Peer Review

Navigating the Perfect Storm: Nursing and Liberal Education

Recently, an unusually intense series of storm cells has affected the education of nurses and the practice of nursing. In 2005, the American Organization of Nurse Executives (AONE) released a statement calling for all registered nurses to be prepared at the baccalaureate level in an effort to educate nurses at a level commensurate with their challenging and complex clinical roles. The goal of this initiative within the nursing profession was to create a more educated workforce in the interest of improving patient safety and enhanced nursing care. Similarly, the National Advisory Council on Nurse Education and Practice (NACNEP) affirmed that a nurse’s role is to manage care on a continuum, to work as peer on interdisciplinary teams, and to integrate clinical expertise with knowledge of community resources. The increased complexity of the scope of practice for registered nurses requires constant adaptation to change. Adaptation requires critical thinking and problem-solving skills, a solid knowledge foundation in a broad range of the arts and sciences, and the ability to analyze and communicate data. Among the three types of programs that prepare a student to become a registered nurse (i.e., high school diploma, associate’s degree, and baccalaureate), the baccalaureate education, with its broader liberal education focus, provides a strong foundation necessary for meeting changing, complex health care needs.

By 2007, the Council on Physician and Nurse Supply released a statement calling for a national effort to substantially expand baccalaureate nursing programs. The statement cited a growing body of research supporting the relationship between the level of nursing education and the quality and safety of patient care. Currently, there is growing consensus in the higher education community that a liberal education should be embedded in all of the professional disciplines.

The Storm's Path

As the intensity of the storm increased, activities at the local, state, and national levels were underway to develop a responsive navigation system. Realizing the storm’s pattern, the Robert Wood Johnson Foundation and the Institute of Medicine (IOM) launched a two-year initiative in 2008 to respond to the need to assess and transform the nursing profession. With more than three million members, the nursing profession is the largest segment of the nation’s health care workforce. In navigating patient care, nurses play a vital role in realizing the objectives set forth in the 2010 Affordable Care Act. This legislation represents the broadest health care overhaul since the 1965 creation of the Medicare and Medicaid programs and one that creates turbulence for the nation’s health care system. A number of barriers contribute to the turbulence and prevent nurses from being able to respond effectively to rapidly changing practice settings and an evolving health care system. Recognizing the need to overcome these barriers to ensure nurses are well positioned to captain the change and advance the profession, the IOM appointed a committee charged with making recommendations for an action-oriented course for the future of nursing.

The Need for Highly Educated Nurses

The IOM committee’s 2010 report, The Future of Nursing, indicates that health challenges facing the nation have drifted dramatically in the twenty-first century. The American population is older and increasingly diverse with respect to race, ethnicity, and cultural and economic status. These variables create changes in the direction of the nation’s health care needs.

Realities of twenty-first-century health care have moved the nursing education model from a clinical service to a liberal education base. At the center of these liberal education competencies are leadership, health policy, system improvement, research- and evidence-based practice, and teamwork and collaboration. These competencies serve as the rudder for application in the clinical setting. In addition, nurses are expanding roles to master technological tools and information management systems while collaborating and coordinating care across interdisciplinary teams. To respond to these increasing demands, the IOM calls for nurses to achieve higher levels of education and suggests that they be educated in new ways to safely navigate the health care storm.

The IOM has described four key missives:

  • nurses should practice to the full extent of their education and training;
  • nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression;
  • nurses should be full partners, with physicians and other health care professionals, in redesigning health care in the United States; and
  • data collection and the information infrastructure should be improved to facilitate workforce planning and policy making.

Today’s nursing professionals have the potential to play significant roles in transforming health care delivery into a safer, higher quality, and more cost-effective system (Institute of Medicine 2010). However, a new storm cell is emerging—the concern over health care outcomes, while the changing US and global markets forecast a nursing shortage that is expected to intensify as the demand for more and different nursing services grows. Despite recent annual increases in enrollments in entry-level baccalaureate nursing programs, the existing numbers of programs are not sufficient to meet the projected demand for nurses.

In an attempt to deter the storm’s path, the University System of New Hampshire (USNH) assessed the current situation and anticipated the increased need for baccalaureate-prepared nurses. In the process, New Hampshire was found to have one of the highest ratios of associate’s to bachelor’s educated nurses in the nation at 8.5:1.5, compared to the national ratio of 3:2. This statistic mobilized stakeholders in the region to plot a new direction for nursing education within the university system.

