March 25, 2008 - The following are notes from the NCSBN Innovation in Nursing Education Summit provided by the NCSBN. NAPNES does not necessarily endorse the information contained below but is provided to interested parties for informational purposes only.

How can educators, regulators and practitioners work together to innovatively enhance nursing education for the next generation of nurses?  This question was the foundation for a discussion that brought together nursing leaders from around the country for a discussion, led by the National Council of State Boards of Nursing (NCSBN) on March 25, 2008.  In addition to NCSBN staff, representatives were invited from six organizations related to nursing education, three boards of nursing, the American Nurses Association and The Robert Wood Johnson Foundation.  The meeting centered on the following objectives:

1. Establish a common understanding between regulators and educators regarding the meaning of innovation in nursing education and its importance in advancing nursing education in the 21st century.
2. Identify real and perceived regulatory barriers to innovation in nursing education and strategize how these can be addressed on the national and state level.
3. Identify exemplars of innovation in nursing education, partnerships and develop resources.
4. Create a vision as to how we can approach issues in nursing education innovatively and in accordance with one another.
5. Disseminate information to regulators and nursing educators across the country.

The meaning of innovation in nursing education

Innovation requires conceptualizing and envisioning new approaches to the teaching/learning process in nursing education. It requires faculty to think differently about the content/curriculum, instructional methods and clinical experiences in today’s nursing education programs.  It requires taking risks and a “non-traditional” approach to create a preferred future for nursing education in the United States.  

Faculty and program administrators should begin by examining the current state of nursing education and ask the following questions:  

• Why do we teach, what we teach; how best do you teach it; and who should teach it?
• What evidence supports the policies, programs, and rules and regulations that have characterized nursing education for decades?
•  How best should we prepare students to practice in a world that is uncertain and unpredictable?

Innovation is a dynamic process that requires communication, collaboration, and partnerships. Innovation means identifying “best practices” and sharing these among educators. It requires collaboration with regulators so that state laws are flexible and congruent with the needs of educators and students, and it necessitates partnerships with practitioners that will enhance the clinical experience.

Innovation arises out of inquiry and is an ongoing process.  This entails examining the existing evidence, investigating where we lack evidence, exploring new methods and creating new evidence for the future’s “next practices”.  Innovation requires evaluation and outcome measurements and dissemination of data across the discipline.

Innovation has broad implications.  The outcome of innovation must be at the point of care and lead to more proficient practitioners who are, in and of themselves, innovative.  New nurses need to learn the concepts of innovation and be able to apply them to their own thinking so they will respond to changes in health care and innovatively shape the education and health care delivery of the future.

Barriers to innovation

What is it that prevents educators and regulators from expanding practices and exploring new ways of teaching?  Barriers (real, as well as perceived) exist across education, regulation and practice.  An overall reluctance, on the part of educators, regulators, and practitioners to move out from the safety net, is a key barrier to innovation.

Educators are bound by tradition, comfort, and the fact that traditional pedagogy elicits an overall positive outcome in terms of student performance. The question arises, could nursing education be better, more effective and elicit better outcomes at the point of care?  Most individuals would respond affirmatively, but educators are bound by the fear of mistakes, of a decline in test scores and of students being deficient in clinical competence. An ineffectual change can impact negatively on a school’s pass rates, faculty evaluations, and the number of applicants applying for admission into a program.  As a result, educators seek the safety and comfort of what is known.

Boards of nursing, whose role is to protect the public and approve nursing education programs, grapple with many of the same concerns.   In the context of the traditional educational scheme, students learn to be competent nurses; they pass the licensure exam and provide safe patient care.  If the board of nursing has approved what it perceived to be an innovative change in a nursing education program and this results in poorer pass rates on the state licensure exam and questions concerning the competence of nurses from that program, the board of nursing may feel they supported a failed plan and they share the responsibility for the decline. As a result, regulators may hesitate to approve non-traditional methods of instruction.

