The Nurse Educator as an Advanced Practice Role

The changing health care delivery system has increased the demand for advanced practice nursing (APN) roles. Within a clinical framework, these roles have been clearly defined as the nurse practitioner (NP), nurse midwife, nurse anesthetist, and clinical nurse specialist (CNS). The initial purpose of these roles was to provide physician replacement and support, respond to changing reimbursement structures, and cost containment. Over time, the value of the APN on many levels has been validated and incorporated into many areas of primary care. Although the concept of advanced clinical practice is certainly inherent in these roles, the larger concept of advanced practice in nursing should be applied to other areas, including the nurse educator.
Although there is no one clear definition of advanced practice nursing, when the accepted tenets are examined, the role of the nurse educator with all of it’s inherent roles and responsibilities, as one of advanced practice, begins to appear within the framework.
The term advanced nursing practice addresses what nurses “do” in the role, and is distinguished from basic practice through specialization, expansion, and advancement. Advanced nursing practice:

• maximizes the use of nursing knowledge
• contributes to the development of the profession functions as a change agent and leader

Certainly, the capacity to potentiate change and promote leadership is inherent in the scope of the educator. This involves multiple roles broadly related to:

• clinical practice
• education
• research
• professional development
• and organizational leadership

The term advanced practice nursing refers to the entire field of advanced nursing practice, and includes all of the APN roles, APN environments, and addresses the environmental factors affecting role development, implementation, and evaluation. Advanced practice nursing “is a way of viewing the world that enables questioning of current practices, creation of new nursing knowledge, and improved delivery of nursing and health care services” (Bryant-Lukosius, et al., 2004).
The concept of advancement, within the APN role, is the major key. In specialization, whether in a clinical or non-clinical role, the expansion of knowledge, skills and role autonomy is evidenced through advancement. There is an engagement in professional activities leading to innovation within the specialty (education) and nursing care (clinical education). The underlying commitment to a nursing orientation to practice is inherent. Nurse educators educate nurses (in academic, clinical, or staff development areas) regarding disease process and management from a nursing oriented perspective, to advance nursing as an art as well as a science. The information synthesis by the APN and by the nurse educator, are the same. It is the “integration of practical, theoretical, and research knowledge to accomplish the objective and assess the outcome” (Bryant-Lukosius, 2004). This integration, the application of role competencies, education, research, leadership, and ongoing professional development are the framework of an advanced practice role. Advanced practice occurs within multiple roles, not only in clinical practice.
The environment of acceptance for APN roles continues to evolve, not only in the larger healthcare environment, but also within nursing itself. The development, acceptability, and demand for APN roles is driven by societal values, expectations, and needs for nursing and health care services (Bryant-Lukosius, et al. 2004). The system influences these roles through need, as when the APN became more prevalent in community settings. Ongoing assessment or these environmental factors must be maintained and dealt with on all levels, including financial. Without ongoing and increasing financial support, the role of the APN can be considered expendable, and this is often seen in education budgets in academic a well as clinical settings.
Although the role of “educator” is inherent in the clinical APN roles (NP, CNS), role conflict, role overload, and time constraints are often cited by primary care APN’s. I stipulate that the “Educator” specialty as recognized as an APN would potentially increase patient, staff, and student satisfaction as the focus would be consistent and not part of a larger agenda. The nursing profession is responsible for defining these roles and establishing standards. The legitimacy is determined by the profession’s support, as well as identification of appropriate evidence to justify the need.

