Patricia Benner, R.N., Ph.D., FAAN copyright 2017
- Oregon Consortium for Nursing Education increased Transitions From A.D.N. To B.S.N. Programs;
- Made A.D.N. Students feel like “First Class Citizens”;
- Transformed Clinical Education;
- Created an Ongoing Culture of Innovation and more…
The innovative Oregon Consortium for Nursing Education (OCNE) collaborative curriculum exemplifies a stellar collaborative change project that sought to answer the State of Oregon’s call to educate nurses for the future health care in Oregon. This February and March, we present new EN videos that tell the OCNE Story of innovation and community building. So far, we have presented 21 exemplary teaching-learning examples of interactive, integrative classroom and clinical learning that were integral to this planned change project.
At the heart of this OCNE experience was a grant designed to transform clinical nursing education and develop more clinically integrated classroom experiences. We started with the examples of excellent interactive teaching that integrates clinical and classroom teaching because the teaching -learning strategies are at the heart of this change project. The curriculum is future-oriented and depends on teaching-learning strategies that aim at deeper learning. (Subscribers can view the living curriculum by viewing these 21 examples of innovative teaching. This is teaching that integrates knowing “that and about” with “knowing how and when.” Integrating both kinds of teaching and learning ensures situated cognition and deeper learning.) In response to this series, we hope readers will add examples of consortia, and other strategies for increasing the number of advanced degree students in our comment section.
Word of OCNE success spread, and as a result, Oregon faculty and leaders have consulted with other states to help design collaborative programs to increase the numbers of A.D.N. students transitioning to B.S.N. programs. In all cases, the goal has been to create well-designed curricula that smooth the transition from A.D.N. to Baccalaureate programs (http://www.ocne.org/; Gubrud-Howe, Schoessler, 2008). As the OCNE White Paper (Gubrud-Howe, Diggers, Tanner, Shores, Schloessier, 2006) states:
The Oregon Consortium for Nursing Education (OCNE) is a partnership of community colleges and public and private university schools of nursing. OCNE was established in response to the critical nursing shortage and the 2001 Strategic Plan promulgated by the Oregon Nursing Leadership Council. The curriculum has been developed, including agreements on: prerequisites to nursing major, graduate competencies, and course descriptions and outcomes. Rubrics and benchmarks have been created and have been pilot tested by faculty throughout the first implementation of the curriculum (Gubrud-Howe, Diggers, Tanner, Shores, Schloessier, p. 1 2006).
Many innovations from OCNE can be translated into other settings. Of course, local context, culture, and established programs will experience different situated possibilities and roadblocks to change. However, examples from other locations will enrich our understanding of how to facilitate this kind of programmatic change in multiple settings. We present the OCNE program at EducatingNurses.com as a source of inspiration, ideas, and evidence that it is possible to transform local nursing education programs and increase the number of B.S.N. nursing graduates. Many nurse leaders have pointed to the OCNE program as a great example of a sustained planned change since OCNE is entering its second decade.
For this series, we interviewed nurse educator change agents, leaders and students, tracing how the OCNE story unfolded over the last ten years. Both students and educators animated and pushed this change forward in Oregon; faculty and Administrators told us of their triumphs in this successful change project. Faculty were honest in describing their initial skepticism and doubts. Many pointed out the existing tensions between between the University program and A.D.N. programs. Their story is inspiring. In the beginning of the second decade of this change, we saw and heard success stories and continuing enthusiasm for program growth and continuous improvement.
The problem associated with finding enough good clinical placements for expanding nursing school enrollments was one of the forces for change. The problems with older models of clinical nursing education were discussed in Dr. Chris Tanner’s (2006) editorial for the Journal of Nursing Education. The problems with older models of clinical nursing education are condensed and paraphrased here:
Limited Number of Clinical Sites: The shortage of clinical sites is a result of expanded nursing school enrollments to meet nursing shortages. Nursing schools compete for scarce clinical placements due to low or unpredictable patient census, and overtaxed nursing staff.
