At the 2005 National Council of State Boards of Nursing (NCSBN) annual meeting in August, a position paper entitled Clinical Instruction in Prelicensure Nursing Programs was adopted by the NCSBN member boards. This position paper was written by the NCSBN Practice, Regulation and Education Committee (PR&E), in response to a resolution made at the 2004 annual meeting. The resolution asked NCSBN's PR&E Committee to develop a position paper to guide boards of nursing in evaluating whether entry-level nurses have received effective, supervised clinical nursing education to ensure safe nursing practice. The boards of nursing asked the committee to investigate the available research, and other evidence, supporting traditional programs that offer clinical experiences with actual patients. They also wanted the committee members to search the available evidence supporting those programs that have alternative clinical education, using distance learning, simulation, and other technical teaching modalities, but little or no clinical experiences.
Because the mission of the boards of nursing is to protect the public, boards have the responsibility of making sure that new graduates are prepared to practice safely. Recent discussion at the boards of nursing has focused on whether nursing programs leading to initial licensure can successfully educate nurses with alternative methodologies that take the place of traditional clinical experiences. In the face of a nursing shortage, programs are asking for education rules addressing faculty qualifications to be waived and are developing programs with only limited (in some cases none) clinical experiences with actual patients. At the same time, nursing employers are reporting that fewer than 50% of new nurses (41.9% for both ADN and BSN graduates) are prepared to provide safe and effective care.1
The PR&E Committee engaged in the following activities in response to this important charge:
* Reviewed the relevant literature, including systematic reviews of medical simulation, computer-assisted learning in undergraduate medical education, and nursing education strategies.
* Surveyed all the boards of nursing.
* Surveyed nursing education organizations and reviewed their responses regarding comments on clinical education requirements in prelicensure nursing programs.
* Consulted with a renowned expert in simulation, Dr William McGaghie from the Northwestern University Feinberg School of Medicine, about simulation.
* Participated in a facilitated, simulated experience at the Patient Safety Simulator Center at Northwestern University Feinberg School of Medicine.
* Engaged in dialogue with a simulation facilitator at the Patient Safety Simulator Center.
* Sought stakeholder input and reviewed the recent position statement by the American Organization of Nurse Executives, "Position Statement: Prelicensure Supervised Clinical Instruction."
The Evidence
It is beyond the scope of this article to review the literature in depth, although this link to the NCSBN Web site has further information on the literature review done for the position paper: http://www.ncsbn.org/regulation/nursingeducation_nursing_education_papers.asp. Click on Clinical Instruction in Prelicensure Programs and A Systematic Review of Studies on Nursing Education Outcomes: An Evolving Review.
In the theoretical background, Dr Patricia Benner's2 research provided evidence that qualified faculty members are essential for providing coaching, feedback, and reflection throughout the nursing program. Her work was closely linked to Ericcson's3 sentinel review of deliberate practice. Deliberate practice would support not only clinical skills, but also critical thinking and judgment. Deliberate practice is beneficial to learning in artificial centers, such as simulation; yet it also requires that a student become engaged in deliberate practice with patients in the real context with a master teacher giving feedback. Similarly, situated cognition4 is an emerging theory that has been studied in a variety of disciplines and represents a shift from some of the traditional psychological theories of learning. This situated cognition theory proposes that learning in the authentic environment provides students with higher-level thinking and reasoning skills.
Although there are few studies addressing clinical experiences with actual patients, it is important to note that there are no studies of programs that have little or no clinical experiences. The existing clinical literature finds that gaining comfort in the role of a nurse and being confident in that role are best learned from practice with actual patients, where there is time for reflection and feedback from a qualified nursing instructor.2,5,6 Building relationships and connecting with patients are identified as important components of nursing.7 Likewise, the 2003 Institute of Medicine's Health Professions Education: A Bridge to Quality8 identifies patient-centered care and working within an interdisciplinary team as 2 essential competencies for all members of the healthcare team. Nurses must practice in the authentic environment if they are going to learn how to "connect with patients" or how to work with interdisciplinary teams. Angel et al9 studied critical thinking in nursing students and found that the learner's knowledge and critical thinking improved after a semester of faculty-supervised clinical experiences. This study provides excellent evidence of the importance of clinical experiences with actual patients in promoting critical thinking. Lastly, the importance of immediate feedback and the opportunity for reflection was found to be crucial for critical thinking and performing nursing skills, both in nursing students and in new nurses.5,10,11
Two excellent systematic reviews provided insight into simulation12 and computer-assisted learning.13 Issenberg et al12 found that simulation can best enhance learning by:
* Providing feedback (47% of articles)
* Repetitive practice (39% of articles)
* Curriculum integration (25% of articles)
* Range of difficulty level (14% of articles)
* Multiple learning strategies (10% of articles)
* Capture clinical variation (10% of articles)
* Controlled environment (9% of articles)
* Individualized learning (9% of articles)
* Defined outcomes (6% of articles)
* Simulator validity (3% of articles)
Again, this debriefing, or immediate feedback to the learner, is as essential for simulation as it is for learning in the clinical setting. Some research, in fact, has shown that clinical performance improved with students who also had experiences with simulation.14 In Greenhalgh's13 systematic review of computer-assisted learning with medical students, the researcher found positive and negative characteristics on online learning and concluded that the best learning takes place with online and traditional teaching methods.
The PR&E Committee also surveyed national nursing education organizations, as well as the boards of nursing, questioning them about whether they thought nursing could be taught effectively without having experiences with actual patients. Although the education organizations provided some feedback, none of them answered the question about whether nursing programs should have clinical experiences with actual patients. A large majority of the boards of nursing that responded thought that nursing students should have experiences that are across the lifespan with actual patients, and these experiences should be supervised by qualified faculty members.
The Committee members also sought feedback from the American Organization of Nurse Executives, which represents nursing employers. This organization disseminated a position statement in September of 2004 stating that the American Organization of Nurse Executives takes the position that, although innovative approaches may be developed, all prelicensure nursing programs must contain structured and supervised clinical instruction provided by appropriately prepared registered nurses.
Lastly, PR&E Committee members sought expertise in simulation from Dr William McGaghie, Professor in the Feinberg School of Medicine at Northwestern University, a renowned expert on simulation in healthcare. The Committee members visited the Northwestern simulation center and took part in actual simulation experiences. It was clear that simulation is an important complement to supervised clinical practice, but the simulation experts also stressed that simulation can never be used as a substitute for experiences with actual patients.
Conclusions
Because the mission of the boards of nursing is to protect the public, they had asked for guidance with evaluating prelicensure programs that do not provide adequate experiences with actual patients. There is evidence, in nursing and healthcare research and by consensus of experts, that clinical experiences with actual patients are an essential part of teaching safe, competent nursing practice to prelicensure students. Therefore, NCSBN adopted the following positions at their 2005 annual meeting:
* Prelicensure nursing educational experiences should be across the lifespan.
* Prelicensure nursing education programs shall include clinical experiences with actual patients; they might also include innovative teaching strategies that complement clinical experiences for entry into practice competency.
* Prelicensure clinical education should be supervised by qualified faculty who provide feedback and facilitate reflection.
* Faculty members retain the responsibility to demonstrate that programs have clinical experiences with actual patients that are sufficient to meet program outcomes.
* Additional research needs to be conducted on prelicensure nursing education and the development of clinical competency.
REFERENCES