Current literature reminds us that active learning helps promote critical thinking and problem-solving abilities. Active learning requires that students be engaged through more than listening, reading, writing, and discussion.
Research has significantly proven the opposition amid adult and child learning styles. Established on the research that adults do not learn in the same style as children, it is practical to accept that one cannot teach adults employing methods developed and planned to facilitate the learning experience of children. Malcolm Knowles, a pioneer in the field of adult learning, hypothesized some assumptions to assist teachers with teaching children and adults. These assumptions include:
The Need to Know. Adult learners need to know why they need to learn something before undertaking to learn it.
Learner Self-Concept. Adults need to be responsible for their own decisions and to be treated as capable of self-direction.
The Role of Learners’ Experience. Adult learners have a variety of life experiences that represent the richest resource for learning. These experiences are, however, imbued with bias and presupposition.
Readiness to Learn. Adults are ready to learn those things they need to know in order to cope effectively with life situations.
Orientation to Learning. Adults are motivated to learn to the extent that they perceive that it will help them perform tasks they confront in their life situations.
The reason most adults enter any learning experience is to create change. This could encompass a change in their skills, behavior, knowledge level, or even their attitudes about things. In a 2006 article published in the journal Urologic Nursing, Sally Russell suggested that, compared to school-age children, the major variances in adult learners are in the degree of enthusiasm, the extent of earlier experience, the level of engagement, and how the learning is applied. Double testing allows the adult student to be engaged in the learning process.
Students need support and validation from their peers. In any classroom, evaluation is necessary. In 2012, the National League for Nursing suggested in its fair testing guidelines that tests and other evaluative measures should be used “not only to evaluate students’ achievements, but, as importantly, to support student learning, improve teaching, and guide program improvements.” Double testing is one such teaching method in which evaluation, peer support, and validation can be instituted to support student learning.
Instructors who teach in higher education can no longer rely on lecturing as their main teaching method. In Teaching in Nursing: A Guide for Faculty, scholars Diane Billings and Judith Halstead emphasize that dependence on the use of the lecture is no longer an accepted teaching technique. Instead, faculty must integrate the use of technology so that students will be more actively involved and engaged in the learning process. Also, faculty must focus more on teaching in a learner-centered fashion, as opposed to the teacher-center approach.
Double testing has been proven to be an effective teaching method. A 2013 study published in Nursing Education Perspectives found that learning, communication, and collaboration were prevalent themes in students’ perceptions and opinions of double testing. According to the researchers, the study found that “a majority of students preferred double testing and indicated that this testing method had more advantages than disadvantages.”
Throughout nursing programs, instructors are responsible for assessing students’ abilities and assuring they are competent to practice nursing. Since one of the nursing instructor’s goals is to prepare students to be safe and competent nurses, I believe that collaborative learning, such as double testing, is an excellent strategy to assist students in being able to successfully care for patients. I have used this teaching method for more than two years with senior two-year nursing students and have found that double testing promotes group interaction, interpersonal skills, and interdependence among the nursing students—qualities needed to work with members of any health care team.
In using the double-testing method, I have also found that students are more engaged and more cooperative; they also exhibit improved critical thinking skills. For example, when double-testing scores were compared over a six-month period, students’ overall grades increased from 69% to 82%. Indeed, a systematic review conducted by The Campbell Collaboration confirms that the benefits of collaborative testing “include—but are not limited to—better critical thinking skills, better collaboration and team work among peers, reduced test anxiety, and improved test taking performance.”
In a 2011 study published in Science, Deslauriers, Schelew, and Wieman compared the amount of learning students experienced when taught—in three hours over one week—by traditional lecture and by using interactive activities based on research in cognitive psychology and physics education. The researchers found that students in the interactive class were more involved and absorbed more than twice the learning than their colleagues in the traditional class.
Twenty-first century students should be allowed some control over their learning. For many years, teacher-centered instruction has been dominant in higher education. In a traditional classroom, students become passive learners or just receivers of teachers’ information; whereas, with double testing, the students make the decision whether or not to participate. This way, students take charge of their own learning and are openly involved in the learning process.
In “Helping Students Get to Where Ideas Can Find Them,” an article published in 2009 in The New Educator, Eleanor Duckworth asserts that teacher-centered learning actually hinders students’ learning. In contrast, double testing is a learner-centered teaching method, which focuses on how students learn instead of how teachers teach.
I believe that double testing is a worthy teaching method that instructors can use in the classroom to enhance student-student and student-teacher interactions. Most educators understand that learners have different preferences and styles of learning and believe that it is essential to use teaching methods and approaches that will satisfy the variety of learning styles in the learning event.
Annie M. Clavon, ARNP, PhD, MS, CCRC, is an associate nursing professor at Keiser University in Ft. Lauderdale, Florida.
For incoming freshmen, attending college can feel like entering a maze. But for first-generation students, that maze can have added twists and turns, as they may not have a role model or rule book to follow when starting out as a first-year student.
