The National Council State Boards of Nursing (NCSBN) convened an Invitational Forum today to collaborate with more than a dozen organizations (for a list of the organizations that were in attendance click here).  The purpose, to discuss the role that state boards of nursing play in the regulation of nursing education.  The NCSBN was armed with studies and research to address issues with nursing education at both the LPN and RN levels.

In the end, the systematic review of the 26 research studies used for this conference found that the IOM competencies listed below are congruent with nursing education:

1. Working effectively within the team
2. Understanding the pathophysiology
3. Delegating tasks to others
4. Analyzing multiple types of data when making client-related decisions
5. Administering meds to a group

IMPLICATIONS FOR NURSING EDUCATION

Based on the systematic review of the research, the evidenced based educational elements of an effective nursing education include:

• Teaching specialty knowledge as independent courses
• Integrate critical thinking, use of information technoloy, and evidence based practice throughout the curriculum
• Use faculty who teach didactic courses to also teach clinical
• Increase faculty availability to students
• Promote quality faculty-student interactions
• Provide transition programs to address specialty knowledge

For those of you interested in greater detail, I've included a good number of the data presented at the forum and details about how the invited organizations worked with the NCSBN on this project.

THE RESEARCH
Here's are the highlights of the research presented at the forum:

Background for Elements of Nursing Education

Systematic review of databases included CINAHL, Medline, ERIC which produced 26 usable studies for prelicensure nursing programs.   A systematic review of the literature produced the following key findings for clinical experiences:

• Deliberate practice
• Feedback by qualified faculty
• Time to reflect
• Experiential learning in the authentic environment
• Involvement in the clinical setting caring for actual patients
• Interdisciplinary team collaboration in the clinical setting
• Gaining confidence
• Building relationships with patients and other professionals
• Development of critical thinking strategies
• Varied teaching strategies work best, including traditional, simulation, and online methodologies
• Support and observation is necessary when using online strategies.

A systematic review of past studies conducted by the NCSBN indicate that best practices in nursing education include learning experiences where students can:

• Make decisions
• Provide direct care to two clients
• Know when and how to call the physician
• Work effectively with the health care team

A systematic review of three studies with students and faculty show these factors are enhanced with clinical experiences:

• Gaining confidence
• Gaining comfort in nurse's role
• Building relationships with colleagues
• Connecting with patients
• Understanding the clinical picture

A systematic review of simulation use in nursing practice indicated the need for the following:

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

This information along with a systematic review of theoretical background, surveys of education organizations, AONES position statement, and surveys to the boards of nursing, led the NCSBN to make the following evidenced-based clinical recommendations for prelicensure nursing programs:

• Education should be across the life span
• Education shall include clinical experiences with actual patients and might also include innovative teaching strategies
• Should be supervised by "qualified" faculty that provide feedback and facilitate reflection.
• Faculty retain responsibility to demonstrate programs have sufficient clinical experiences to meet program's defined outcomes
• Additional research is needed on prelicensure education and the development of clinical competency.

Elements of Education Study

The Elements of Education study involved two rounds of surveys.  The first to prelicensure nursing programs and the second to graduates of those programs that had been in practice for less than one year.  In total 410 schools and 7,497 graduates responded to the surveys.  The NCSBN presented demographics on these numbers including program types (LPN, ADN, Diploma, BSN, etc), graduate types (LPN, ADN, Diploma, BNS, etc.), gender, race and employment location.  For the purposes of this article we are not presenting those numbers.  However, I have listed the numbers numbers below that I found most interesting:

SPECIALTY AREA Where are the new graduates working.  Graduates were allowed to choose up to two specialty areas.
	RN %	LPN %
Critical Care	34.5	3.1
Medical-surgical unit	39.4	17.3
Pediatrics or nursery	7.8	4.0
OB	7.5	1.5
Psychiatry	2.3	3.7
Operating Room	3.8	0.6
Long-Term Care	8.7	66.0
Physician / Dentist Office	1.6	7.2
Home health	1.2	5.1
Other	9.5	18.0

ADEQUACY OF PERPARATION BY CLINICAL EDUCATION
	RN %	LPN %
Administer Medications	81.5	82.3
Provide direct care to 2 clients	76.4	77.7
Work effectively within team	66.0	74.2
Perform psychomotor skills	64.0	71.3
Teach clients	63.9	61.5
Document legally def. account	56.1	63.6
Make data-based decisions	55.9	49.7

ADEQUACY OF PERPARATION BY CLASSROOM EDUCATION
	RN %	LPN %
Understand pathophysiology	68.8	64.0
Teach clients	62.7	62.9
Use IT to enhance patient care	62.1	64.6
Recognize medication side effects	59.0	64.6
Meets clients' emotional needs	57.2	63.8
Analyze multiple types of data	54.3	53.2
Understand clients' cultural needs	52.4	59.2
Utilize research findings	50.3	52.6

INADEQUACY OF PREPARATION
	RN %	LPN %
Administer meds to groups	52.1	27.5
Delegate tasks to other nurses	22.3	28.2
Supervise care by others	24.5	26.5
Know when and how to call MD	21.7	20.4

When looking at the elements of education: clinical, didactic, and interdisciplinary; the surveys continued to produce interesting results.

