EvidenceBased Nursing Education

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Evidence-Based Nursing Education Nancy Spector,
PhD, RN, Director of Education June 5, 2007 North
Dakota Board of Nursing
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Mission of NCSBN

• The National Council of State Boards of Nursing
  (NCSBN), composed of Member Boards, provides
  leadership to advance regulatory excellence for
  public protection.

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• Resources in Education
• www.ncsbn.org
• Go to Programs Services/Education
• Position Paper on Clinical Experiences
• EBNER
• Education Systematic Review
• White Paper on Board of Nursing Approval
  Processes
• nspector_at_ncsbn.org

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Background

• Boards of nursing need evidence for their
  approval rules and regulations
• Legislators are asking for waiving of nursing
  education rules and regulations
• Data for promoting more consistent nursing
  education regulation

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Methodology for Conducing Systematic Review of
Nursing Education Outcomes Studies

• Modified Cochrane technique
• Studies categorized for strength of evidence
• Databases identified
• Inclusion criteria specified
• Specific keywords
• Inter-rater reliability

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Categories(Polit Beck, 2004 Gallagher, 2003)

• Level I
• Randomized controlled trial, systematic review,
  meta-analysis
• Level II
• Quasi-experimental, correlational, descriptive,
  survey, evaluation, qualitative
• Level III
• Expert opinion and consensus statements

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Databases

• CINAHL
• Medline
• Eric

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Keywords(In collaboration with medical librarian)

• Education
• Nursing
• Teaching
• Education research
• Learning methods
• Learning strategies
• Research-based education
• Outcomes of education

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Inclusion Criteria

• Study of educational outcomes
• Identification of design
• Sample description
• Comparison being studied or objective
  (qualitative studies)
• Reporting of results
• English only studies (included studies outside
  U.S.

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Inter-rater Reliability

• Practice, Regulation and Education Committee
  members reviewed studies for the same criteria,
  individually.

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Sample

• 25 Studies
• 3 Level I
• 22 Level II
• 0 Level III

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Systematic Review Key findings in literature
forclinical experiences

• Deliberate practice
• Feedback by qualified faculty
• Time to reflect
• Experiential learning in the authentic
  environment
• Becoming involved in the clinical setting by
  caring for actual patients
• Collaborate with interdisciplinary teams in the
  clinical setting

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Systematic Review - Other key findings

• Gaining confidence
• Building relationships with patients and other
  professionals
• Strategies to develop critical thinking
• A variety of teaching strategies is best,
  including traditional, simulation, and online
  methodologies
• When using online strategies, provide support and
  observation of unsupervised students

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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
• Platzer, Blake Ashford (2000) found the
  importance of immediate feedback and the
  opportunity to reflect

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Literature (Contd)

• Bjørk Kirkevold, (1999)
• Longitudinal, videotaped study from 8-14 months
  after licensure
• Interviews of patients and nurses
• Practicing skills of dressing changes ambulation
• Had short orientation of 3 weeks no
  opportunities for reflection or feedback

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Literature (Contd)

• Bjørk Kirkevold, (1999) (Contd)
• Same omissions and faults after 14 months of
  practice
• Contaminated wounds
• Misuse of gloves
• Failed to wash hands
• Dangerous tube removal
• Decreased caring
• Inadequate physical support during ambulation
• Privacy not provided

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Systematic Review Simulation(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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Studies ProvidingTheoretical Background

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

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Conclusions

• 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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Implications

• Evidence available to support clinical
  experiences
• Qualified faculty are importantbut what is
  qualified
• More work with simulated learning

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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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Besides collecting the evidence, PRE Committee
members

• 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
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Design

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

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Table 1. Study Participants
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Indicators of the Construct in the Theoretical
Model

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

• 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)

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

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

• 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

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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

• Reliability (RN version)
• 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

• 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 RNs

• 93 RNs are female with average age of 32
• 78.1 White 7.4 Black 8 Hispanic 3.9 Asian
  2.7 other

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Interesting Practice Characteristics

• Surveyed 9.9 months after receiving license
• Average hours per week - 36.1
• Work mandatory overtime 8.8
• Types of shifts 68.2 are 12-hour
• Employed by hospitals 87.9
• Critical care - 34.5
• Medical-Surgical 39.4

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Important Practice Findings

• Areas RNs Reported Being Adequately Prepared by
  Clinical
• Administer medications (81.5)
• Provide care to 2 clients (76.4
• Work effectively within a team (66)
• Perform psychomotor skills (64)
• Teach clients (63.9)
• Document (56.1)
• Make data-based decisions (55.9)

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Important Practice Findings

• Areas RNs Reported Being Adequately Prepared by
  Classroom
• Understand pathophysiology (68.8)
• Teach clients (62.7)
• Use IT to enhance patient care (62.1)
• Recognized medicine side effects (59)
• Meet clients emotional needs (57.2)
• Analyze multiple types of data (54.3)
• Understand clients cultural needs (52.4)
• Utilize research findings (50.3)

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Inadequacy of Preparation

• Areas RNs Reported Not Being Adequately Prepared
• Administer medicine to groups (52.1)
• Delegate tasks to other nurses (22.3)
• Supervise care by others (24.5)
• Know when and how to call a physician (21.7)

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Outcome

• Difficulty with Assignment
• 19.7 reported typical assignment is too
  challenging

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Significant Practice Relationships with Outcome
Measures
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Curriculum Characteristics Interesting
Clinical Findings For RNs

