Foundations of Nursing Education

The executive team at Hartford Community College (HCC) has determined the time has come to change the current two year associate degree (ASN) program to a four year bachelor degree (BSN) program. I have been asked to chair the nursing curriculum committee as I am the director of the allied health programs. This report has been created for the Board of Directors to assure them that the program will be consistent with all state and national professional standards and guidelines while factoring in current trends in social, economic and institutional areas.

Justification for Change

Changes in healthcare are happening more rapidly than ever before. With the implementation of the Affordable Care Act, health providers are required to provide affordable, high quality care at a reduced price. Patients in acute care settings are sicker and older than twenty years ago. It is estimated that the population 65 years and older will be 20% by the year 2030 (The Institute of Medicine [IOM], 2010). In order to provide excellent patient care, nurses need to be more knowledgeable and have higher levels of critical thinking skills than ever before.

The IOM (2010) report also recommends that 80% of the registered nurse (RN) workforce hold a BSN degree, with a target date of 2020. American Community Survey (ACS) data showed that RNs holding a BSN or higher rose from 49.7% in 2000 to 55.2% from 2008 to 2010, an increase of 5.5%. At a growth rate of 5.5% over ten years, much still needs to be done to reach the 80% goal by 2020 (Health Resources and Services Administration Bureau of Health Professions, 2013).

Need for BSN Program

The first example of a need for the change from an ASN to a BSN program is a result of societal influences. Nurses, now more than ever, must meet the demands of the healthcare consumer. With the rapid increases in technology, many of our patients use this technology to look up symptoms or their diagnoses on the internet. As the patients become more informed, nurses need to keep up at minimum, but preferably stay a step ahead. Social trends are supplying the healthcare field with better informed consumers; we need to supply these consumers with better informed healthcare providers.

The second example of a need for change is part economic and part political. As the population ages, comorbidities increase. It is imperative that the nurses we are preparing are able to meet the challenges in dealing with an older, sicker population. Statistically, acute care centers with a higher percentage of BSN nurses have better patient outcomes and decreased mortality (IOM, 2010). Although California has not yet introduced legislation for the “BSN in 10” like New York and New Jersey, the American Nurses Association is pushing the requirement nationwide of new nurses obtaining their BSN degree within 10 years of licensure (Trossman, 2008). As the need for better critical thinking skills becomes necessary to best serve the consumer, education is the driving force to acquire these skills.

External Forces

The IOM is the main external force behind these changes. In addition to creating a goal of 80% BSN RNs by 2020, they have studies showing the improved outcomes for not only patients, but for institutions as well. Studies show the mortality rate decreases by 5% with a 10% increase in BSN nurses on a unit (Davis, 2003, September 23).

Many healthcare insurers follow the Medicare payment policies. The Medicare policies include but are not limited to what constitutes an appropriate admission diagnosis, how the institution will be reimbursed, how many days are covered for a specific diagnosis related group (DRG). Medicare offers an incentive plan for quality care based on patient satisfaction surveys as well as penalties for hospital acquired conditions (HACs) and readmissions with the same diagnosis within 30 days (Cubanski et al., 2015). BSN nurses are better able to comprehensively teach their patients self-care, reducing readmission rates. As evidence based practice is a large part of the BSN program, this would aid in a reduction of HACs. Both of these improvements would contribute to the bottom line of an institution.

Recommendation to Guide Quality and Safety Initiatives

Although there are five organizations to choose from when integrating quality and safety initiatives into the curriculum, the Quality and Safety Education for Nurses (QSEN) initiative aligns closely with what we are trying to accomplish. QSEN was formed by nursing educators to help improve the quality and safety of nursing practice nationwide. Starting with phase I in October of 2005, QSEN has brought a set of six competencies to fill the gaps in nursing curriculum, thereby improving quality and safety.