In turn, while parents are proud of their college-bound daughter or son, they too are unfamiliar with the road they are about to travel. Yet, parents can still offer ample support for students just by showing up at family orientation events, asking questions from the program staff, and seeking out other parents to share information, guidance, and direction.
In the Rutgers College of Nursing Educational Opportunity Fund (EOF) Program, parents are strongly encouraged to be a support base to their students. The EOF program has a Family Orientation Day where not only parents, but the entire family is invited to attend. Family Orientation Day provides an overview of what students are expected to do in the intensive six-week Summer Readiness Program. The College of Nursing has the only EOF program exclusively for nursing students in the state of New Jersey.
In 2011, parents were given a firsthand account from a parent whose daughter completed the summer program the previous year. She and her daughter spoke to the audience and answered questions. Additionally, the mother stayed through the entire day to privately speak to parents, many of whom indicated this was especially appreciated. Having a parent whose child went through the program offered them a sense of relief and comfort, making it easier to leave their daughter or son on campus.
At the end of the Summer Readiness Program, the students “graduate” to become members of the College of Nursing (Class of 2015). The students participate in a celebration entitled “Culture Kitchen,” where students and/or parents prepare a dish from their culture. It is truly a feast! Students represent many countries, and sampling the cultural cuisine is a cherished memory of the Summer Readiness Program. This past year’s program was especially gratifying because one parent insisted on being a part of the team in setting up the buffet table and working with the students and staff! It was important for her to become actively involved and not sit on the sidelines.
Perhaps the most moving part of the Culture Kitchen program is watching the students reflecting on their summer experience and seeing the proud faces of their parents. Students benefit from their parents’ support and involvement, and parents are encouraged to be a part of the students’ college experience. The EOF Program wants parents to feel welcomed; we understand the daunting process of wanting their child to be educated along with the difficulty of “letting go” so their daughter or son can progress into adulthood and become a distinguished nurse.
While many nursing schools around the country have successfully increased their enrollments as well as the racial and ethnic diversity of their student populations, there continues to be a severe shortage of nursing faculty–and especially minority faculty. According to the American Association of Colleges of Nursing (2005), fewer than 10% of the nation’s nursing educators are people of color.
To address this urgent need for more culturally diverse nursing faculty, the School of Nursing at Thomas Edison State College, an online college based in Trenton, N.J., received a $600,000 grant from the Health Resources and Services Administration (HRSA) to establish the Minority Nurse Educator program. Now entering its third year, the program provides experienced minority nursing faculty with the opportunity to enhance their skills and expand their expertise by preparing them for online teaching. With minority nursing educators in such short supply, training them to teach in distance learning programs will help make this scarce resource available to greater numbers of students than ever before.
Participants complete a 32-week Certificate in Distance Education Program (CDEP), then teach a 12-week online nursing course at Thomas Edison State College, under the guidance of an experienced mentor from the School of Nursing. Upon completion of the program, the minority faculty are ready to use their new distance teaching skills to introduce and expand online education programs at their own local institutions and across the nation.
Establishing the Need
In 2001-2002, Thomas Edison State College implemented its online RN-to-BSN program. Demographic data from the student population indicated that 25% of the students were racial and ethnic minorities. At that time, the program was open only to New Jersey residents. (It has been offered nationally since 2004.) The percentage of minority nurses in New Jersey at this time was 23%, which indicated that minority students were well represented at the School of Nursing.
Because of the high percentage of students of color in the program, we wanted to attract a similar percentage of minority faculty who could serve as mentors and role models. Our outreach efforts consisted of professional calls to minority nurses known to the dean, calls to several historically black nursing programs and requests for referrals from personal contacts. In the early days of the program, when the number of students enrolled was fewer than 250, these recruitment methods were sufficient. However, as enrollment grew, we found it increasingly difficult to maintain a similar minority mentor-to-student ratio using only these three methods.
Thomas Edison State College was already training nurse educators in online pedagogy, so it occurred to the dean that the same training could be offered to minority nursing faculty recruited as mentors for the online RN-to-BSN program. The idea for the grant was born. Once they became certified in distance education, the minority educators could be utilized not only by Thomas Edison State College but by any nursing program in the nation with online capability, regardless of geographical location. In addition, we felt that this could be a potential way to address the faculty retirement brain drain by enabling minority nurse educators to extend their tenure in the profession past the traditional retirement age.
To invite experienced minority nurse educators to participate in the CDEP, the School of Nursing used several recruiting strategies, including announcements in the nursing media, one-on-one recruitment at major national minority nursing association conferences, and advertisements in national and local newspapers and Web sites. In the first year, 19 educators were accepted into the program, with a 75% completion rate. For this first group of participants, the mentored online teaching experience is now in progress and will continue throughout this year.
A Growing Diversity
Summer 2007
Of the 15 first-year participants who completed the CDEP, 67% are African American, 13% are Asian, 13% are Hispanic and 7% are American Indian (see Figure 1). Seventy-five percent of these nurse educators hold a master’s degree in nursing and 25% hold doctoral degrees (see Figure 2). The doctorally prepared candidates are from the African American and American Indian ethnic groups.
