Not your mother's nursing school

Kathleen B. Gaberson

Much has been written about the growing nursing shortage. Health care professionals, administrators, policy makers, legislators, regulators, third-party payers, and consumers are concerned about whether we will be able to recruit and retain a well-educated, experienced nursing workforce to meet projected needs. As a Baby Boomer, I will be contributing to the problem when I retire next year, among the first of my generation to be eligible for early Social Security benefits. Our retirements not only will reduce the number of professional nurses in the workforce but also will produce a worrisome loss of expertise and wisdom gained from many years of professional experience and continuing education. I'd like to think that I have also contributed to a solution to the problem by devoting the last 35 years of my career to educating nursing students for entry into the profession.

Nursing students inevitably enjoy their clinical learning activities more than the classroom work; new students eagerly anticipate the first time they can enter a clinical setting and learn from their instructors and clinical staff members how to care for real patients. Most nurses also enjoy working with nursing students--patiently answering questions; sharing their clinical wisdom; and even learning from the students about newer theories, interventions, and evidence for practice. Their passion for the profession and commitment to excellence is truly inspiring to students.

Although most of my students enjoy listening to stories about "how we used to do it," many of them become discouraged and demoralized when staff members question and even criticize current nursing education methods. How will we recruit new nurses into the workforce when important role models and future colleagues express dissatisfaction with and disapproval of the way in which students are prepared for professional practice?

A clever old television commercial touted a company's new cars as "not your father's Oldsmobile." The prospective buyer was urged to replace the old impression of a staid family sedan with the image of a lively, exciting, fun vehicle. If I could characterize contemporary nursing education programs to nurses who have been in practice for some time, I would say that they're "not your mother's nursing school." Nursing education has undergone considerable change in the 40 years that I have been practicing, and unless you have held academic appointments, you may not be fully aware of the changes or understand the rationale behind them. We need to understand current nursing education trends and practices so that we can facilitate the successful integration of new graduates into the profession--graduates who have not been educated in our mothers' nursing school or ours, but in programs that are responding to the contemporary realities of higher education and health care.

MYTHS DEBUNKED

Well-meaning nursing staff members often give advice to students based on both their own educational experiences and common myths about professional nursing education and preparation for licensure. Let's debunk some of those myths and replace them with accurate information to guide our responses to contemporary nursing students.

Myth 1: Diploma and associate degree nursing programs include more clinical hours; BSN programs are highly theoretical and don't offer as much practical experience.

This myth actually predates the existence of associate degree nursing programs, and at one time, it may have had some basis in fact when comparing diploma and baccalaureate nursing programs. In contemporary professional nursing education programs, however, students spend approximately the same amount of time in clinical learning activities regardless of the type of program. Although it is true that baccalaureate nursing students spend more time in the classroom than associate degree or diploma students do, that difference is due largely to the total length of the program, including non-nursing general studies requirements. The number of credits or hours allotted to clinical courses is remarkably similar in all nursing programs. Baccalaureate nursing programs contain courses not usually required by diploma and associate degree programs, such as community health and nursing research, but the clinical knowledge that is tested on the licensure examination is the same for all nursing graduates and requires approximately the same amount of time to teach and learn.

Myth 2: If a program isn't accredited by the National League for Nursing, it isn't a good program.

The National League for Nursing (NLN) once was the only accrediting body for nursing education programs, including practical nursing, diploma, associate degree, baccalaureate, and master's levels. In response to US Department of Education policy, however, the National League for Nursing Accrediting Commission (NLNAC) was formed in 1997 as an accrediting body separate from its associated membership organization, the NLN. (1) It is no longer accurate to refer to "NLN accreditation," although old habits die hard, and it is not uncommon to hear even nurse educators make this error.

In 2000, the American Association of Colleges of Nursing formed the Commission on Collegiate Nursing Education (CCNE) as its associated accrediting body. Consistent with its mission, this organization accredits only baccalaureate and higher degree programs in nursing. (2)

With two accrediting bodies for nursing education, baccalaureate and master's-degree programs may be accredited by either the NLNAC or CCNE. Diploma and associate-degree programs are accredited only by the NLNAC. Accreditation by either organization is an important indicator that a nursing education program meets external quality standards.

Myth 3: New graduates should take state boards immediately after graduation before they forget everything.

Seasoned nurses often use the term "state boards" to refer to the licensure examination for professional nursing, but that language dates back to a time when each state administered its own examination. What we remember about our state boards will not help new graduates anticipate what the current licensure examination will be like. In 1982, the National Council of State Boards of Nursing (NCSBN) implemented the National Council Licensure Examination for Registered Nurses (NCLEXRN). The NCLEX-RN is a national examination with a single passing standard. The test plan for the NCLEX-RN is evaluated every three years after a practice analysis of newly licensed professional nurses, and the test plan may undergo a major or minor change. The passing standard also may be revised at the same time. (3,4)

The format of the NCLEX-RN is very different from the state board examinations that we remember. Since 1994, this examination has been administered via computer, and it is a single, unified examination, not divided into the content areas of medical, surgical, psychiatric, obstetric, and pediatric nursing. The test result is not a numeric score; the candidate receives only a pass or fail outcome. Because the NCLEX-RN is constructed and administered using a Computer Adaptive Test format, each candidate's examination is different, although all test items relate to the test plan. The examination can vary in length from 75 to 265 items, depending on how quickly the computer program determines the level of the candidate's ability, and can take up to six hours to complete. (3)

The most important thing to remember about the NCLEX-RN is that it focuses on critical thinking ability. Most of the examination items test cognitive ability at the application or higher levels. (5) Memorization and recall of facts is unlikely to lead to a passing result; candidates must demonstrate the ability to analyze scenarios, apply knowledge to unique situations, set priorities, and delegate appropriately. Taking the test immediately after graduation, therefore, will not necessarily result in success because success does not depend on recall of content.