Rationale for Selected Recommendation

As we move forward, we need to access resources to aid us in this journey. Why reinvent the wheel when so many others are paving the way for you. QSEN was formed by nursing educators for the sole purpose of improving quality and safety through education (Dolansky & Moore, 2013). They have more than 100 teaching strategies available to us. Their areas of improvement include evidence-based practice, patient centered care, quality improvement, informatics, collaboration, and teamwork. These are the areas in which we will need to guide our students so that we have competent graduates with excellent critical thinking skills.

Barrier to Recommendation

A possible barrier to this recommendation is the education level of our current faculty members. Although some of our faculty has the required master degree (MSN) required for teaching BSN students, there are not enough. There will be an additional expense to hire adjunct faculty to instruct while our faculty obtains the necessary education levels for the new program.

Argument for Using a Theory

The constructivist theory is based on the idea that new learning is built on a foundation of old learning. It takes the cognitive learning theory one step further. The learner wants to learn. Instructors need to understand that past experiences color the way the person learns. New knowledge is compared, contrasted, and built upon previous knowledge. It is then sorted and stored (Braungart, Braungart, & Gramet, 2014). The ability to compare, contrast, sort, and recall is the thinking we want to encourage and build in our graduates.

Critical thinking involves several processes: what do I know about this, why is this different, is there anything else like this, and what should I do? Rather than rote textbook knowledge, critical thinkers look at what they know compared to how this is different to come up with solutions. Humans are not textbooks; no amount of memorization is going to cover every possible nuance. We want our nurses to look beyond the textbook.

Sometimes they might not even know why something is right. A nurse I know took a central line class. The question came up what should you do if you removed a peripherally inserted central catheter and the tip was broken. Not being sure, she whispered to her neighbor, “Put the patient in Trendelenburg on their left side.” The instructor overheard and stated she was right, and then asked “Why would you do that?” The nurse stated she knew it was what needed to be done for a fat embolism in a postop hip patient, it seemed very similar. Critical thinking allowed her to take a process she knew and apply it to a totally different situation. This is the kind of thinking that allows for better patient outcomes. This is the kind of thinking we want to promote in our graduates. Social learning and critical thinking are strongly emphasized in constructivism by problem solving scenarios (“Constructivism,” n.d.).

Theory Critique

There are advantages and disadvantages to any learning theory. One advantage to the constructivist theory is that it addresses the way humans think and learn. It is like building a house, the foundation is laid and then you build. You put down a learning foundation and build on it from there. By connecting the simpler concepts and correlating them to concepts already learned, you build a strong network of knowledge. Another advantage to the constructivist theory is that as the learners build their house of knowledge, the foundation is simple, and each additional layer builds from and expands on the layer before. Each layer reinforces the layer below, making the knowledge more permanent (“Constructivism,” n.d.).

One disadvantage to the constructivist theory is that it does not address emotions. If a learner is having difficulties at home, but is stoic and hide their emotional distress well, they may not give enough attention to the material being presented to learn. By not adding the information to the previous layers, the current layer is weak and may not stand up to the next layer that needs to be built. By missing a step, the foundation of learning is weakened. Another disadvantage to the constructivist theory is that learners who are more intuitive and grasp a concept quickly may become bored when the subject is slowed down due to a lack of understanding by other learners. Boredom could cause the quicker learners to miss a step because their minds have wandered off somewhere. On the flip side of the coin, there may not be enough time during a class session to adequately teach the slower learners. If a class had a high percentage of slow learners, individualized learning may become too time consuming for the instructor (“Constructivism,” n.d.).

Key Components

The educational philosophy that we will be using to develop the new BSN program is authentic learning. Authentic learning fits our concept of constructivist learning and critical thinking skills. There are four key components of authentic learning. The first is simulation activities or a role playing scenario where at the end a discussion is held regarding the findings or outcomes of the simulation. The second includes open ended questions which support critical thinking skills and discussion. The third is students engaging discussions in a social learning environment. The fourth is students plan projects to direct their own learning (Rule, 2007).