In 2005 The Scope of Practice for Academic Nurse Educators was developed by the National League for Nursing’s Certification Governance Committee. The purpose of this document is to describe academic nursing education as a specialty area and an advanced nursing practice role within professional nursing. This recognition, and the introduction of a Nurse Educator Certification exam requiring a minimum of a Masters degree points toward the establishment of the nurse educator as an accepted APN role. Certainly without such an exam, the nurse educator role meets the criteria of other accepted APN roles as has been discussed, but testing will provide the needed data to continue to justify and promote the role, leading to increased acceptance and potential financial consideration.
The current nursing shortage has presented the nursing profession with an unprecedented need on multiple fronts. No longer is the need only at the bedside and in other clinical care areas, but the need for graduate-level educated nursing faculty is overwhelming. Because of the inability of institutions to staff nursing programs, qualified applicants are being turned away or being put on waiting lists of up to three years at nursing schools around the country. The profession as a whole is shrinking in numbers related to attrition from aging, retirement, and career dissatisfaction. But, how can we “fight the fire without water?” It is only in the preparation of qualified, motivated, nurse educators that the profession can move forward on all levels. The “bar” for this area of specialization should be set high, because the nurse educators hold the future of the profession in their hands. Having these professionals maintain and exemplify the standards of advanced practice, and be recognized for the degree of advancement and scholarship that must be attained in meeting those standards is imperative. It ensures that from the new student nurse in the classroom to the seasoned nurse engaging in ongoing staff development, the “learner” will be afforded the opportunity to have the best “teacher” they possibly can, and in that, patients will have the opportunity for the best care.

References:
Bryant-Lukosius, D. et al. (2004) Advanced practice nursing role: development, implementation,
And evaluation. Journal of Advanced Nursing 48(5), 519-529.
Lindell, D. et al. (2005) The Scope of Practice for Nurse Educators, http://www.nln.org/publications/Scope/index.htm, retrieved 7/20/06

Leadership and Nursing

The Nurse. Two words. Words that historically would bring forth a mental image of the caregiver, the angel in white, tending to the needs of the sick, the needy, and dying. An image formed on battlefields and in hospital wards. The Nurse was respected and emulated. Little girls “nursed” their dolls, bandaged their “boo-boos”. Someday they would grow up to be The Nurse, and be proud of the profession they had chosen. They would comfort their patients; give good care, holding the hand of the mother during childbirth and the hand of the elderly as they died. Know each day that they were making a difference in the lives of others, and in this pride there would be the call to others to become The Nurse too. Supporting each other, as well as those that would come after them. Until the day that The Nurse started to ask the question, as described by Malloch & Porter-O’Grady, “why do I feel so bad”?