There is a partial truth in this statement, however. Research by the NCSBN reveals that candidates who take the examination within approximately one month of eligibility are more likely to pass on the first attempt. (6) Candidates should be advised to prepare thoroughly for the examination by identifying areas of weakness, often through diagnostic standardized testing, reviewing content in those areas, and answering hundreds to thousands of practice test items. Many new graduates also complete a commercial NCLEX-RN preparation course.

Myth 4: Nursing students today don't get enough experience with clinical skills. A new graduate may never have practiced a particular skill such as indwelling catheter insertion.

We need to remember that the health care environment may be very different today than when we were in nursing school. Patients spend less time in acute care facilities, and the acuity of illness, number of comorbidities, and intensity of care have increased dramatically. Patient needs are more complex; technological and scientific advances have produced new treatments, equipment, and medications; and nursing care has changed accordingly. Nursing students may not encounter the same patient on successive days in the clinical setting, and even if the patient is the same, his or her needs may change drastically from one day or hour to the next.

Some of the skills that we learned through sustained practice with a relatively stable patient population simply aren't commonly encountered anymore. Concerns about health care-acquired infection have reduced the use of indwelling urinary catheters, for example. Nursing students often worry about their clinical competence, and their anxiety grows when practicing nurses express dismay that the students haven't performed a particular skill repeatedly. We need to remember that the focus of the NCLEX-RN is on critical thinking, not discrete knowledge. If graduates know how to think critically, solve clinical problems, and identify and use appropriate resources for continued learning, they will be able to learn quickly any clinical skills that they did not develop in their nursing education programs.

SUPPORTING NURSING STUDENTS, GRADUATES, AND FACULTY MEMBERS

Experienced nurses can support nursing students and new graduates by demonstrating knowledge, understanding, and acceptance of the ways in which nursing education has changed since we were in school. Our expressed or implied longing for the good old days of our mothers' nursing schools merely increases the anxiety and insecurity of nursing students, discouraging them from seeking employment in our settings. Likewise, criticism of new graduates' educational preparation may contribute to dissatisfaction and low morale, resulting in decreased retention rates and costly staff turnover.

Nursing faculty members, whose workloads have increased dramatically because of enrollment growth in all types of nursing programs, need your support for their efforts to produce competent graduates who are prepared to pass the NCLEX-RN and adjust quickly to their entry into professional nursing practice. If we demonstrate respect for their knowledge of the changing demands of higher education and health care and for their skill in teaching an increasingly large and diverse population of nursing students, we will be working with them as partners to cultivate our future professional nursing colleagues.

Editor's note: NCLEX-RN is a registered trademark of the National Council of State Boards of Nursing, Inc, Chicago, IL.

REFERENCES

(1.) About NLNAC. History of nursing accreditation. National League for Nursing Accrediting Commission, Inc. http://www.nlnac.org/About %20NLNAC/AboutNLNAC.htm#HISTORY. Accessed December 26, 2007.

(2.) Commission on collegiate nursing education recommended for maximum recognition term; no stipulations or compliance concerns cited [news release]. Washington, DC: American Association of Colleges of Nursing; December 19, 2006. http://www.aacn .nche.edu/Media/NewsReleases/2006/CCNERecognition.htm. Accessed December 26, 2007.

(3.) NCSBN fact sheet. National Council of State Boards of Nursing. https://www.ncsbn.org / NCSBN_Fact_Sheet_August_2007.pdf. Accessed December 26, 2007.

(4.) Report of findings from the 2005 RN Practice Analysis: linking the NCLEX-RN[R] examination to practice. National Council of State Boards of Nursing. https://www.ncsbn.org/vol_21_web.pdf. Accessed December 26, 2007.

(5.) NCLEX-RN[R] examination. National Council of State Boards of Nursing. https://www.ncsbn.org /RN_Test_Plan_2007_Web.pdf. Accessed December 26, 2007.

(6.) Eich M, O'Neill T. NCLEX[R] delay pass rate study. January 2007. National Council of State Boards of Nursing. https://www.ncsbn.org/delay study2006.pdf. Accessed December 26, 2007.

KATHLEEN B. GABERSON

PHD, RN, CNOR, CNE, ANEF

PROFESSOR AND CHAIR, DEPARTMENT OF NURSING EDUCATION

SHEPHERD UNIVERSITY

SHEPHERDSTOWN, WV

COPYRIGHT 2008 Association of Operating Room Nurses, Inc.
COPYRIGHT 2008 Gale, Cengage Learning