• Activities allowed
• Call physician only 55.9
• Delegate tasks 87.6
• Supervise care 85
• Clinical sites used
• 100 used medical-surgical units in hospitals
• 87.7 Critical care
• 77 Community or public health
• Preceptors/Adjuncts
• 82.1 used adjuncts/preceptors
• 20 of clinicals were supervised by
  adjuncts/preceptors

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

• Content Not Taught
• Use of IT 8.4
• Evidence-based practice 11.7
• Critical care 9.1

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Interdisciplinary Elements

• Clinical activities with other health care
  professionals 58.6
• Didactic course work with other health care
  professionals 23.2
• NOT available 32.5

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Relationship Between Curricular Elements and
Preparation

• The graduates were significantly (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, womens health,
  psychiatric and mental health, and
  medical-surgical nursing were taught independently

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Relationship Between Characteristics of Faculty
to Preparation

• The graduates were significantly (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
• Assist with clinical skills
• Also predictive of difficulty with assignments

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January 26, 2006, Invitational Highlights

• Transition
• More Research
• Expectations of new graduates
• Qualified faculty
• Disseminate the results
• Willingness to collaborate
• More inter professional communication

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Putting it all together EBNER Recommendations

• 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 role of the nurse
• Provide team building experiences

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EBNER Continued

• Deliberate experiences with actual patients
• Provide experiences for relationship building
  with patients
• Provide clinical experiences with actual patients
• Provide experiences for gaining confidence
• Provide opportunities for reflection
• Provide feedback
• Faculty-Student Relationships
• Faculty teach clinical and didactic courses
• Faculty are available to demonstrate and assist
  with skills
• Faculty assist with classroom projects
• Faculty are available to answer questions
• Faculty provide current information

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EBNER Continued

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

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Transition to Practice
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Transition to Practice

• CAT allows licensing within days of passing NCLEX
• NCSBNs 2002 2004 Employers studies
• lt 50 of new nurses are providing safe and
  competent care
• Health care is more complex practice frenzy!
• Increasing nurse and nurse faculty shortages
• Increasing evidence that a formal, structure
  transition program will protect the public

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Transition to Practice

• Not a New Concept
• M. Kramers Reality Shock Why Nurses Leave
  Nursing1974
• P. Benners work with novice to expert (1980s)

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Transition to Practice

• Literature
• Bjork Kirkvold, 1999
• Santucci, 2004
• Feedback
• Resources
• Safe environment
• Elements include role, skills, reshaping values

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Transition to Practice

• Literature
• Studies on retention and satisfaction
• Altier Krsek, 2006 Krugman et al., 2006
• Halfer, 2007
• Pine Tart, 2007

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Transition to Practice

• Literature
• Studies on Cost Benefit
• Pine Tart, 2007 savings of 823,680
• Halfer, 2007 savings of 707,608

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Transition to Practice

• NCSBNs Past Research
• Knowledge type General Specialty
• Placement Posthire had better outcomes
• Consistency Work same schedule with same
  preceptor

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Transition to Practice

• NCSBNs Research
• Kevin Kenward (2006) 2004 data
• Design and length of programs are inconsistent
• LPNs/VNs are most neglected
• Hospitals fare better than assisted care

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Transition to Practice

• NCSBNs Research

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Goals of the Study

• To describe the transition experience of newly
  licensed RNs
• To identify factors that influence transitions
  into practice
• To examine the impact of the transition
  experience on clinical competence and safe
  practice issues of newly licensed RNs

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Outcomes

• Primary Outcomes
• Clinical competency
• Practice errors and risks for practice breakdown
• Secondary Outcomes
• Stress level
• Job turnover

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New Nurse-Preceptor Dyad

• Two assessments
• - New RN self-assessment
• Corresponding preceptor/mentor assessment

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Results Most Competent Areas
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Results Least Competent areas
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Results Transition Programs

• Without preceptor, new RNs (3-6 months) practiced
  at LESS competent levels.
• This points to need for longer transition
  programs.

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Results Transition Programs

• Relationship to practice errors
• More competent in clinical reasoning,
  significantly fewer errors.
• More competent in communication and interpersonal
  relationships, significantly fewer errors.

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Results Transition Programs

• Perceived stress (almost always)
• Felt overwhelmed with patient care
  responsibilities 24
• Fear of harming patient due to inexperience
  2.8
• Felt expectations unrealistic 15.6
• All were signficantly related to practice errors

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Perceived Stress During 1st Year
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Results Transition Programs

• Internship programs were significantly less
  likely to feel expectations were unrealistic (and
  therefore fewer practice errors).
• Transition programs that addressed specialty
  knowledge, nurses were significantly less likely
  to feel expectations were unrealistic (and
  therefore fewer practice errors).

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Joint Commission Validation
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Results Transition and Turnover
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2007 Transition Forum

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

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Speakers Transition Forum

• 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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Themes Transition Forum

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

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Vision

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

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Premises of Transition Model(s)

• Failure to transition new nurses is a public
  safety issue
• Transition is facilitated by active engagement of
  the new nurse and the preceptor
• Transition programs will improve practice and
  decrease errors
• A standardized, national transition program will
  help the formation of professional nurses
• A standardized, national transition program will
  increase nurse retention

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Some Thoughts

• Flexible
• Robust include all settings and all levels of
  education
• National Web site
• Preceptor education
• Relate to license?
• Pilot study of states
• How do we gain consensus?

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Next Steps
NCSBN will look at feasibility of a national,
standardized model
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