Geographically, our first-year grant participants come from many different parts of the country, including Georgia, Florida, New Jersey, New York, Missouri, Oregon, Pennsylvania, South Carolina, Tennessee and Virginia. The majority are from the East Coast (see Figure 3).
As the program became more widely known, we received many additional inquiries and applications. The second-year cohort of grant participants consists of 42% master’s-prepared nurse educators and 58% who are doctorally prepared. The geographic range has expanded as well, with new participants from Alabama, California, Indiana, North Carolina, North Dakota, Oklahoma and Texas.
We are currently constructing a database of grant participants who have completed the CDEP through the Minority Nurse Educator program. Information from this database will be shared upon request with schools of nursing across the United States who are interested in utilizing experienced minority online educators to increase their faculty diversity.
To promote collaboration and yearly networking, the HRSA grant has also enabled Thomas Edison State College to establish an annual Distinguished Lectureship on Cultural Diversity, which is hosted by the School of Nursing every fall. The first annual event, held last October 11, included speakers such as Kem Louie, PhD, RN, FAAN, past president of the Asian American/Pacific Islander Nurses Association, and Hilda Richards, EdD, RN, FAAN, past president of the National Black Nurses Association. Information about the 2007 lectureship will be available in local and national nursing publications and on our Web site at www.tesc.edu/nursing/hrsa/php.
In summary, the Minority Nurse Educator program has proven to be successful. Nursing educators from across the country have demonstrated support for the concept of sharing minority nursing faculty in cyberspace to increase diversity in the nursing profession. The program has drawn highly talented minority nursing educators from a wide range of ethnic backgrounds and geographical locations, and the number of educators who have expressed interest in participating has increased. As of this writing, some of our grant participants are already applying what they have learned in the CDEP course, and the feedback from the grant participants in general has been very positive (see sidebar).
Experienced Educators Invited
The third-year cohort of grant participants in the Minority Nurse Educator program will begin their CDEP courses this summer and fall. If you are an experienced nurse educator of color who is interested in expanding your skills into online teaching and course development, Thomas Edison State College School of Nursing would like to hear from you.
We are looking for candidates with at least two years experience teaching in a baccalaureate nursing program or equivalent. A minimum of a master’s degree in nursing is required; a doctorate in an appropriate field is preferred. Please send a CV to [email protected].
Acknowledgment
Funding for the Minority Nurse Educator program and annual Distinguished Lectureship was made possible (in part) by grant award # DIIHP05199 from the Health Resources and Services Administration. The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the U.S. Department of Health and Human Services or the Health Resources and Services Administration, nor does mention of trade names, commercial practices or organizations imply endorsement by the U.S. government.
As anyone in the field would surely attest, nursing is a career that is both incredibly rewarding while also fraught with significant demands and challenges. One area in particular that has been making strides in supporting nurses is the expanded and refined use of simulation—in order to practice the clinical skills necessary to ensure safe patient care.
Using life-like computerized mannequins to replicate the complex patient environment of the clinical setting, simulation offers nursing students the opportunity to practice in a safe atmosphere before beginning full-time work in a real clinical setting. Simulation benefits students, faculty, and health care providers, and also carries the power to transform the health care system through improvements in quality, safety, efficiency, and care outcomes.
At a number of nursing schools throughout the country today, simulation is integrated as part of the formal nursing curriculum, resulting in success for students and faculty alike. However, this wasn’t always the case. As with any new technology, simulation technologies are sophisticated systems that come with many advantages, but some challenges to manage as well. It took time—combined with a passion for nurse education and a persistence to get it right—for appropriate curriculums to be developed.
Overcoming the myth of simulation
Early uses of health care simulation date back to the 1960s and include the use of airway simulators for anesthesia training and CPR instruction, as well as for medication administration training. For instance the Institute of Medicine’s (IOM’s) 1999 report, “To Err Is Human: Building a Safer Healthcare System” highlights the promise of deliberate practice in curbing medical errors through improved communications, team performance, education, and training, all of which can be accomplished with the use of simulation.
Motivated by early simulation success, in the early 2000s many provider organizations and schools of medicine and nursing purchased or received donations of high-fidelity simulators ranging in costs of $75,000–$100,000 each. While there were high expectations for immediate use and derived benefits of these simulation technologies in nursing, some people in the industry had the notion that nursing simulators would perform on their own with the simple click of a button—and that students would “magically” learn the content. With that idea, faculty members were left to fend for themselves in conducting simulation design, implementation, management, and monitoring.
In 2004, staff at Robert Morris University integrated these very life-like simulations into their nursing curriculum. That effort has led to today’s unprecedented and innovative template for nursing simulation curriculum at the Robert Morris University School of Nursing and Health Sciences.