Critique of Philosophical Approach

An advantage to authentic learning is that it occurs naturally in nursing practice settings. It can be simulated in educational settings (Candela, 2012). By computer and classroom simulations, we can expose the students to a wide range of situations to improve and expand their critical thinking skills. Authentic learning will set them up to become lifetime learners, as they will have a basis in learning from practice settings.

A disadvantage to authentic learning comes from a lack of preparation or incomplete thought processes when planning learning activities. If students cannot connect what they are learning to real life, they may become disengaged (Candela, 2012).

Delivery Modalities

Delivery modalities will consist of classroom theory and simulation labs. Classroom theory is the time to deliver the new ideas and help our student construct their knowledge. Lab simulations are a safe environment for our students to learn the physical skills needed, while connecting the physical skills with the new knowledge base.

Justification of Modalities

A justification for using traditional classroom education lies in the expense of nursing school. Not everyone is able to afford the technology needed to attend online classes. Some students need a structured learning environment as they are easily distracted when sitting in front of a computer at home. Traditional classroom education allows for structure, social learning, and feedback as well as just listening to a lecture (Anderson, 2013).

Simulations are used not only in nursing education, but in education over many different “service” professions and general public education as well. The Great California Shake Out is an example of community simulation education. The military, fire and police departments all use simulation as part of not only initial, but also ongoing education. In the American Heart Associations (AHA) Advanced Cardiac Life Support (ACLS) classes, various life threatening heart rhythms are simulated while the students “run the code” to practice life saving techniques. That so many different organizations use simulation is a testament to the advantages.

Potential Barriers

Potential barriers can exist in any learning modality. For traditional classroom education, it can be difficult for students who need to work, especially if they work night shifts. Students that have difficulties in their home lives may have problems paying attention in class.

The potential barriers to simulation experiences can be both financial and technological. Simulation labs can be expensive to set up and maintain. Technology improves every day, so the technology of the simulation lab can quickly become outdated.

Formative and Summative Assessment

A formative assessment is used to determine understanding of concepts. It is useful during teaching periods to make sure all the students have adequate understanding of the subject. Formative assessments are considered “low stakes” assessments, where a grade given, if any, is not worth a great deal of points. Formative assessments allow students to reflect on areas where they may need additional information or better understanding. They also allow faculty to see which students might benefit from additional help, or to assess their teaching methods to see if they are failing to impart critical information (Carnegie Mellon, n.d.).

Summative assessments are used after a topic of information has been completed to evaluate understanding of the entire topic. Examples are higher point exams at the end of the study of a body system or unit and term papers. A final exam is a type of summative assessment. Feedback given in formative assessments and previous summative assessments give the student a map of what to study for a final exam (Carnegie Mellon, n.d.).

Formative Assessments Benefits

The first advantage to formative assessments is the evaluation of learning in a low stress environment. Discussions and case studies with both peer and instructor feedback allow for a deeper understanding of the material. A student who may be having difficulty understanding a concept, when heard it in the words of his peers, may obtain a better understanding (Sasser, 2015).

The second advantage to formative assessments is that a faculty member, reflecting on the teaching process, may realize something is missing in the information they are imparting when a larger majority of the students fail to understand a subject. This would allow a quick addition of the missing or misunderstood information. In real time anything that is lacking in the teaching can be addressed and improved (Sasser, 2015).

Summative Assessment Benefits

Summative assessments evaluate overall learning. One benefit is the ability to test the retention of material. If a unit of study is five or six chapters long, the most recent chapter would be the freshest memory. By using summative assessments, you are able to test the retention of the earlier parts of the unit. The final exam typically covers the entire coursework, and assesses overall retention. Students who have participated in exam reviews will have had a chance to study the areas in which they did not perform well. Since many final exams are cumulative, there is the opportunity to make up for lower scores on previous summative assessments.