The Importance of a Liberal Education in Nursing

The Association of American Colleges and Universities (AAC&U 2007) defines a liberal education as one that intentionally fosters, across multiple fields of study, wide-ranging knowledge of science, cultures, and society; high-level intellectual and practical skills; an active commitment to personal and social responsibility; and the demonstrated ability to apply learning to complex problems and challenges.

At Keene State College (KSC), academic programs are solidly based in the liberal arts and sciences ensuring graduates acquire the knowledge, skills, and attitudes to navigate the rapidly changing world. According to President Helen Giles-Gee, “Building upon the liberal arts education offered at Keene State, we were pleased to initiate a BSN [bachelor of science in nursing] program that supports the development of higher order skills, abilities, and knowledge leading to an adaptable nursing workforce to alter the path of the perfect storm in southwestern New Hampshire. In congruence with the mission of the college, the needs of the state and region are served. By adding a professional nursing degree program, KSC would enhance its ability to meet the health care needs of the community.”

In 2007, a new general education program called the Integrative Studies Program (ISP) set sail. The program has three sets of outcomes: intellectual skills, perspectives and interdisciplinary outcomes, and integrative outcomes. Key to the design of the program was its conceptual framework based on AAC&U’s Greater Expectations Report (2002), in which a set of twenty-first-century outcomes for a liberal education were initially identified. Since then, AAC&U has recognized Keene State College as a Campus Action Network Partner and an exemplar program in LEAP (Liberal Education and America’s Promise). Identifying the relevance of general education for the nursing program, Provost Mel Netzhammer says, “The Integrative Studies Program complements the directives of nursing organizations and educators to place baccalaureate nursing education firmly on a liberal education backbone.”

The KSC Nursing Program Differences

The chancellor of the University System of New Hampshire (USNH) charged Mary-Ellen Fleeger with the design and implementation of a baccalaureate nursing program at Keene State College. Creating a new program provided opportunities to meet other goals desired by the system and the college. The USNH Board of Trustees has encouraged the institutions to expand options that promote increased use of facilities and potentially decrease time to degree for students. The new nursing program was developed to do just that, with the addition of a full-time summer session for students beginning the upper-division sequence of nursing courses.

Further, the nursing courses—theory and clinical—do not begin until the second semester of the junior year, so students can first complete all of the general education courses that lay the groundwork for nursing knowledge and practice. Courses in the humanities, arts and sciences, and interdisciplinary domains serve as the hulls of the education vessel and provide the supporting framework for the nursing course progression. Specific allied course requirements were selected to complement the institution’s ISP. According to Melinda Treadwell, dean of the School of Graduate and Professional Studies, “This integrative nursing curriculum builds upon a community of scholars at Keene State while advancing the art and science of nursing.” Treadwell goes on to say that having nursing faculty also teach an ISP course truly integrates professional studies across other disciplines. In addition, collaboration with local health care agencies and academic partners facilitates the preparation of students and provides the Monadnock, NH, region with its future workforce.

Finally, the KSC program is a continuum for nursing education. The program has an option for currently practicing nurses to complete a baccalaureate degree in a time- and cost-efficient manner while acquiring the knowledge, skills, and attitudes to navigate twenty-first-century heath care storms.

How the Nurse of the Future Framework Educates Nurses Differently

In 2005, the Massachusetts Department of Higher Education (DHE), with the support of the Massachusetts Legislature, entered into a dialogue with nursing professional associations, industry, and other health care stakeholders, and with public and private higher education institutions, to develop statewide and regional programs to address the storm cells of nursing education and practice. In 2006, a working group was commissioned and composed of deans and faculty representing all segments of nursing education, nursing practice leaders, and clinical nursing staff representing the continuum of care. This group reviewed professional standards, initiatives, and best practices in nursing education to form a foundation for moving the priorities forward. To expedite the process, the group formed two subcommittees: the Massachusetts Nurse of the Future (NOF) Competency Committee, charged with furthering the development of a seamless continuum of nursing education by identifying a core set of nursing competencies; and the Massachusetts Organization of Nurse Executives (MONE) Academic Practice Integration Committee, charged with using the identified competencies as a framework for developing a statewide transition-into-practice model.

