Creating a Teaching Learning Environment

The challenges of creating an innovative teaching environment in today’s schools of nursing can be arduous due to budget constraints and faculty shortages. However, the health agencies in government and private sectors have been collaborating with initiative campaigns to improve patient safety and quality in care delivery in order to bridge the gap between education and practice.

Three of the nine comprehensive guidelines of American Association of Colleges of Nursing’s (AACN) The Essentials of Baccalaureate Education for Professional Nursing Practice (2008) are the highlights of this report. They are Essentials II-Patient Safety, III- Evidence-based practice and VI- Communication and Collaboration. These AACN’s essentials are complementary with the core competencies of the learning models from Robert Wood Johnson Foundation’s (RBJF) Quality and Safety Education for Nurses (QSEN) and Lenburg’s Competency Outcomes and Performance Assessment (COPA).The evaluation and assessment methods used to measure performance outcomes are addressed in lieu of the three core competencies.

The nursing students in their final semester from baccalaureate degree program are in the process of synthesizing the accumulative knowledge, skills and abilities/attitudes (KSA) acquired from classroom didactics and clinical trainings since entry in the nursing program.The instructors serve as facilitators and objective examiners in the learner-centered mode of education. The students’ passion for nursing and openness to innovative learning environment will promote a seamless transition to survive the demands of the complex and constantly evolving health care system. Keywords: Core Competencies, Outcomes, Patient Safety, Evidence-Based Practice, Communication &Collaboration, AACN’s essentials, RWJF’s QSEN, KSA, COPA.The nursing profession needs nurses that are immune to the complexities of current health care industry.

They need nurses that are effective communicators and collaborators in delivering patient-centered care. They need nurses that can manage and lead the interdisciplinary team advocating for the latest evidence-based practices that prioritize patient safety and quality improvement. These are the key core competencies endorsed by AACN’s The Essentials of Baccalaureate Education for Professional Nursing Practice (2008).These essentials are established in the hope of bridging the gaps of education and professional practice.

The economic, political and social structures of this country dictate the changes and reforms in the health care arena. The aging baby boomers, cultural diversity brought by influx of global migration, nursing staff shortage, the prevalence of chronic illnesses, the advancement of medical researches and technologies are few of the factors/issues that stimulated the nursing education to re-design the curricular frameworks to meet the needs of the community.RWJF’s QSEN and Lenburg’s COPA are two of the latest evidence-based and competency-based learning models developed separately but shared similar core competency goals (Armstrong, Spencer & Lenburg, 2009). QSEN and COPA echo the AACN’s essentials. These models show remarkable promises in producing competent practitioners based from the data survey that improve census in enrollment/retention and success in licensure examinations. These models enhance the students ‘critical thinking and clinical reasoning; therefore, impacts the patient safety and quality of care (Armstrong & et al, 2009).

The current health care system mimics the operation of many customer service related business companies wherein customer satisfaction is the number one priority. High patient satisfaction is the end to excellent care and service. However, excellent care usually is equated to low incidents of medical errors and patient mortality. The nursing profession is in the business of promotion, prevention and maintenance of their patients’, patients’ families/loved ones and their community’s health and well-being.

According to Sherwood & Drenkard (2007), “Though ‘do no harm’ is the paramount value in the health professions, mistakes do happen; however, systems can be designed to reduce the probability of error and improve the quality”. Patient Safety is second in the lists of nine essentials of AACN’s (2008). Patient safety is defined as “minimization of risk of harm to patients and providers through both system effectiveness and individual performance” (p. 13). QSEN listened to the voices of AACN and Institute of Medicine or IOM in making patient safety as top priority in core competency lists.According to AACN (2008), the latest research shows that the nurses [not other health care providers] who are involved in direct patient care are usually the first to “recognize, interrupt, evaluate and correct health care errors” (p.

13). When the publication of ‘To Err is Human: Building a Safer Health System’ by Kohn, Corrigan & Donaldson [2000] came out, the media headlines sensationalized the incidents of death and near death related medical errors (Odell & Barta, 2011, p. 370-371). Who would forget the incident in Cedar Sinai hospital in L.