The second benefit again is on the faculty side. By conducting exam reviews of summative assessments, the instructor can see where there might be an overall lack of understanding. By readdressing the lacking information, the instructor can prepare the students for a cumulative final exam, and change future coursework lessons to address the deficiency.

Formative Assessment Limitations

Since formative assessments have little or no grade value, one disadvantage is that students may not take them seriously. Students may find themselves pressed for time, and choose not to complete them in order to make time for other studies. A second disadvantage is that formative assessments performed during class time can take away from teaching time. Instructors may not be able to cover all the course material required if a discussion runs over the allotted time (Sasser, 2015).

Summative Assessment Limitations

One of the limitations of a summative assessment is that students may experience “test anxiety”, and not perform to their potential because of the fear of not doing well. In a term project, they may not adequately paraphrase or cite, which would lead to plagiarism. A second disadvantage is that summative exams are also used as a standard by which to evaluate the instructor, so the instructor may “teach to the test” for fear that the students will not perform well. This method of teaching does not build on previous knowledge for better understanding; it is more memorizing than understanding (Concordia Online Education [Concordia], 2013).

Analysis of Assessments

Classroom Assessment Techniques (CAT) will be used for assessment of learning. These assessments will allow for exploration, discussion, reinforcement, and understanding of the curriculum. By creating a pre-course questionnaire, we will be able to assess the prior knowledge of our students. This will allow the instructors an opportunity to assess ahead of time which students may need some additional help. Another advantage to CAT is that students come to understand that learning and teaching are processes of discovery, experimentation, and reflection (Vanderbilt University The Center for Teaching [Vanderbilt], 2015).

ANA Code of Ethics

The American Nurses Association (ANA) Code of Ethics was originally developed in 1950 to address the need for a set of professional standards. The Code of Ethics was updated the first time in 1976, again in 1985, and in 2001 the nine provisions were updated and named the Code of Ethics for Nurses with Interpretative Statements (Nelson & Alt, 2014).

The nine provisions were updated again in 2015. According to the ANA, only minor changes were made to the principles and links have been added. The nine principles address compassion, commitment, protection, accountability, duty or self and others, ethical environments, safety of the workplace, advancement of the profession, collaboration, integrity, values, and principles of social justice (American Nurses Association [ANA], 2015).

We will integrate the Code of Ethics into our coursework. Every course of the BSN program has an opportunity to stress on or more principles. The current ethics course will be revised to place a greater emphasis on the Code of Ethics.

Analysis of FERPA

The Family Educational Rights and Privacy Act of 1974 was enacted to protect the educational information of students in programs that receive federal funding. It offers parents and students the right to correct inaccurate information in addition to keeping information regarding disciplinary actions private. It does not cover privacy of name, address, telephone number, date of birth, or awards; however the institution must disclose that this “directory information” may be released (U.S. Department of Education, n.d.).

At the start of each new semester, information will be provided on disclosure of directory information. With this information will be a form the student may fill out to suppress the release of directory information. In addition, information about the process to correct inaccurate information, as well as the appeal process if the institution does not believe a correction is necessary will be included at the start of each semester. There will be a need to meet with our legal counsel to develop a process by which we can maintain integrity if there is a problem with a student at a clinical site while protecting the students privileged information. This process, after it is developed, will be included in the student handbook. It will be included as a separate document each semester until such time as it has been printed in the handbook.

Analysis of ADA

Title II and Title II of the American with Disabilities Act (ADA) covers education after secondary school, Title II covers state funded colleges, universities, and vocational schools while Title II covers private institutions. As a community college, HCC already falls under Title II of the ADA. Under the ADA modification of programs is not required when it will fundamentally affect the program (Leuchovius, n.d.). We will, however, continue to act in accordance with Title II of the ADA.

In addition, we will implement printed core requirements for the BSN program based on the report The Americans with Disabilities Act: Implications for Nursing Education report (Southern Regional Education Board [SREB], 2015) has a list of core standards with types of accommodations that would be expected in a nursing program. By using these standards we will assure we are in compliance with the ADA.