Increased Patient Acuity: Patient acuity and complexity have left less time for nursing staff supervision of students, especially for hands-on procedures, requiring faculty to spend most of their time supervising procedures leaving little time “for more development of critical thinking skills or providing feedback to students”.
Inefficient Use of Students’ Time: Students often spend 12-hour shifts with staff nurses, leaving much of the students’ doing routine tasks repeatedly, “…which does not contribute significantly new learning nor the development of clinical judgment.”
Experience with a Variety of Patients: “…Students need experience with patients across the life span, patients with even highly prevalent problems, those who are learning to manage chronic conditions, or those making significant changes in health behavior.”
Other Critical Experiences: With the old total patient care it is impossible to plan and ensure that students get clinical experience with “interdisciplinary teamwork, working with families in the provision of care, or managing crisis situations…”
These issues related to clinical learning in practice were widely recognized by OCNE educators. They designed a new model for clinical teaching.
The five elements of the OCNE Clinical Education model are sequenced across the curriculum to support student development of clinical judgment and clinical practice knowledge:
- Concept-based experience
- Case-based experience
- Intervention-skill based experience
- Direct focused client care experience
- Integrative experience where students took up full nursing responsibilities in a clinical setting for an extended period of time (http://www.ocne.org/)
In previous articles and videos on EducatingNursing.com, (2016) we have applauded the spiraling aspects of the OCNE Curriculum so that concepts are reintroduced in different contexts and at different levels of complexity. Subscribers can click here to read “Concept-Based Curricula in a Practice Discipline“. (Benner, P. 2016. Concept-Based Curricula in a Practice Discipline)
In another of our modules, ( Benner, P., Deep Learning while Teaching the Discipline’s Most Important Concepts), the need for deep learning in a clinical setting is addressed:
The clinical education model emphasizes integrating theoretical and clinical use of knowledge. Many practice educators (Lave; Murrtaugh, de la Rocha, 1984; Lave, 1996; Benner, Kyriakidis and Stannard, 2010; Benner, et.al, 2009) make a distinction between applying technical knowledge or techniques, and situated thinking and problem solving in actual clinical situations. OCNE in designing their clinical education model thought about this distinction and increased their focus on clinical reasoning and situated use of knowledge. The example we often use is the distinction between learning to apply the techniques of measuring blood pressure, and the interpretation and thinking required to assess the significance of a particular patient’s blood pressure over time.
Other Forces for Change that Shaped OCNE’s Successful Collaboration:
- Oregon State’s mandate to the state’s nursing leadership to create new educational programs for the future of healthcare in Oregon.
- Community college and baccalaureate faculty acknowledged the difficulties of content overload in both programs along with difficulties in preparing students to safely practice in today’s health care.
- Both baccalaureate and ADN faculty were concerned about the low percentage of ADN students going on to complete a baccalaureate degree in the face of a ten-year legal mandate for all nurses to have a BSN degree.
Notable Impediments to the Change:
- Faculties from two types of schools didn’t trust one another. For years, each program had been lauding the merits of their graduates while emphasizing the limits of the “other” program graduates.
- The Consortium of 13 schools needed to trust one another in order collaborate to develop an agreed upon joint curricula.
- Both degree programs were in competition for students and this made trusting one another more challenging.
OCNE Leaders and Educators Chose Successful Change Strategies
The following six agreed-upon guiding principles guided interactions among group members:
- Inclusiveness – all members were to be heard
- Collegiality – respect and collaboration were encouraged
- Courage and Perseverance – the long view for development and implementation would require both
- Shared collaborative leadership – with an ethic of participation and shared responsibility for success was fostered
- Healthy Conflict – constructive disagreement within groups or individuals would be encouraged
- Beneficence – action for the benefit of others, without competition and adversarial stances to be fostered
These six guiding principles helped with developing an interactive and collaborative community between A.D.N. and B.S.N. faculty. Expert group facilitators were used to help forge a new community of collaboration and trust. The Executive Committee used fun, ice-breaking strategies that focused on leveling the playing field, creating trust and solidarity and collaboration between schools and faculty. Immediate implementation of new ideas was carried from the Curriculum Committee back to participating campuses creating a culture of innovation and creativity. Successful innovations on one campus were reported back to the Executive Committee, and were often transferred to other campuses, informally.