Laying the foundation for curriculum development
Integrating simulation in nursing education requires an understanding of these high-fidelity mannequins, which are as true to life as one can imagine, with an advanced level of realism. They speak, they bleed, and they react. They respond to interventions with changes in heart rate, lung and heart sounds, and vital signs. As a result, some of the most effective uses of these simulators is to recreate what are known as low-occurrence, high-risk scenarios such as strokes, heart attacks, and other critical health situations. While these medical situations may not happen with regular frequency, when they do, they require an incredibly swift and accurate response from nurses. In other words, the ability to teach and practice responding to these situations, in the safe and controlled environment of the simulation lab, is invaluable.
But implementing simulations in educational settings—universities, colleges, and career schools—has not been easy. To meet this challenge, an interdisciplinary team at Robert Morris University School of Nursing and Health Sciences, in Moon Township, Pennsylvania, took on the task of investigating barriers and roadblocks to simulation adoption, from understanding the technology behind the mannequins to curriculum writing and development of a well-planned educational experience, in addition to faculty development and pilot testing.
Among the issues under review were the following:
How prevalent is simulation in nursing education?
How can nursing faculty design an effective simulation experience?
What constitutes a worthwhile simulation experience for nursing students?
What’s the best way to measure learning outcomes, including knowledge and critical thinking?
Considering curriculums
After much research; hands-on experience; and feedback from students, teachers, and even system designers, RMU implemented its currently used Simulation Learning System (SLS) curriculum in 2009. At the heart of the program are the following three components:
Get Real: Simulation Resources
Clinical Simulation in Nursing, www.nursingsimulation.org
International Nursing Association for Clinical Simulation and Learning, www.inacsl.org
Society for Simulation in Healthcare, http://ssih.org
Simulation Innovation Research Center, http://sirc.nln.org
RMU Regional RISE Center, http://risecenter.rmu.edu
Pre-scenario: Nurse faculty members receive guidance on a wide range of areas, including simulation set-up, features and functions, and anticipated possible student reactions. They are also advised to think about others—besides the students and mannequins—who should be involved with the SLS process to make it as real as possible (i.e., should there be parents or other family members?). Time parameters are also important. Each scenario can range from as little as 20–30 minutes, to 50 minutes or an hour. Reading materials and relevant background research are also suggested for the faculty. And finally there are pre-scenario learning activities, which prepare students with the tools necessary to be successful during the scenario, without giving away the details.
Scenario: Faculty instructors receive tips on how to run the scenario, including making changes to the mannequin to best suit their needs, guiding students through the experience, and facilitating a debriefing where students view and reflect on their performance, answer critical-thinking questions, and link theory to practice.
Post-simulation: This is the debriefing component and the chance to evaluate how the scenario went. Part of this phase is faculty administering post-exams, post-tests, and concept mapping to solidify what students have learned with the simulation. In addition, students have the ability to reinforce content with animated movie clips, which clarify concepts related to pathophysiology or procedural skills.
RMU also responded to common faculty recommendations for implementing high-fidelity human simulation (HFHS), including:
Appoint a dedicated coordinator or champion.
Offer technological support.
Provide adequate facilities.
Use standardized programming forms.
Arrange for adequate facilities.
Fund supplies that enhance realism.
Offer workload release time.
Next steps for RMU
With its new Regional Research and Innovation in Simulation Education (RISE) Center, RMU continues its commitment to simulation learning and advancement. Opened in 2009, the RISE Center features two high-fidelity treatment rooms, a critical-care room, two classrooms/debriefing areas, and a low-fidelity nursing skills practice lab.
With additional funding, RMU has hired both a simulation technician and simulation specialist, who integrated simulations, including approximately eight scenarios with over 100 students. Students who are about to graduate or transition also rely on simulations to prepare for the real-world nursing environment.
Thus far, more than 120 Robert Morris nursing students and five nursing faculty have participated in simulation experiences facilitated through the SLS. Post-evaluations reveal positive results from students on dimensions such as satisfaction, value, simulation realism, and applicability of the simulation to real-world clinical settings. In addition, students demonstrate improved SLS post-test scores following simulation experiences.
An administrative software system allows RMU to track usage statistics; usage rates have increased exponentially, from four scenarios in 2008 to more than 20 in 2011, as have the types of simulations offered.
Additional simulation recommendations
Among the recommendations for an effective simulation experience are these:
Ensure adequate time and resources. Invite faculty to learn about simulations and underlying technologies, while creating a sense of anticipation about the simulation experience among students.
Utilize standards and guidelines as much as possible. The first set of simulation standards was recently released by the International Association of Clinical Simulation and Learning (INACSL) and can serve as a guide for both novice and expert simulation educators.
Overcome faculty fears relating to lack of support, assistance, and time.
Hire staff that can assist in implementing, managing, monitoring and evaluating the simulation program. Rely on a technician to handle technical glitches, video, and sound.
Solicit feedback from both faculty and students on issues such as usability, learning experience, and outcomes.
Seek out other nursing schools with experience and expertise in using simulations.
Partner with providers, associations, and reputable vendors.
Consider simulation certification.
Rely on highly developed simulation learning systems that alleviate the pressure of simulation design, implementation, administration, pre- and post-testing, and tracking. Especially important are competencies related to Quality and Safety Education for Nurses (QSEN,www.qsen.org) competencies, which should be integrated into every simulation experience.