Analysis of HIPAA

The Health Insurance Portability and Accountability Act was designed to prevent unauthorized access of health information. Sharing of health information is limited to only what is necessary for certain activities, like continuity of care and insurance billing. Fines range from $250 to $25,000 for HIPAA violations. Clinicals need to be a part of any nursing program, but we need to respect the privacy rights of all patients.

In our ethics course, HIPAA will be covered in depth. Not only will our students need it during their studies, they will need it during their entire professional career. Students will be required to identify themselves as students and ask permission of patients to prior to providing care. Special care will be made to make sure any documents with information that can identify patients will be shredded prior to leaving the clinical area. Any reports or case studies required of students will have only the initials and age of the patient to preserve their right to confidentiality.

As an educator of potential healthcare providers, we must strongly impress on our students the importance of protecting patient confidentiality. Special emphasis will be placed on the privacy rule during the courses of study. This rule was established to create a national standard for medical records and personal health information. It specifically limits uses of protected health information (PHI), and requires authorization from the individual for use of any PHI (U.S. Department of Health & Human Services [HHS.gov], n.d.).

Analysis of Copyright Laws

Federal copyright laws were put into place to protect “original works of authorship” including written material, music, recordings, architecture among others (U.S. House of Representatives Office of the Law Revision Counsel, n.d.). Under copyright law, authors must be given proper credit. Faculty may use, with permission, materials to teach as long as the author is properly credited. In order to avoid plagiarism and ensure originality by our students, we will Turnitin, a software programs that will compare our student papers to web pages, other student papers, and articles from books and publications (Turnitin website, n.d.).

Analysis of Accreditation Method

HCC already hold accreditation through the California Board of Registered Nursing for the ASN program. Accreditation for a BSN program will require that we have an agreement with a college or university that already has the ability to grant bachelor degrees (California Board of Registered Nursing [BRN], 2015), as well as submit a new application to the BRN for approval.

To be more attractive to student and potential employers, we will also seek accreditation by the National League of Nursing (NLN). The Commission for Nursing Education Accreditation (CNEA) is the branch of the NLN that carries out accreditations. Their mission is to promote excellence as well as integrity, and they are highly regarded world-wide (National League for Nursing [NLN], 2015). Their mission and core values align perfectly with what we are trying to accomplish.

Conclusion

In this report we have outlined that the new BSN program will comply with all state and federal regulations. The change is needed as employers and governing organizations recognize that a BSN should be the entry level for nursing. The world is rapid changing, due in large part to technology. Healthcare seems to be changing even more rapidly than the world in general. Nursing needs to keep ahead of the demands of newer technology and better informed patients, while making sure that the patients have correct information from valid resources. By implementing this program, we are helping to create the more educated workforce justified by the IOM.

The baby boomers are aging. While the length of life today is to be celebrated, with longer lives come more complex medical issues. We need to send nurses who have the tools and skills to attend to these more complex patients. We will follow QSEN guidelines to assure our program is relevant and current. QSEN has tools and resources available to us to aid in our journey.

We will combine the constructivism theory with authentic learning to stimulate the critical think skills of students. Hiring adjunct faculty while our current faculty increases their education levels will help us ride out the wave of transition. By offering a blend of traditional classroom and simulation labs we address needs of those who learn in different ways. Formative and summative assessments as well as CAT will be used to assess learning.

To cover the need for legal accountability, the ANA Code of Ethics will be integrated into all new classes, and there will be special emphasis on it during the ethic course. Handouts will be provided to notify students of their rights under FERPA and ADA until such time as these can be included in the printed student handbook. We will base our core standards on the report from SREB to ensure compliance of ADA standards. Turnitin will be used to scan student papers for originality. Our faculty will be held to the highest standards regarding use of educational material. We will seek accreditation from the NLN as well as the BRN.

References

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