Creativity and Connections: The Future of Nursing Education and ...

CREATIVITY AND CONNECTIONS: THE FUTURE OF NURSING EDUCATION AND PRACTICE: THE MASSACHUSETTS INITIATIVE MAUREEN SROCZYNSKI, DNP (C), MS, RN,⁎ GAYLE GRAVLIN, EDD, RN, NEA, BC,† PAULETTE SEYMOUR ROUTE, PHD, RN,‡ NANCY HOFFART, PHD, RN,§ AND PATRICIA CREELMAN, MS, RN|| Education and practice partnerships are key to effective academic program design and implementation in a time of decreasing supply and increasing demands on the nursing profession. An integrated education/practice competency model can positively impact patient safety, improve patient care, increase retention, and ensure a sufficient and competent nursing workforce, which is paramount to survival of the health care system. Through the contributions of nursing leaders from the broad spectrum of nursing and industry organizations within the state, the Massachusetts Nurse of the Future project developed a competency-based framework for the future design of nursing educational programs to meet current and future practice needs. The Massachusetts Nurse of the Future Nursing Core Competencies © expand on the Institute of Medicine's core competencies for all health care professionals and the Quality and Safety Education for Nurses competencies for quality and safety to define the expectations for all professional nurses of the future. The Massachusetts Nurse of the Future Nursing Core Competencies define the knowledge, attitude, and skills required as the minimal expectations for initial nursing practice following completion of a prelicensure professional nursing education program. These competencies are now being integrated into new models for seamless, coordinated nursing curriculum and transition into practice within the state and beyond. (Index words: Academic–practice partnerships; Competency-based curriculum model) J Prof Nurs 27: e64–e70, 2011. © 2011 Elsevier Inc. All rights reserved.

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N 2006, NURSING practice and education leaders in Massachusetts were among the first in the country to begin to focus on the question of how to better educate the nurses of the future. The purpose of this article is to describe the success of the efforts of Massachusetts in

*Former Chief Nursing Consultant for the Massachusetts Department of Higher Education Nursing Initiative and President/CEO of Farley Associates, Inc., Norton, MA. †Associate Chief Nursing Officer at Lahey Clinic, Burlington, MA. ‡Dean and Professor, Graduate School of Nursing, University of Massachusetts-Worcester campus, Worcester, MA. §Founding Dean and Professor, Alice Ramez Chagoury School of Nursing, Lebanese American University, Byblos, Lebanon. ||Nurse Clinical Education Coordinator, Quinsigamond Community College, Worcester, MA. Address correspondence to Dr. Sroczynski. E-mail: [email protected] 8755-7223/11/$ - see front matter e64 doi:10.1016/j.profnurs.2011.08.007

bringing nursing education and practice leaders together to address nursing workforce needs for the future. After a number of meetings to frame the dialogue, the Massachusetts Department of Higher Education (DHE) and the Massachusetts Organization of Nurse Executives (MONE) convened a facilitated working session entitled “Creativity and Connections: Building the Framework for the Future of Nursing Education and Practice.” This invitational session brought together 32 experienced professionals from the major statewide stakeholders in nursing education and practice. Included were nurse leaders from the continuum of practice settings, nurse educators from public and private higher education and all degree levels, and representatives from the DHE, MONE, the Board of Registration in Nursing, the Massachusetts Center for Nursing, the Massachusetts Association of Colleges of Nursing, the Massachusetts/

Journal of Professional Nursing, Vol 27, No. 6 (November-December), 2011: pp e64–e70 © 2011 Elsevier Inc. All rights reserved.