The next phase for simulation in nursing
As new developments occur, simulations within the nursing curriculum are likely to change and evolve somewhat rapidly. Among the new and emerging trends:
Team spirit: Team training will occur across disciplines and specialties. Team STEPPS, (http://teamstepps.ahrq.gov/) is an evidence-based team training system developed by Department of Defense’s Patient Safety Program in collaboration with the Agency for Healthcare Research and Quality (AHRQ.).
Research: Research on simulations will surge. Especially critical are issues related to the impact of simulation on patient outcomes and on provider effectiveness. Among the questions currently under investigation: How can simulation be used for high stakes testing situations? What are the knowledge and clinical competency outcomes of students when simulation technology is used for clinical experiences? (NCSBN study)
Patient safety: Simulation will emerge as a patient safety strategy. Organizations will increasingly view simulation as a tool to promote patient safety, prevent medical errors, and curtail costly readmissions.
Not long ago, I was facilitating a workshop on fostering civility in nursing education when a faculty member approached me during the break. The soft-spoken professor related her thoughts in a quiet voice, her eyes reflecting a certain sadness as she spoke. She said, “Please think about us—the clinical faculty, I mean—when you are speaking about incivility in nursing education. I am a member of the clinical faculty, and I can tell you, unequivocally, that we are a marginalized group. We are not considered part of the ‘real faculty’ and are often referred to as ‘minions and underlings.’ We are frequently told that we have no clout nor can we provide input into the theoretical courses or exams.” I asked the faculty member how she responded to these incivilities. She said, “I just take it—it’s like swallowing a very bitter pill.”
What I call the in-group and the out-group of nursing faculty teams—and I use the word “team” lightly—is further illustrated by a story described in a study I recently conducted to examine faculty-to-faculty incivility and ways to effectively address the problem. Approximately 13% of the respondents reported experiencing racial, ethnic, sexual, gender, or religious slurs within the past 12 months. One respondent wrote, “During a faculty workshop, faculty members were asked to work in small groups. One group contained four minority faculty members. A non-minority faculty member asked, ‘Do I have to paint my face black to be in this group?’”
Another faculty member related the incivility of perceived ageism that exists in her nursing program. She explained that when she met with her dean to seek advice about returning to graduate school to complete her doctoral degree, the dean laughed and said, “Are you kidding, at your age? You can’t be serious. By the time you finish your degree, you’ll be ready to retire. We prefer to invest in younger faculty.” Other forms of discrimination are also apparent: a student recently commented on faculty bias in the classroom, saying, “Students are often subjected to religious, racial, and anti-gay/lesbian content. We [students] feel vulnerable and do not know how faculty and administrators will react if they complain. It’s appalling and inexcusable.”
Regardless of their origin, uncivil encounters are an affront to human dignity and an assault on a person’s intrinsic sense of self-worth. The effects can be devastating and longlasting. Incivility may come from myriad sources; it is complex, disordered, and multidimensional. Taking time to engage, communicate, and listen with intention has a profound effect on preventing and healing the effects of incivility.
I often refer to incivility as a dance, an expression of feeling and social interaction that gets articulated through a variety of movements, gestures, and actions.1 Each observer and participant interprets the dance within the context of his or her personal experiences, through the lens of his or her own world-view. Because of this individual perception and interpretation, it becomes essential to actively listen, consider the intent of the action, and engage in meaningful and solutionbased conversation.
More than two decades ago, Ernest Boyer asserted that institutions of higher education play a vital role in helping students develop a sense of civic and social responsibility, and become productive citizens of the academy and the community.2 The promotion of civility and good citizenry is especially important in nursing and other health-related disciplines where the risk assumed by not addressing uncivil behavior reaches well beyond the college campus and can negatively impact patient safety, recruitment and retention, and commitment to the nursing profession. Because nursing programs are places where students and faculty provide direct care to patients through clinical experiences, uncivil and disruptive acts must be addressed so that such behaviors do not spiral into aggression and jeopardize the learning and practice environment.