Practitioners may also pose barriers to innovation. Hospitals and other institutions, fearing liability, place constraints on students and faculty.  Hospital-based policies may be rigid and prevent students from delegating, interfacing with physicians and the interdisciplinary team and other interactions that would increase a student’s proficiency and maximize their clinical experience. As a result, students’ preparation to problem-solve and care for patients may be limited.
 
Regulations regarding nursing education vary widely from state to state. The variation in state laws concerning nursing regulation can be confusing for educators who may have to adhere to regulations from more than one state if the school is located on a state border. The lack of consistency and uniformity among nurse practice acts leads to the question of why is a certain rule required of schools in one state and not another? Schools that border on states with different rules have difficulty making changes and innovation is stifled. 

There is also a lack of communication among educators and regulators.  This can enhance barriers and may create perceptual barriers. Regulations are too prescriptive in the eyes of educators, but in reality may not be as dogmatic as they are perceived to be. Educators may believe regulations that prevent innovation exist when they don’t or may not understand how to work within the context of the regulations. 

How do we maintain quality and promote innovation?

Innovation is not a substitute for quality or a reason to lower standards. Nursing programs must uphold standards and quality measurement tools should be used to evaluate outcomes. Innovative changes must be monitored.  The following are methods for maintaining quality amidst innovative changes:

1. Have quality indicators in place;
2. Hold individuals (faculty and nursing program administration) accountable;
3. Have informed students;
4. Monitor changes; examine strengths, process and outcomes. 

A vision for the future

A vision for the future must begin with the acknowledgment that, despite the successes of the status quo, there is a need to change the way nursing education is taught and students learn and think.  There is a need to improve the delivery of health care and there is also a need to do things differently in the light of a faculty shortage, a lack of clinical sites and constrained resources. We can view these as barriers or as an impetus for innovation.  

In order to create an educational system that is responsive to a challenging and changing environment, we need to transform the culture within nursing education from one that is traditional, safe, and rooted in the past, to one that is innovative, audacious and guided by the future.  Innovators take risks, make mistakes, and persevere. Perhaps, the first step in promoting innovative practices is giving permission for faculty to take risks and make mistakes. Faculty need to be the leaders in this process.  Institutions should provide incentives and rewards for innovative teaching.

Communication needs to occur between regulators and educators at the state level.  Educators need to learn regulations and understand what they mean.  Regulators should strive towards uniformity among the states.  Laws need to be flexible and based on as much evidence as possible.

Partnerships between practice and education are imperative. Chief nursing officers and other nursing administrators must be a part of the change and must also think innovatively. Flexibility must exist at clinical sites that allow for improved learning methods and innovative practices.  Flexibility must also exist in nursing education programs.  Faculty must learn to think differently to maximize student experiences.  Not every clinical experience must take place on a Medical-Surgical floor.

We must come to the realization that innovation depends on trial and error.  Not every innovative idea will be successful, but we must recognize failure as a step in moving forward.  In addition to generating ideas, we need to evaluate the outcomes of innovation and determine how these affect patient care.  This information should be disseminated and shared.

Exemplars

Innovative methods are already embedded in some nursing programs.  The Texas and North Carolina Board of Nursing Educational Consultants talked extensively about their board’s efforts to collaborate with educators and promote innovative nursing education programs.  Some of the efforts currently underway that were discussed include:    

• The Mayo Clinic Model: a  partnership between practice and education
• Texas State Board of Nursing:  Nurse Practice Act has regulatory language that encourages innovation in nursing education.
• North Carolina State Board of Nursing:  Educational consultants work with educators to interpret regulations and encourage new education models
• The University of Portland Dedicated Education unit 

Suggested plan

1. Create a multi-organizational website that will build evidence for innovation and be a resource for educators.  All organizations will have access to this and it will allow innovative educational experiences to be documented and shared.  This would include identifying best practices and outcome indicators.
2. Develop a document that addresses the role of regulation and education as partners in innovation.
3. Encourage conversations at the state level between educators, regulators and practitioners.
4. Literature review on innovation in nursing education.
5. Hold a conference, multi-organizational, on innovation in nursing education.