THE MASSACHUSETTS INITIATIVE

Rhode Island League for Nursing, and individuals knowledgeable of national accrediting standards of the National League for Nursing (NLN) Accrediting Commission. The summit began with a review of emerging best practices from across the country. The American Organization of Nurse Executives' (2006) guiding principles for the role of the nurse in future patient care delivery and the journey and vision of the Oregon Consortium for Nursing Education were presented on Day 1 (Creativity and Connection, 2006). Day 2 included brainstorming and multivoting to identify the priorities for the future of nursing practice and education in Massachusetts. The primary outcome of the conference was the development of a mission statement and a structure to frame future work. The participants agreed to establish a formal coalition to create a seamless progression through all levels of nursing that is based on consensus competencies that include transitioning nurses into their practice settings. Although the participants represented a wide range of perspectives on nursing education and nursing practice, there was agreement on these top priorities: • Creation of a seamless progression through all levels of nursing education • Development of sufficient consensus on competencies to serve as a framework for educational curriculum • Development of a statewide nurse internship/ preceptor program. Following the invitational session, a working group composed of deans and faculty representing all segments of nursing education, nursing practice leaders, and clinical nursing staff representing the continuum of care was established (see Table 1). The group's objective was to create a structure and processes to accomplish these priorities. The group formed two working committees. First, the Massachusetts Nurse of the Future (NOF) Competency Committee focused on developing a seamless continuum of nursing education built on a set of identified competencies. The NOF

Table 1. NOF Competency Committee: Organizational Representation Massachusetts DHE cochair ⁎ MONE cochair ⁎ Massachusetts Association of Colleges of Nursing ⁎ Massachusetts Board of Registration in Nursing Massachusetts Center for Nursing Massachusetts Community College Deans Association Massachusetts/Rhode Island League for Nursing ⁎ Massachusetts Senior Care Association Home Care Alliance of Massachusetts Licensed Practical Nurse Education Faculty representatives Southeastern Massachusetts Staff Nurse Council ⁎ The authors represent these lead organizations in the NOF project.

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Competency Committee met monthly, usually for 4 hours with individual and small group work occurring between meetings. Second, the MONE Academic Practice Integration Committee agreed to use the identified competencies to develop a statewide transition into practice model. The volunteers in both committees remained committed and consistent, although there were occasions when new members replaced some who had to resign because of other commitments. A process was developed to provide new members with sufficient orientation and background materials to support their understanding of the work and enable them to fully engage in the initiative. Efforts were also made to ensure that the contributions of all members would be acknowledged as project reports were disseminated. These practices were consistent with the circle practice (Baldwin & Linnea, 2010) that was used to facilitate all the meetings that were held as the project progresses.

Competency Development The NOF Competency Committee began its work by developing a set of assumptions to serve as a framework and provide guiding principles for the design of a competency-based education and practice partnership model (see Table 2). Using these assumptions as a set of shared beliefs for its diverse membership and using circle practice (Baldwin & Linnea, 2010) as a methodology insured that contributions of all group members were recognized. The NOF Competency Committee worked for 3 years reviewing the literature and synthesizing state, national, and international evidence. Nurse competencies collected from other states, current practice standards, education accrediting standards, national and international initiatives, and projected patient demographic and health care profiles for Massachusetts were analyzed. Examples of extant competency models reviewed include the Institute of Medicine's (IOM, 2003) core competencies for all health care professionals, the Quality and Safety Education for Nurses (QSEN, 2007) model, and the Accreditation Council for Graduate Medical Education (ACGME; see Table 3). This 3-year effort resulted in the NOF Nursing Core Competencies (2010).

The Model The NOF Nursing Core Competencies model represents the essential competencies that inform future professional nursing practice and curricula (see Figure 1). Nursing knowledge in its totality reflects the overarching art and science of nursing as a scholarly profession and a practice-based discipline. Therefore, nursing knowledge serves as the central core of the model. Ten essential competencies that guide nursing curricula and practice emanate from the central core and include patientcentered care, professionalism, leadership, systems-based practice, informatics and technology, communication, teamwork and collaboration, safety, quality improvement, and evidence-based practice (Technology Informatics Guiding Educational Reform [TIGER], 2007,

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Table 2. Assumptions and Guiding Principles for Competency Development Assumptions

Guiding principles

Education and practice partnerships are key to developing an effective model.

Nursing education and practice settings should facilitate individuals to move more effectively through the educational system. An integrated practice/education competency model will positively impact patient safety and improve patient care. Nursing practice should be differentiated according to the RN's educational preparation and the level of practice and further defined by the role of the nurse and the work setting. Practice environments that support and enhance professional competence are essential. Advancing the education of all nurses is increasingly being recognized as essential to the future of nursing practice. Evidence has demonstrated that nurses with higher education levels have a positive impact on patient care. The competencies are designed to be applicable across all care settings and to encompass all patient populations across the life span. In this global society, essential to the care of diverse populations are the need for evidence-based knowledge and sensitivity to variables such as age, gender, culture, health disparities, socioeconomic status, race, and spirituality. There is a differentiation in competencies among practicing nurses at various levels of experience. Competence is developed over a continuum and can be measured.