Within the past decade, the nursing shortage has presented many faces: fewer persons are interested in nursing as a career, enrollment in nursing programs has dropped, and fewer nurses are being employed by hospitals. Increasingly, nurses are expressing dissatisfaction with their practices. Toxicity in the workplace has been a major cause of the decreased interest in nursing. When the conditions of the workplace began to effect practitioners, and practice, to the point that nurses questioned their own value, I believe it was then that the lack of interest in nursing began.
Workplace toxicity has continued to foster a “glass half empty” view among many practicing nurses. Disappointed, overworked, and overwhelmed, nurses stopped promoting themselves, as well as nursing, as a worthwhile profession. A consistent “dissent in the ranks” has led to mistrust and decreased sense of comradery among staff. This lack of satisfaction has several causes, but similar outcomes: decreased retention, (especially among specialty nurses); frequent turnover; early retirement; and/or departure from nursing altogether. More foreign nurses, travel nurses and agency nurses are used to maintain staffing levels. The changing composition of the nursing workforce and the dissatisfaction of practicing nurses contribute to the complexity of the nursing shortage. (Donley, 2005). In a profession where healing of others has been the focus, the struggle at this time is to try to heal itself.
The causes of the nursing shortage are multi-factorial. During the 1990’s, the change in health care reimbursement structures led to fewer nurses being employed, especially within hospital settings. The structures that promoted nursing orientation, education, and training were eliminated because these were perceived as “non-essential”. These systems of internal support essentially disappeared and it became a “sink-or-swim” environment. This amounted to professional poisoning, and potentially professional suicide. As my interest goes to being a nurse educator in multiple environments, academic education as well as within a practice setting, I think that these supports need to be returned. I feel that nursing needs to protect, preserve, empower, recruit and retain within what it has right now. Many nurses see the solution to the problem as being more “bodies”, through recruitment, bonus structures and job incentives. These programs, although well intentioned, may not be enough in spite of best efforts because of factors beyond the best recruiter’s control.
Unlike other periods of nursing shortage, the profession itself is now also influenced by the same societal demographics that are causing the problem. The aging of the Baby Boomer generation is influential in the increased need for nurses, but the majority of practicing nurses are part of the same demographic. This affects clinical as well as academic settings, as many of the Masters and Doctoral prepared are also aging, with new educators not entering the teaching setting. As of 2000, 60% of the nursing workforce was over 40 years of age, and the percent of RNs under age 30 had fallen by nearly 40% since 1980. It was estimated that nearly half of the nursing workforce would reach retirement age between 2010 and 2015. (Buerhaus, Staiger, & Auerbach, 2003). The succeeding generations have had different options, as well as being significantly smaller in number, as birthrates have decreased. The increase in educational opportunities, particularly for women, has made differences among the generations. Understanding the quantitative, as well a qualitative differences, is vital in shaping nursing workforce policies, and attracting new members to the field. Nursing has to see the shortage differently, in order to seize opportunities for growth in other ways. It is perhaps impossible to increase in number when the population itself is smaller, and of that population, opportunities are more varied (Donley, 2005).
What are the leverage points that nursing must promote? From the perspective
of an educator I believe we must start there. Education of new nurses, current nurses, and most importantly, of the public at large. Where do we begin? Foremost, nurses have to promote nursing! There is no way to attract new practitioners, or keep existing practitioners, if nurses continue to be entrenched in negatives. Identity is the biggest leverage point that one can have. Knowledge of who you are, what you bring to the table, and what you stand for should be the basis from where all else flows. Nurses must establish, promote, and be proud of their identity. Increasing the nursing “voice” and being seen as being important, with significant societal impact will break the stereotype of being “second tier” to physicians. Having an increased feeling of control over practice and decision–making and being a collaborator in care comes with confidence in clinical knowledge and the nurse’s professional role. Become political. Increase media savvy, and use the media to increase the image of nursing and deflate long held stereotypes.
Nursing education itself must rise to the “new occasion”. Nursing education remains hospital-centric, when the majority of health care is delivered outside the hospital setting. Future models have to promote independence and critical thinking, problem solving and analytical skills in order to keep pace with challenges in health care. Patient care and curriculum development will be based on evidence, clinical indicators, consensus and best practice. Faculty and staff development educators will need to add content, educate in multiple formats (technology) and follow knowledge almost as it is being discovered. Nurses have to be mentored and fostered in confidence throughout their educational process, and have to understand that their learning will be life-long. I think that nurses have been socialized to think that once you “are a nurse”, that is it. It is from that mentality that the fear and reluctance to continue education, therefore the professions inability to create a viable succession, has come. In leadership within an organization, one must learn how to recognize and foster succession. We need to do that in nursing. From the beginning, nurses need to be “educated to educate” those that will come next, in whatever context that takes (e.g: preceptorship), as opposed to the often described “eating the young” phenomena. Faculty must overall, help students find meaning and calling in their practice.
What resources do we need? We have ourselves as our most valued resource, and we don’t cost anything. The linear-thinking mentality of “when…..then” is self defeating because “when” may not come. The many financial and system related obstacles that effect nursing are generally not within our locus of control. In that, we need to use ourselves in the ways previously stated. With increased credibility, there is attention, respect, and often money. Investment must be fostered. Promotion of education, through accessibility and affordability, will increase the number of advanced practice nurses; thus adding to professional credibility. With this, financial gains may then be commensurate. Nursing has long been perceived as a woman’s job. Not the career of an educated, responsible, professional as has been the perception of the roles maintained historically by men. Increased pay is well deserved, but in this health-care environment, it is an uphill battle that will be won only based on criteria more measurable than years of service. Increasing career satisfaction though an environment of respect and support from our own administration is imperative. As stated in my self-assessment, I believe that staff empowerment in all settings is the key to satisfaction and productivity in even the most trying circumstances. People feeling they are being listened to. Feeling empowered and valued increases the health, energy, and harmony of a system. When the system is broken down by stress and dysfunction, the toxic environment is formed. (Malloch & Porter-O’Grady, 2003).
In their discussion of organizational toxicity, Malloch and Porter-O’Grady identify ten sources of this dysfunction. With regard to the educational setting, I will discuss four toxic behaviors:

· Vertical Authority Structure
Within nursing schools and institutions, there has long been a hierarchical mentality. With pressure on faculty/managers to maintain enrollment/productivity, and standards, and with obtaining tenure/standards of care as often being a motivating factor, a toxic environment can be fostered due to the stress on the instructor/manager to perform, with the needs of the student /staff being lost in the process. With regard to faculty/staff collaboration, this structure can often stifle creativity and expression due to the need to stay within the structure.

· Abuse of Power
The abuse of power is toxic in any environment. This may come from the frustration, insecurity, or poor preparation of the leader, be it a nurse educator or a nurse manager on a unit. The ensuing demoralization that ensues for the student or staff may be irreversible. Particularly in nursing education, where there is a human factor as well as a straight “three R’s” type of learning, there is an increased anxiety factor. If an educator/manager/preceptor comes from the aspect of “learning through fear”, that can effect a students/staff integration, confidence, and ultimately, their success.

Inconsistency and Dishonesty
I think this behavior is extremely detrimental in the educational, as well as work environment. Just as a clinical practice nurse is responsible for the honest and consistent care of their patient, I feel so is an educator/preceptor for the care of their student. Being open, honest, and communicating regarding progress, strengths and weaknesses is imperative. In my original AD RN program I witnessed poor educational leadership examples with regard to “ambushing” students, and at times embarrassing them publicly. These were cases where students had no idea that they were being perceived as weak until they were ultimately made examples of. Inconsistent and “mixed” messages and at times, outright lies. An educational environment should allow for trust, as students are relying on the educator to guide their future; not cause them to question it.

Toxic Mentoring
Educators/preceptors should not bring their “baggage” to the learning environment. Self-awareness is necessary to lead in any capacity, and this includes the ability to be able to allow others to just “be”. Being an effective educator does not mean that one should try to create others in their image, and discount those that do not aspire to be in that image. Sharing experiences as a way of healthy mentoring reinforces the need to learn over a lifetime. As I have stated, nurses have to be given the positive educational experience so as to desire to continue to learn, as well as teach so as to allow for succession of competent practitioners.

I hope as an educational leader in multiple settings to be able to transform educational experiences to as positive as they can be. Different environments will call for different approaches. Academia allows for some more control than a practice setting, so adjustments will have to be made. Hopefully, in trying to incorporate my leadership style into these, in nurturing my own flexibility, I will be able to reach nurses on a level that will stimulate them to want to know more and do more. Nursing will continue to face many challenges to it’s identity and sustainability due to economics, demographics, and politics, but if in being part of the growth of a nurse, I can plant some seeds that may someday become a garden, then I will have accomplished my goal and hopefully helped them on the road to accomplishment of their own.

References:

Bauerhaus, P., Staiger, D., & Auerbach, D. (2003). Is the current shortage of hospital nurses ending? Health Affairs, 22(6), 191-198.

Donley, R. Sr. (2005). Challenges for nursing in the 21st century. Nursing Economic$, 23 (6), 312-318.

Porter-O’Grady, T, & Malloch, K. (2003). Quantum Leadership. A Textbook of New Leadership. Sudbury, MA: Jones and Bartlett

Program Assessment

Evidence-based practice is an approach that “enables clinicians to provide the highest quality of care in meeting the multifaceted needs of their patients and families”. When providers know how to find, critically appraise, and use best evidence, and when patients are confident that providers are using evidence-based care to provide best practice, optimal outcomes are achieved for all (Melnyk and Fineout-Overholt, 2005).
This concept, as we have learned and applied it within a clinical system as patient caregivers, is one that must be applied within an educational system. Just as in clinical environments, the educational system is experiencing new trends and demands from both within and without. Technological advances, the immediate availability of information, changing student demographics and diversity, have required faculty to assess their impact on student learning and outcomes. As a clinical situation must be an environment that promotes health, an educational system must be an environment to promote learning. The collaboration of faculty with regard to the development of “courses and curricula to systematically help students synthesize, practice, and develop increasingly complex ideas, skills, and values” (Allen, 2004, p.2) is imperative. This is accomplished through ongoing program assessment and planning. Program assessment is best understood in this context as “best practice in higher education” (Allen, 2004, p.2).
The six steps of an assessment program are:

• develop learning objectives
• check for alignment between curriculum and objectives
• develop an assessment plan
• collect assessment data
• use of results to improve the program
• examine the assessment process and correct as needed (Allen, 2004, p.55).

The assessment plan describes how learning objectives will be assessed, and should describe a process that that will generate meaningful data, and is manageable and sustainable over time (Allen, 2004, p.10).
An assessment plan must be of a manageable size and scale. All objectives would be examined over a continuum, beginning with those that are generally well mastered by students and progressing toward the more challenging objectives. The assessment plan should remain focused on student learning as the motivation for program change. Evidence found through data collection and assessment must be collected with all ethical considerations, should be tested for reliability and validity, and subject to quality assurance. Reliable and valid data may then be used for subsequent decision-making and change. Faculty reflection on data should be used to respond to deficiencies in meeting objectives, as well as to lead to program improvement. The assessment plan should always include the examination of the assessment process (Allen, 2004,p.57). As a mission may change, so may the originally stated objectives, and assessment plans may need to change. The process of plan implementation is in and of itself an ongoing learning experience for those implementing it.
The components of an assessment plan are directed at answering the questions who, what, when, where, and how:

• WHO will do WHAT
• WHEN they will do it
• WHERE and HOW will they us the information that is collected (Allen, 2004).

General organization of an assessment plan as described by Allen involves:

• creating a matrix listing learning objectives
• description of how the objectives align with the curriculum in place
• measures of assessment
• time frame for assessment
• and who will be involved

A supplemental summary of data related to each objective and/or an impact statement may be provided later. The plan must employ a strategy to assess student mastery of the stated objectives. The chosen strategy must give an “unambiguous assessment of the relevant learning objective”(Allen, 2004, p.58), so as to provide results that give useful information about the program. The areas of content (knowledge students acquire), process (student ability to apply knowledge critically), and outcome (ability to show combination of content and new application of knowledge), should be assessed, with direct and/or indirect strategies used in implementing the assessment plan.

Currently, my clinical placement is at an undergraduate nursing program. As my area of interest is nursing in the community, I would like to focus on the curriculum with regard to student preparation for servicing this population. As measures of assessment must be able to yield desired and useable data relative to the question being asked or the objective being evaluated, I think direct assessment/analysis of a community based student project over the course of a semester (based on a learned concept) would be an appropriate way to assess understanding of objectives. This would illustrate the ability of a student to apply learned knowledge to meet the objectives of nursing community-based clients.

• Data from surveys of students with regard to their own perceptions of self-efficacy in caring for community-based clients may also be a measure of student ability to meet objectives, as well as the relativity of curriculum content to “real world” environments.
• Survey data of community mentors/preceptors regarding student performance may be assessed as indirect information regarding students learning needs to meet objectives, as well as address deficiencies in course content.
• The use of technology as an adjunct to traditional education is a given in 2006, and web-assisted evaluation tools would also be appropriate. The data gained through this assessment plan would be used to evaluate course objectives relative to curriculum and a student’s ability to meet these objectives, and used to make appropriate change to enhance learning.
  Program assessment and planning is time consuming, but is a necessary and indispensable tool to keep an educational system meaningful and viable in a competitive environment. A meaningful, manageable and sustainable plan will work toward the ultimate goal of improved student learning.
  
  References:
  Allen, M.J. (2004). Assessing Academic Programs in Higher Education. Boston, Mass.: Anker
  Melnyk, B.M. & Fineout-Overholt, E. (2005). Evidence-Based Practice in Nursing and
  Healthcare. Philadelphia: Lippincott Williams & Wilkins