Relationship Between Characteristics of Faculty
to Preparation
Relationship Between Characteristics of Faculty
to Preparation

• The graduates were significantly, using multiple
  regression, more likely to report being
  adequately prepared when faculty
• Demonstrate skills in clinical
• Assist with classroom projects
• Provide current information in the classroom
• Student is required to demonstrate skills
• Answer questions about content
• Answer questions during clinical
• Also predictive of difficulty with
  assignments
• Assist with clinical skills

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Relationship Between Characteristics of Faculty
to Preparation
Putting it all Together - EBNER

• Adjunctive teaching methods
• Promote faculty student online interaction
• Facilitate learning simulation
• Combine online and traditional strategies
• Assimilation to the role of nursing
• Provide interdisciplinary experiences
• Provide experiences for the role of the nurse
• Provide team building experiences

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Relationship Between Characteristics of Faculty
to Preparation
Putting it all Together - EBNER

• Deliberate experiences with actual patients
• Experiences for relationship building with
  patients
• Clinical experiences with actual patients
• Experiences for gaining confidence
• Opportunities for reflection
• Feedback
• Faculty-student relationships
• Teach clinical and didactic courses
• Faculty are available to demonstrate and assist
  with skills
• Faculty assist with classroom projects
• Faculty are available for questions
• Faculty provide current information

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Relationship Between Characteristics of Faculty
to Preparation
Putting it all Together - EBNER

• Teaching methodologies
• Integrate critical thinking
• Use critical thinking strategies
• Integrate evidence-based practice
• Integrate pathophysiology
• Teach population courses separately
• Require students to demonstrate skills before
  performing them on patients

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Characteristics of Transition Programs
Characteristics of Transition Programs

• Type Routine orientation (68.9) and
  internship/residency (12.2) both 13.2)
• Duration Up to 6 weeks (85) 7-12 weeks (12)
• Preceptor/Mentor
• Assigned to same preceptor 34.5
• Worked the same schedule 43.3
• Focus on Program
• General 55
• Specialty 20.2
• 5.7 of PNs did not receive an orientation or
  internship

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Relationship Between Transitionand Outcomes
Relationship Between Transition and Outcomes

• When specialty knowledge was addressed, using
  multiple regression
• Significantly more likely to feel adequately
  prepared by education
• Significantly less likely to find assignments too
  difficult

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Other Transition Work
Other Transition Work

• Placement of the transition program
• Same mentor with same schedule
• Transition programs are inconsistent (NCSBN,
  2006)
• LPNs/VNs assigned to patients earlier and
  caseload is heavier (NCSBN, 2006)
• 38.9 of RNs participated in ships and
  orientation only 16.2 of LPNs/VNs (NCSBN, 2006)
• Transition Forum February 22, 2007, in Chicago

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Invitational Forum Highlights
Transition Forum Highlights

• February 22, 2007
• 41 states, 5 countries, 200 participants
• Discuss vision of transitioning new graduates
  from broad perspective
• Examine national and international perspectives
  of transitioning new nurses
• Seek input from stakeholders and participants
  about effective transition models

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Invitational Forum Highlights
Transition Forum Highlights

• Dr. David Leach, ACGME Transition to Practice
  A Journey to Authenticity
• Cathy Krsek report of UHC/AACN yearlong
  residency
• Carol Dobson report of Scotlands Flying Start
  Program
• Suling Li NCSBNs report linking transition
  programs to safety
• Susan Boyer and Patty Spurr statewide
  initiatives

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Invitational Forum Highlights
Transition Forum HighlightsPanelists

• Representatives from
• AACN
• ANA
• AONE
• NAPNES
• NLN

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Invitational Forum Highlights
Transition Forum Highlights

• Do the right thing for the right reasons
• The context of the workplace Frenzy!
• A national, standardized transition program is
  desired
• The transition program should last 6 months to 1
  year
• Preceptors need to be acknowledged and educated
• Articulate the evidence to the practice arena
• Collaborate extensively for buy-in

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Invitational Forum Highlights
Vision for the Future of Transition

• Transition program of 6-12 months
• Standardized
• National
• Collaboration of practice, education, regulation

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EBNER (Contd)
Too much to do, Too little time!