It is imperative that leaders in nursing education and practice develop collaborative curriculum models to facilitate the achievement of a minimum of a baccalaureate degree in nursing (BSN) by all nurses. There is a need to develop a more effective educational system that is capable of incorporating the shifting demographics to prepare the nursing workforce to respond to current and future health care needs and population health issues.

The nurse of the future will be proficient at a core set of competencies. Nurse educators in both education and practice settings will need to use a different set of knowledge and teaching strategies to effectively integrate the NOF Nursing Core Competencies into curriculum. Note. Data from Massachusetts DHE NOF Competency Committee (2010).

2009). The order of the competencies does not indicate any hierarchy; all competencies are of equal importance. The competencies are connected by broken lines because distinctions between individual competencies may be blurred; they overlap and are not mutually exclusive. The relationship between each of the competencies and nursing knowledge is reciprocal and continuous. The 10 competencies were further articulated using the knowledge, attitudes, and skills (KAS) approach, that is, the cognitive, affective, and psychomotor domains of learning, and were intended to serve as a basis for consistent performance expectations across academic and practice settings. The definition of each competency

defines the expectations for all professional nurses of the future. The KAS for each of the competencies are the expectations for initial nursing practice following completion of a prelicensure professional nursing educational program (see Figure 2).

Communication, Feedback, and Gap Analysis Following the development of the first draft for the competencies, a formalized process of focused communication was developed to seek feedback from stakeholders and nurses throughout the state. This process

Table 3. Core Competency Comparisons IOM Apply quality improvement Provide-patient centered care Work in interdisciplinary teams Employ evidence-based practice Use informatics

ACGME

QSEN

Practice-based learning and improvement Systems-based practice Patient care; interpersonal and communications skills Professionalism

Teamwork and collaboration

Medical knowledge

NOF

Quality improvement Safety

Quality improvement safety systems-based practice

Patient-centered care

Evidence-based practice

Patient-centered care communication leadership Teamwork and collaboration professionalism Evidence-based practice

Informatics

Informatics


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Source: Massachusetts Department of Higher Education Nurse of the Future Competency Committee (2010) Nurse of the Future Nursing Core Competencies.

Figure 1. Nurse of the Future Core Nursing Competencies (source: Massachusetts DHE NOF Competency Committee, 2010).

included online feedback opportunities, two statewide summits, and campus meetings with faculty from public and private associate, baccalaureate, and master's entry nursing education programs. In addition, meetings with nursing leadership groups and nursing practice councils from a variety of health care organizations were held around the state.

A gap analysis process adapted from the QSEN project (G. Sherwood, personal communication, 2006) was then developed for nursing programs in collaboration with their practice partners to evaluate their curriculum against the NOF competencies. The purpose of the gap analysis was to identify the differences between what is currently being taught and what nursing programs and

Figure 2. Competency example.

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Table 4. The Improvement Process (Institute for Healthcare Improvement, 2007) Plan 2006–2007

• Formation of committee structure • Literature review of competencies and frameworks for future of nursing education • Analysis of emerging best practices, competencies and standards ▪ IOM ▪ Oregon Collaborative for Nursing Education ▪ Quality and Safety in Nursing Education ▪ Accreditation Council for Graduate Medical Education (ACGME) ▪ Agency for Healthcare Research and Quality ▪ American Association of Colleges of Nursing ▪ American Nurse Association ▪ American Organization of Nurse Executives Guiding Principles for Future Care Delivery ▪ Bologna Accord ▪ Commission on Collegiate Nursing Education ▪ Competency, Outcomes Performance Assessment model (COPA) ▪ International Council of Nurses ▪ NCLEX-RN Detailed Test Plan ▪ NLN Accrediting Commission ▪ Technology Informatics Guiding Educational Reform (TIGER) • Examination of predicted Massachusetts patient demographics • Review of current practice and education competencies in use in Massachusetts

Do 2006–2008

Development of initial NOF Core Nursing Competencies document All-day retreats Regional meetings Presentation to nursing professional organizations across the state Two statewide summits for nursing faculty and nursing leadership