Planned and “Unplanned Spontaneous Local Change” were Both Encouraged
In order to prepare students for Oregon’s future health care needs, OCNE leaders emphasized teaching innovation in clinical reasoning, interactive and integrative clinical and classroom learning and teaching. As noted above, the five elements of the OCNE Clinical Education Module were used in all the Consortium schools. Flexibility in sequencing and other aspects of the curriculum were endorsed based upon local resources and contingencies such as available clinical placements.
The Consortium added value to faculty in each school by creating an online shared resource center for teaching and learning ideas. As noted on the website: “Largo is our learning activities repository, where we share instructional resources with each other. Download teaching resources by course and add your resources on the Largo site.” (http://www.ocne.org/).
Evidence of the Successful and Sustained Change were Evident in Student, Faculty and Administrative Interviews
Faculty told us that they could never go back to power points and lecture after learning to use unfolding case studies, and flipping the classroom so that students prepared to use knowledge in class.
It is remarkable that students found continuity and similar interactive and effective teaching in most of their clinical practice.
Faculty often interpret “academic freedom” in very individualistic ways. But these students find that having a similar level of effectiveness in all their teachers to be one of the strengths in their OCNE education. This diffusion of change was facilitated by a grant that focused on the OCNE Clinical Education Model. Committees, and frequent meetings and sustained connection and coordination ensured interactive teaching. Lectures and power-point slides were limited to “micro lectures” to get the students on the same page. These unified teaching and learning strategies changed the students’ expectations about learning. They learned to focus on class preparation that was called the student’s “ticket to class.” The classroom was used for problem solving and multiple learning exercises that required using relevant knowledge in actual clinical situations.
The OCNE Program brought a new sense of entitlement and justice to students in A.D.N. Programs. Students had examples from the classmates ahead of them that the transition to the Oregon Health Sciences Campus was worthwhile, and smooth. The A.D.N. faculty played an active role in encouraging students to seek Baccalaureate and higher degrees after graduation. The former culture of divisiveness melted away. The first two years of the nursing A.D.N. curriculum matched the one in the Oregon Health Sciences University. We were impressed by how much ongoing coordination and connection exists within the consortium. Students meet one another in the large shared simulations, faculty attend the annual OCNE summit meetings, and participate in OCNE cross-campus committees. We begin this story by having the two Co-Directors of OCNE, Paula Gubrud-Howe and Linda Wagner tell the story of their ongoing coordination of OCNE and some of their hopes for the future.
(NOTE: Next month we will add student and faculty experiences with the OCNE curriculum and teaching, learning strategies.)
Benner, P., Sutphen, M., Leonard, V., Day, L. (2009) San Francisco: Jossey-Bass, Carnegie Foundation (Palo Alto, CA)
Benner P., Hooper-Kyriakides P., Stannard D. (2011) (Second Edition, first edition 1999) Clinical Wisdom and Interventions in Acute and Critical Care: A Thinking-In-Action Approach. New York: Springer Publishers
Gubrud-Howe,P., Driggers, B., Tanner, C., Shores, L., Schoessler, M. (2006) White Paper on OCNE Clinical Education Redesign, pp. 1-5.
Lave, J., Murtaugh, M.,&de la Rocha, O. (1984). The dialectic of arithmetic in grocery shopping. In B. Rogoff & J. Lave (Eds.), Everyday cognition (pp. 9–40). Cambridge, MA: Harvard University Press.
Lave, J. (1996) “The practice of learning, the problem with ‘context.’” In: Chaiklin, S., Lave, J. (1996) Understanding Practice. Cambridge, UK: Cambridge University Press. pp. 3-32. (see p.7)
Oregon Consortium of Nursing Education (OCNE) Website http://www.ocne.org/
Tanner, C., (2006). The Next Transformation: Clinical Education. Journal of Nursing Education Editorial, volume 45, 99-100