While promoting civility is one of the primary functions of higher education, in some respects the system is failing. This failure may be related to a lack of understanding about the topic in general, and ways to prevent and address incivility in particular. I define incivility as rude or disruptive behaviors that often result in psychological or physiological distress for people involved, and if left unaddressed, may progress into threatening situations.3 Exposure to uncivil behaviors can result in physical symptoms such as headaches, interrupted sleep, and intestinal problems and can cause psychological conditions like stress, anxiety, irritability, and depressive symptoms. Thus, it is important to foster civility—an authentic respect for others requiring time, presence, a willingness to engage in genuine discourse, and an intention to seek common ground.4
Similarly, it is important to raise awareness about the importance of fostering a civil and healthy academic work environment. According to researchers, a healthy academic environment consists of a number of factors, including a clear mission with shared values and norms; high morale, job satisfaction, and an esprit de corps; competitive salaries and benefits; reasonable workloads; positive employee recruitment and retention; policies to eliminate incivility; respectful communication, teamwork, and shared decision making; organizational support and collegial relationships; and competent, honest leaders who collaborate with faculty to share decision making.5,6,7
Awareness may be raised by describing specific rationale for establishing and sustaining healthy academic work environments. First, the costs of incivility are vast. Uncivil behavior adds to employees’ stress level, erodes self-esteem, damages relationships, and threatens workplace safety and quality of life.8 Incivility also lowers morale, causes illness, and leaves workers feeling stressed, vulnerable, and devalued. The human and financial costs of these behaviors may be disastrous.9 Second, the recent Institute of Medicine Report10 includes several recommendations that call for nurses and other health care workers, such as physicians, to collaborate to advance the nation’s health. To fulfill these recommendations, we must establish civil and respectful relationships and interactions. Third, the American Nurses Association Code of Ethics for Nurses with Interpretive Statements Provision 1.5 promotes a civil, healthy work environment by requiring nurses to treat colleagues, students, and patients with dignity and respect, and states that any form of harassment, disrespect, or threatening action will not be tolerated.11 Similarly, the American Nurses Association Standards of Practice reinforce the need for objective standards such as collaboration, ethical conduct, and communication for nurses to be accountable for their actions, their patients, and their peers.12 These rationales and fostering a healthy academic work environment are difficult, if not impossible to achieve in the absence of skilled, ethical leadership. Successful change requires both formal and informal leadership—leaders who hold formal positions as well as individuals without a formal title or authority, but who have significant influence with members throughout the organization.
Once awareness is raised and leaders agree that changes are needed to foster a civil workplace, it is highly desirable to use empirical measures to determine levels, types, and frequency of civil and uncivil factors, and to reveal strategies for fostering a healthy workplace. Some examples of empirical measures include the Organizational Civility Scale (OCS)13 and the Culture/Climate Assessment Scale (CCAS).14 Other data sources are also helpful, such as formal and informal reports, evaluations, satisfaction surveys, performance evaluation information, regulatory reports, and information from focus groups and open forums. Once a comprehensive organizational assessment has been conducted, strategies can be implemented to improve areas of concern and to reinforce efforts already in place to enhance areas of strength and excellence.
Specific strategies include aligning the organizational mission and values with a focus on civility and respect. Successful organizations intentionally focus their vision for the future so that employees are able to meet organizational objectives as well as achieve personal satisfaction in their work. Organizational values undergird the formulation and implementation of norms of decorum. Without functional norms, desired behavior is ill defined and thus, members of the campus community are left to “make things up as they go along.”
Healthy academic work environments do not occur by accident—creating them requires intentional and purposeful focus. Unfortunately, many faculty, students, and administrators are unaware of how their behaviors affect others, and many are ill equipped to deal with incivility. Thus, strategies to prevent and address incivility must be taught, practiced, reinforced, and supported. We must make civility a priority. Faculty and staff meetings are excellent venues to raise awareness, discuss acceptable and unacceptable behaviors, establish norms of behavior, and practice and role-play civil interactions. When faculty and staff collectively co-create norms for behavior, they are more likely to approve of and conform to these behaviors. Once the norms are agreed upon, they become the standard for faculty and staff interactions. It is also important to establish, implement, and widely disseminate confidential, non-punitive policies and procedures for addressing incivility. This includes enforcing sanctions if indicated, and perhaps more importantly, to reward civility and collegiality. Although positive motivators are preferred, the consequences for violating the agreed-upon norms must be clearly stated and enforced. Ignoring or failing to address the uncivil behavior damages the organization as much, if not more, than the incivility itself.
Acting civilly and respectfully isn’t always easy, especially in a high-stress learning environment where constant change is the norm, and where faculty and students experience complex and demanding workloads. Yet, we must make civility a priority for our students, colleagues, practice partners, and ourselves. Incivility takes a tremendous toll on everyone throughout the campus and practice community. In a fast-paced work environment, patience is often in short supply, yet it remains a virtue we should value and uphold. Each individual must set a positive example to lead the transformation for cultivating civility in nursing education.
References
C.M. Clark, “The Dance of Incivility in Nursing Education as Described by Nursing Faculty and Students,” Advances in Nursing Science (2008), 31(4), E37–E54.
E. Boyer, Campus Life: In Search of Community. Princeton: The Carnegie Foundation for the Advancement of Teaching, 2009.
C.M. Clark, “Faculty Field Guide for Promoting Student Civility,” Nurse Educator, 34(5),194–197.
C.M. Clark and J. Carnosso, “Civility: A Concept Analysis,” Journal of Theory Construction and Testing, 12(1), 11–15.
C.M. Clark (in progress), “Pathway for Fostering Organizational Civility.”
M. Brady, “Healthy Nursing Academic Work Environments,” OJIN: The Online Journal of Issues in Nursing (2010), 15(1),Manuscript 6.
National League for Nursing. “Healthful work environments for nursing faculty.” Retrieved February 26, 2012, www.nln.org/newsletter/healthfulworkenv.pdf.