Study 2008–2009

Gap analysis of curriculum in partnerships of ADN and BSN programs and practice partners Development of pilot curriculum models Sharing with faculty at campuses across state Sharing with nursing leaders and staff nurses at practice sites across state Online site for submission of feedback

Act 2009–2010

Second literature review Revision of competency document incorporating current best practices and feedback Statewide summit to share process and final outcomes Sharing of model and process within New Hampshire and Rhode Island

Adapt, adopt, and spread 2010–2011

Tracking of dissemination and usage across state, region, and country

their clinical practice partners believe should be taught to professional nursing students to enable them to achieve the NOF Nursing Core Competencies by graduation. Eight nursing programs in collaboration with one or more respective clinical practice partners were selected through a competitive application process to participate in DHE-funded projects to conduct gap analyses of their curriculums and report the results to the NOF Committee. The gap analyses revealed similar gaps across both associate degree in nursing (ADN) and bachelor of science in nursing (BSN) programs with the competencies of systems-based practice, informatics and technology, quality improvement, evidence-based practice, and communication having the greatest differences between current curricula and NOF competencies. The process also identified the need for a common language between education and practice and the need for practice to be involved earlier in the education process for students in professional nursing programs.

Findings from the gap analysis were used in conjunction with another review of the literature and comparison with nationally accepted models, guidelines, and standards to further refine and clarify the competencies for initial publication (American Nurses Association, 2004; Technology Informatics Guiding Educational Reform [TIGER], 2007, 2009) (see Table 4). The NOF Nursing Core Competencies were compared with the following nationally recognized works: The Essentials of Baccalaureate Education for Professional Nursing Practice (American Association of Colleges of Nursing, 2008), the Bologna Accords (Alexander & Runciman, 2003), the Competency Outcomes and Performance Assessment (COPA) model (Lenburg, 1999), the NLN Council for Associate Degree Nursing Competencies Task Force (NLN, 2000), and the ACGME Outcomes project (ACGME, n.d.). Pertinent information from these comparisons were then incorporated into an updated version of the NOF competencies and became the


framework for the design of a new seamless curriculum model linking a community college program to one of the state university nursing programs.

The Curriculum Using the NOF Core Nursing Competencies as the linking pin, the community college associate degree program and the university baccalaureate degree program developed a one-plus-two-plus-one curriculum model (1 year with aligned prerequisites, 2 years at the community college, and the final year in the online program from the university). This model allows students to seamlessly move from the community college to the university and fully complete BSN requirements within 15 months of completing ADN requirements. The process involved having the university accept the passage of National Council Licensure Examination for Registered Nurses (NCLEX-RN) to meet the university's residency requirement and directly aligning the prerequisites of the community college with the BSN program. Although the students take a total of 131 credits, which is 10 more credits than the generic BSN program, they save $25,000 in tuition fees through this combined program. This model is now serving as a prototype for other nursing programs in the state and the New England region.

Transition Into Practice While the NOF Competency Committee was focusing on the competency development and the integration of the competencies into curricula, the MONE Academic Practice Integration Committee used a similar process to review the literature and current best practices to identify the components of a transition into practice model. Focusing on the concepts of preceptors, preceptees, and organizational climate, this committee is continuing to work on the integration of the competencies into a formalized transition into practice model that can be shared statewide. The committee is working with the assumption that transition into practice begins with a nursing student's first clinical experience, and this further emphasizes the need for links between education and practice competencies.

Widening the Circle As academic and practice leaders within Massachusetts began to discuss and share the outcomes of the NOF work with other nursing and health care professionals in the New England region, there was significant enthusiasm for collaboration on a regional scale. With the support of a grant from the Robert Wood Johnson Foundation Partners Investing in Nursing's Future program, the NOF work expanded to encompass nursing education programs and practice leaders in Rhode Island and New Hampshire. These states are now using the Massachusetts gap analysis process to design new seamless progression curriculum models. Although each state is creating models specific to their needs, the Massachusetts NOF Core Nurse Competencies have served as a foundation in the development of partner-

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ships between nursing education and practice leaders. It is evident that this work has addressed a desire by all parties to redesign nursing education to meet the needs of health care systems of the future.