Despite these numbers, nearly 1 in 5 of all graduates (RNs 19.7% and LPNs 17.7%) reported difficulty with their client assignments up graduation.  The average RN program provided 758 clinical hours, of which 595.9 were in direct patient care.  The average LPN program had 639.5 clinical hours with 467.4 in direct patient care.  While not differentiating between the RN and LPN programs, the NCSBN reports that 80% of clinical hours are spent taking care of two patients or less and only 20% are spent taking care of more than two.

The NCSBN provided information on didactic issues including general content, content related to client populations, content not taught, link between didactic and clinical components, and interdisciplinary activities.  While I am not including those numbers here, the survey results reported that students were more likely to feed adequately prepared if:

• Higher percentages of faculty that teach in both didactic and clinical setting
• Information technology and evidence-based practice are taught
• Pathophysiology, critical thinking, information technology and evidence-based practice is taught as integrated content throughout the curriculum
• Content on different patient populations (Peds, Psych, etc.) are taught as independent courses.

As another component of the study, NCSBN looked at the characteristics of the faculty.  In this area, faculty practice and preparation, and faculty-student interactions was reviewed.

When looking at faculty practice and preparation, I think the majority of attendees at the forum were surprised to see the following numbers:

FACULTY PRACTICE & PREPARTATION
	Programs
Percentage of faculty:	RN Mean	LPN Mean
Required to practice	13.3	22.8
With joint appointments	2.6	9.1
With MSN as highest degree	59.5	24.2
With Doctorate as highest degree	13.9	1.0

When looking at the Faculty-Student Interaction numbers below, it may at first glance appear to be good.  But what we're actually looking at means that from about 25% to 50% of students lack student-faculty interactions in the areas measured.

FACULTY-STUDENT INTERACTION
Faculty available to:	RN %	LPN %
Answer questions about content	73.3	77.4
Assist with classroom projects	55.0	63.8
Answer questions during clinical	74.1	79.2
Assist with clinical skills	75.3	77.5
Demonstrate skills in clinical	74.6	78.1
Provide current information in classroom	67.0	73.5

Summarizing the relationship of characteristics of faculty to preparation for practice, the graduates felt more adequately prepared when faculty were available to:

• Demonstrate skills in clinical
• Assist with classroom projects
• Provide current information in classroom
• Assist with clinical skills
• Require students demonstrate skills
• Answer questions during clinical
• Answer questions about content

Finally, the NCSBN looked at transition to practice.  Noting that 54% of employers surveyed indicated that new graduates were not prepared for entry in to their practice setting.

When evaluating transition, the survey looked at four areas: type, duration, preceptor/mentor, and focus of the program.

Under types of orientation, the NCSBN looked at "ships" (internship, externship, etc.), and routine orientation.  Here are the numbers reported by the new graduates surveyed.

TYPES OF TRANSITION PROGRAMS
	RN %	LPN %
"Ship"	26.4	12.2
Routine Orientation	35.2	68.9
Both	35.4	13.2
None	3.0	5.7

Staggering in the numbers is how short these transition periods lasted.  In fact, the average length of orientation for these new grads was just 11 weeks.

DURATION OF TRANSITION PROGRAMS
	RN %	LPN %
< = 6 weeks	35	85
7-12 weeks	44	12
3-6 Months	15	2
> 6 Months	6	2

THE FORUM

Participants at the forum were asked three questions after the presentation of the research material.  The questions asked were:

1. Considering that the mission of the boards of nursing is to protect the public, what do you see as the critical elements of nursing education that are necessary for producing safe nurses?
2. Considering the mission of the boards of nursing is to protect the public, what insights do you have regarding the literature, the results of our past studies, and the results of our elements study?
3. Based on the literature, the results of past studies, and the results of the elements study, what insight do you have for future research?  Please identify possible collaborations for joint research endeavors.

To answer these questions, the participants were divided into three smaller groups.  Each question was discussed for 45 minutes.  After each discussion session the groups reconvened and listed their responses and further discussion was allowed.  This process repeated for each question.

The answers and ideas were both excellent and abundant.  In a follow-up to this article, I will report on the answers to these questions in some detail.

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GROUPS ATTENDING THE INVITATIONAL FORUM

American Association of Colleges of Nursing
American Nurses Association
American Organization of Nurse Executives
Center for Innovation, National Board of Medical Examiners
Citizen Advocacy Center
Commission on Collegiate Nursing Education
Department of Physiological Nursing, UCSF
Joint Commission on Accreditation of Health care Organizations
Kaiser Permanente
National Association for Practical Nursing Education and Services, Inc.
National Federation of Licensed Practical Nurses
National League for Nursing Accrediting Commission
National League of Nursing
National Organization of Associate Degree Nurses
National Student Nurse Association
University HealthSystem Consortium

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