P.M. Forni, The Civility Solution, New York, NY: St. Martin’s Press, 2008.
C. Pearson and C. Porath, The Cost of Bad Behavior: How Incivility is Damaging Your Business and What to do About it. New York, NY: Penguin Group, Inc, 2009.
Institute of Medicine Report (2010). “The future of nursing: Leading change, advancing health,” Robert Wood Johnson Foundation Publisher.
American Nurses Association. (2001). Code of Ethics for Nurses With Interpretive Statements. Washington, D.C.: American Nurses Association.
American Nurses Association. (2010). Nursing Scope and Standards of Practice. (2nd ed). Silver Spring, MD: American Nurses Association.
C.M. Clark and R.E. Landrum, “Organizational Civility Scale.” Retrieved February 26, 2012, http://hs.boisestate.edu/civilitymatters/
C.M. Clark, M. Belcheir, P. Strohfus, and P.J. Springer, “Development and Description of the Culture and Climate Assessment Scale, Journal of Nursing Education (2012), 51(2), 75-80.
In the 25 years I have been a bedside nurse and the 15 simultaneous years as a nursing faculty member, I have seen plenty of changes in how health care is delivered and how nursing is taught. What has not changed much is human nature—both of the nurse and the patient. Our patients’ fundamental needs, such as food, warmth, compassion, and alleviation of suffering, have remained constant. Nurses have responded to these basic needs much in the same way since the dawn of science, although the means to meet them may have changed. The foundation of the innate capacity of nurses to respond to these needs were perhaps already in them even before they entered the profession. In nursing school, this vitality is awakened through countless lectures, nursing care plans, evidence-based papers, and process recording. Nurses are “increasingly called on to perform highly skilled technical-scientific and relational work.” Therefore the motivation to cultivate virtue (compassionate practice) and virtuosity (technical skills) amongst nurses stems from the need to practice safely and accurately in less-than-optimal circumstances.1
What’s a nursing virtue?
A philosophical definition of virtue tells us it is “a force that has or can have an effect.” For example, the virtue of a medication is to cure. Essentially, a “virtue is a capacity or power and always a specific one.”2 The virtue of nursing—the power to heal the sick—is one of the critical elements of its professional value with its unique excellence in the records of the healing arts, as a distinct and effective form of treatment and wellness modality. An effective nurse is one who excels in nursing, either independently or collaboratively. In a virtuous nurse, life-saving skills and virtue converge at every patient care interface anywhere in the health care systems. Often, these virtues and values “remain unspoken, and perhaps unrecognized, but nevertheless profoundly influence what they attend to in a particular situation, the options they consider in taking action, and ultimately, what they decide” to do in response to the patient’s needs.3
A nurse is a “force” that has the power to heal or promote positive changes in the patient. And if this force is coupled with the great virtues of politeness, prudence, generosity, mercy, courage, gratitude, humility, honesty, tolerance, and gentleness, our potential for healing is unimaginable, if not already irreplaceable. The opposite is also true. The lack of these virtues in a nurse is a threat to patient safety and quality, and may lead to incivility and practice breakdown.4 The Quality and Safety Education for Nurses (QSEN) initiative proposed competencies for the new nursing graduate to “value” patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics.5 Attaining safety and quality in nursing requires not only the skillful application of evidence-based knowledge, but also relies on the cultivation of values and virtue education in nursing in order to develop a competent and respected nurse.
It is beyond the scope of this article to discuss the treatise of these virtues. Often they are vaguely alluded to in the mission statements of schools and health care institutions. It is recognized that all virtues evolve over time and can be learned through experience.2 Nurses have the unique opportunity to get to know their patients over time. This allows them to “experience” their patients with greater intensity. This lasting interchange influences the formation of values in the nurse. Over time the nurse is expected to develop an ethical appreciation of the patient, not merely as a problem to be solved, but as an individual to be cared for. According to Benner, “the dominant ethic found in stories of everyday practice is one of care and responsibility.” Therefore, the development of virtuous practice is closely linked with the “development of skillful moral comportment that is derived from experience.6 Moral comportment results from reflection-on-action on the virtue of nursing during the span of a nurse’s career.3
According to Gallup’s annual survey of professions, nursing has been voted the most trusted profession in America for their honesty and ethical standards for the 11th consecutive year.7 Perhaps this reflects the collective ethical comportment that nurses manifest in practice.1 If we are to remain faithful to this public trust, nursing education must provide evidence-based clinical encounters that cultivate virtue development and growth.
The virtues already in place
Long before a student enters the nursing program, the foundations of these virtues were perhaps already laid down through their relationships with families, peers, their community, and the world at large. A study by Benner, Tanner, and Chesla showed that nurses come to clinical situations with a fundamental disposition toward what is good and right or what can be considered as virtues.8 The nursing faculty then accelerates the application of these virtues in the healing arts. It is with humility, both intellectual and experiential, that a faculty member may acknowledge the academic and clinical success of today’s graduates. This is partly the result of the richness of experiences, traditions, and cultures that students bring to the nursing program. Through carefully designed experiential learning activities, we can sustain our students’ innate and acquired virtues to be incorporated into their professional practice.