Lessons Learned Opportunity and innovation are born out of crisis (O'Neil Hewlett & Bleich, 2004). Innovation, however, is not easy, and gaining consensus among invested stakeholders can be challenging. The lessons learned from the development of the Massachusetts model for the future of nursing revolved around the process of building partnerships, developing meaningful communication, and sustaining commitment. Holding the meetings in a neutral territory that was neither an education nor practice site was helpful in balancing the power within the group. The use of circle practice was beneficial in the development of a safe and respectful environment, facilitated the process of making “the elephants” in the room visible to all and easier to manage, and allowed the group to successfully move through any conflict. The provision of food at all meeting fueled both the body and mind and supported active participation over the lengthy but necessary process of improvement. The Massachusetts model emerged from the sustained and committed efforts and contributions of all the participants in both the NOF Competency Committee and the MONE Academic Practice Integration committee. Labeling their efforts as the coalition of the willing, members of both committees worked with their organizations to disseminate the work across the state. The Carnegie Foundation Study (Benner, Sutphen, Leonard & Day, 2010) and the IOM report on the Future of Nursing (IOM, 2010) have identified academic practice partnerships as foundational to the transformation that is needed in nursing education. Although partnerships may differ in form and approach across states and regions, the unifying theme is the creativity that arises from the circle of connection between education and practice.

Acknowledgments The authors acknowledge the support of Beth Kantz, MS, RN, in the compilation of the competency document and the members of the NOF Competency Committee and the organizations they represent as contributors to the competency development.

References Accreditation Council for Graduate Medical Education. ACGME Outcome Project. Retrieved from http://www.ACGME. org/outcome/comp/compFull.asp. Alexander, M., & Runciman, P. (2003). ICN framework of competencies for the generalist nurse: Report of the development, process and consultation. Geneva, Switzerland: International Council of Nurses. American Association of Colleges of Nursing. (2008). The essentials of baccalaureate education for professional nursing practice (2nd ed.). Washington, DC: Author.

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American Nurses Association. (2004). Nursing scope and standards of practice. Silver Springs, MD: Author. American Organization of Nurse Executives. (2006). AONE guiding principles for the role of the nurse in future patient care delivery. Retrieved from http://www.aone.org/aone/resource/gps.html. Baldwin, C., & Linnea, A. (2010). The circle way: A leader in every chair. San Francisco: Brett-Koehler. Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Educating nurses: A call for radical reform. San Francisco: Jossey-Bass. Creativity and Connections. (2006). Report from the invitational working session. Retrieved from www.mass.edu/nursing. Institute for Health Care Improvement. (2007). The improvement process. Retrieved from http://www.ihi.org/IHI/ Topics/HIVAIDS/HIVDiseaseGeneral/HowToImprove/. Institute of Medicine. (2003). Health professions education: A bridge to quality. Washington, DC: National Academies Press. Institute of Medicine. (2010). The future of nursing: Leading change, advancing health. Washington, DC: National Academies Press. Lenburg, C. (1999). The framework, concepts and methods of the Competency Outcomes and Performance (COPA) Model. Online Journal of Issues in Nursing. Retrieved from https:// nursingworld.org/mods/archive/mod110/copafull.htm.

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Massachusetts Department of Higher Education Nurse of the Future Competency Committee. (2010). Nurse of the future nursing core competencies. Boston: Massachusetts Department of Higher Education. National League for Nursing Council of Associate Degree Nursing Competencies Task Force. (2000). Educational competencies for graduates of associate degree nursing programs. New York: Author. O'Neill Hewlett, P., & Bleich, M. (2004). The reemergence of academic–service partnerships: Responses to the nursing shortage, work environment issues, and beyond. Journal of Professional Nursing, 23, 273–274. Quality and Safety Education for Nursing. (2007). Quality and safety competencies. Retrieved from http://www.qsen.org/ competencies.php. Technology Informatics Guiding Educational Reform (TIGER). (2007). Evidence and informatics transforming nursing: 3-Year action steps toward a 1-year vision. Retrieved from www. tigersummit.com/Downloads.html. Technology Informatics Guiding Educational Reform (TIGER). (2009). Tiger Informatics Competencies Collaborative (TICC) final report. Retrieved from www.tigersummit.com/ uploads/TIGER_Collaborative_Exec_Summary_040509.pdf.