In 2008, Massachusetts was one of eighteen states selected to attend the first National Nursing Education Capacity Summit sponsored by the US Department of Labor, the Robert Wood Johnson Foundation, and the AARP Center to Champion Nursing in America. In 2009, Massachusetts was invited to participate as an exemplar state at the second countrywide Nursing Education Capacity Summit. Massachusetts is recognized nationally for its ongoing strategic partnerships, education redesign, and clinical placement system. In a leadership role, Massachusetts is currently working with other states in the New England region (New Hampshire, Vermont, and Rhode Island) to support them in developing their own statewide models for partnership, education redesign, and clinical placements as they prepare the nurses of the future.

A member of the Academic Practice Integration Committee, Thomas W. Connelly, Jr., now serves as director of nursing at Keene State College. Connelly states, “It is a pleasure to create a nursing program at KSC built upon the NOF framework. This is a wonderful opportunity for the college and the local community to assess the health care needs of our residents and to build partnerships, capitalizing on our current resources and working collaboratively to create pathways for success.”

The Nurse of the Future Nursing Core Competencies were completed and made available in August 2010, at www.mass.edu/currentinit/NiNofCompetencies.asp. Nursing students at KSC will be educated with the knowledge, skills, and attitudes not only to facilitate their academic and clinical success but to prepare them for a lifelong rewarding career in the discipline of nursing.

End of Program Outcomes

The KSC bachelor of science in nursing prepares “Nurses for the Future” who

  1. Demonstrate accountability for practicing nursing within established moral, legal, ethical, regulatory, and humanistic principles;
  2. Demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal quality and value;
  3. Use information and technology to communicate, manage knowledge, mitigate error, and support decision making;
  4. Identify, evaluate, and use the best current evidence coupled with clinical expertise and consideration of patients’ preferences, experiences, and values to make practice decisions;
  5. Function effectively within nursing and interdisciplinary teams, fostering open communication, mutual respect, shared decision making, team learning, and development;
  6. Minimize risk of harm to patients and providers through both individual performance and system effectiveness;
  7. Use data to monitor outcomes and care processes, and design and test changes to continuously improve the quality and safety of health care;
  8. Influence the behavior of individuals or groups of individuals within their environment in a way that will facilitate the establishment and acquisition/achievement of shared goals;
  9. Deliver holistic nursing care and advocate for health promotion and disease prevention strategies at the individual, family, community, and global levels;
  10. Demonstrate effective communication skills with clients that foster mutual respect and shared decision making to enhance patient satisfaction and health outcomes.

Conclusion

USNH is demonstrating will and commitment to face the storm and educate nurses who will be prepared for tumultuous times ahead. In response to the IOM report, USNH, in collaboration with KSC, designed a newly established BSN program to meet the health care needs of the Monadnock region, New Hampshire, and the nation. By addressing the issues of innovation, community resources, liberal education, nursing supply and demand, and the projected health care needs of the nation, the curriculum can ensure graduates demonstrate the Nurse of the Future Core Competencies. These competencies, anchored in the liberal education mission of the college, will prepare the KSC nursing graduate with the knowledge, skills, and attitudes to weather the challenges in health care and to charter the waters of change in the years to come.

Acknowledgments

A special thanks to Lynette Hamlin, Ph.D., R.N., C.N.M., F.A.C.N.M., who served as a consultant in the development of the program.

References

AARP Center to Champion Nursing in America. 2011. Available at: http://championnursing.org

American Organization of Nurse Executives. 2005. Available at: http://www.aone.org

Association of American Colleges and Universities. 2002. Greater Expectations: A New Vision for Learning as a Nation Goes to College. Washington, DC: Association of American Colleges and Universities.

Association of American Colleges and Universities. 2007. College Learning for the New Global Century. Washington, DC: Association of American Colleges and Universities.

Council on Physician and Nurse Supply. 2008. Available at: http://www.physiciannursesupply.com/

Institute of Medicine. 2010. The Future of Nursing. Available at: http://www.iom.edu/Reports/ 2010/A-Summary-of-the-February-2010-Forum-on-the-Future-of-Nursing-Education.aspx

National Advisory Council on Nurse Education and Practice. 2008. Available at: http://www.hrsa.gov/advisorycommittees/bhpradvisory/nacnep/Reports/sixthreport.pdf

Robert Wood Johnson Foundation. 2011. Available at: http://www.rwjf.org


Mary-Ellen Fleeger and Thomas W. Connelly, Jr. are both with the Department of Nursing at Keene State College.

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