Strategies for virtue-inclusion in nursing education
Self-reflection is an essential component in value education. Benner et al. advocate for educators to “foster opportunities for students to learn how to reflect on their practice.”1 When provided with a safe climate for critical reflection, students can examine the virtues of nursing in the context of its success and practice breakdown. Integration of virtue education can easily be incorporated into classroom, simulation, and clinical activities. An essential first step would be to conduct a comprehensive curriculum review to identify gaps in moral or value education content and offer recommendations. Specific teaching strategies are offered below:
Lecture/classroom teachings
Enrich courses by integrating dilemma-based ethics and bioethics with attention to everyday notions of good practice and relational ethics.1
Organize small-group, student-led ethics committees and sponsor “brown-bag” discussions on similar topics.
Integrate current events dealing with bioethics in health care, education, and politics into clinical topics as appropriate.
Offer elective courses on ethics and value education. Collaborate with other schools within the university that may already have a course offered on the subject.
Require reflection papers and journal entries on ethics and values, exploring their impact on quality, safety, and patient satisfaction.
Conduct small in-class surveys or opinion pools on ethical dilemmas using interactive or online programs.
Infuse unfolding medical-surgical case studies with ethical questions and offer guide questions for self-reflection.
Use questioning to engage students in clinical thinking.1,9 Choose questions that allow learners to make decisions and defend their choices.10
Sponsor informal activities, such as a movie night, for students to watch ethics-themed films, followed by a panel discussion.
Clinical simulation
Create simulation scenarios with built-in ethical dilemmas.
Infuse simulation exercises with inter-professional collaboration that uses the multi-disciplinary approach in dealing with ethical issues.
Use the standardized “patient” in clinical simulation of ethical issues. Standardized patients (SP) are individuals who are trained to portray a patient with a specific condition in a realistic, standardized, and repeatable way.11 The use of SP will enhance virtue development because it allows for “nuances such as stance, touch, and orientation fused with physical presence and action” that cannot be replicated with a static manikin.6
Clinical teachings
Encourage student to attend ethics committee meetings in the hospital, school, or community.
Encourage students to ask a moral or ethical question during pre-and post-conferences.
Conduct bedside rounds as an alternative to post-conference. This allows for personal interaction between the students and the patient. This will help cultivate empathy, honesty, and politeness.
This list of teaching activities is by no means exhaustive. It is important to consider that even brief but specific endeavors can be used to integrate virtue education and facilitate discussion and reflection. Ongoing faculty development activities on virtue education will also be needed in order to elevate the quality and effectiveness of these educational strategies.1
If virtue can be taught, as I believe it can be, it is not through books so much as by example.2 A student who responded to the Carnegie National Student Nurses’ Association survey said the biggest challenge in nursing education she faced was “being lectured on caring and building trust by instructors who don’t practice what they preach.” 1 As clinical faculty, we have the moral imperative to model the virtues we want our students to emulate. We provide plenty of skills practice for bed, bath, and invasive procedures, both in real-time and in simulation, but there are very limited or non-existent “skill labs” for students to practice empathy, compassion, gentleness, humor, and the highest of all virtues: love. It is time to return virtue and value education back into the nursing curriculum.
References
P. Benner, M. Sutphen, V. Leonard, and L. Day, Educating Nurses: A Call for Radical Transformation.San Francisco, CA: Jossey-Bass, 2010.
A. Compte-Sponville. A Small Treatise on the Great Virtues: The uses of philosophy in everyday life. New York: Metropolitan Books, 2001.
C. Tanner, “Thinking like a nurse: A research-based model of clinical judgment in nursing,” Journal of Nursing Education, 45 (2006), 204-211.
S. Luparell, “Incivility in Nursing: the connection between academia and clinical settings.” Critical Care Nurse, 31(2), (2011) 92-95.
L. Cronenwett, G. Sherwood, J. Barnsteiner, et al, “Quality and safety education for nurses,” Nursing Outlook, 55(3), (2007) 122-131.
P. Benner, “The role of experience, narrative, and community in skilled ethical comportment.” Advances in Nursing Science, 14(2), (1991) 1-21.
J.M. Jones, “Nurses Top Honesty and Ethics List for 11th Year,” (2010), retrieved from http://www.gallup.com/poll/145043/nurses-top-honesty-ethics-list-11-year.aspx.
P. Benner, C. Tanner, and C. Chesla, Expertise in Nursing Practice: Caring, clinical judgment and ethics. New York: Springer, 2010.
F.A. Lim, “Questioning: A teaching strategy to foster clinical thinking and reasoning,” Nurse Educator, 36(2), (2011) 52-53.
K. Bain, What the Best Teachers Do. Cambridge: Harvard University Press, 2004.
Association of Standardized Patient Educators. Standardized patient terminology definition. ASPE Quarterly Newsletter (2010), 9(3), 9.