A? The neonatal twins of the famous actor Dennis Quaid were given an adult dose of heparin.The media attention is a wakeup call to the entire health care practice councils. They acted on the issues by putting patient safety in the forefront of health care practice. Patient safety is in the top lists in core competencies for all medical disciplines that are involved in providing direct patient care. The nursing academia established initiatives called QSEN, with the overall goal since 2009 that states, “To equip future nurses with the knowledge, skills, and attitudes [KSAs] needed to continuously improve the quality and safety of the health care systems within which they work (Odell & Barta, 2011).

Evidence-based practice or EBP is the application of the scientific KSAs in all areas of the nursing fields. EBP brings progress and development that improves the old/traditional practices and blend with new evidence-based and competency-based practices. EBP is the cornerstone of patient safety, quality care, and cost-effectiveness in health care (Odell & Barta, 2011, p. 370). The innovative learning strategy models of COPA and QSEN are the byproducts of EBP that enhances the students’ critical and analytical thinking as well as clinical reasoning and judgments.EBP promotes positive patient care outcomes; therefore increases patient satisfaction.

The use of EBP also facilitates cost effective delivery of care. (AACN, 2008) EBP is the terminology introduced by medicine arena that nursing adopted to elevate the profession. EBP is the third essentials of AACN (2008, p. 15). EBP according to IOM [2003] is defined as, ‘care that integrates the best research with clinical expertise and patient values for optimum care’ (Odell & Barta, 2011).The applications of high technological tools such as simulator manikins, digital cameras, interactive computer software, and website search engines, etc.

in classrooms and clinical laboratories are few of the remarkable progress that facilitates optimal learning. The application of competency-based instructions formed the students’ foundation to scientific research methods. The students’ ability to investigate, question theories and conceptual models assist in development of KSAs in critical thinking, clinical reasoning/judgment during didactic and clinical rotations.According to AACN (2008) essentials, “Baccalaureate education provides a basic understanding of how evidence is developed, including research process, clinical judgment, interpersonal perspectives, and patient preference as applied to practice” (p. 16).

Graduating nursing students have been exposed to research courses that taught them the different methodologies in research; common research terminologies; KSA in critiquing literatures; statistical analysis and interpretations, etc.EBP improved applications of research findings in actual practice and learned how to disseminate findings (Odell & Barta, 2011, p. 372). The familiarization with legal and ethical implications is a crucial component in research education like confidentiality of subjects.

One of the most important roles of a nurse is advocacy. AACN (2008) emphasizes that baccalaureate education includes, “the protection of patients’ rights, including those of the most vulnerable patients, in situations where actual or potential conflict of interest, misconduct, or the potential for harm are identified” (p. 16).Communication is the imparting or interchange of thoughts and information to another individual or group of individuals.

The transmission of information between the deliverer/s and receiver/s create subjective interpretations that can lead to a better understanding if both parties are in the same wavelength of thinking and interpretation of the information. Otherwise, it can bring negative messages that lead to conflicts, confusions, and chaos. Communication and collaboration is the 6th essentials of AACN (2008). Effective communication truly improves the quality of care.The ability to interact with colleagues, patients and families and other people involved in patient care will determine the effectiveness of the nurses’ role in interdisciplinary team collaboration in a patient-centered delivery care model. (AACN, 2008 p.

22) Competencies in communication are focused on conflict resolution and crucial conversation skills to build team collaboration among co-nurses and delegation of tasks to assistive staffs. In the art aspect of nursing profession, communication with compassion is the center of holistic nursing model.Communication is traditionally geared to active listening, empathy and ability to assess and educate patients (Sherwood & Drenkard, 2007). The students can practice their communication skills through role playing and simulation exercises in the clinical laboratory. The simulation practice can be simultaneously video record, which is useful in debriefing and dialoguing between students and instructors as a form of evaluation and assessments for areas of communication that needs improvement.Simulation in clinical laboratory provides practice in a safe and non-threatening environment, thus conducive to learning.

Numerous study findings in teaching communication to nursing students compiled by Zavertnik, Huff & Munro (2010) implies that, “The traditional classroom in teaching of communication skills does not allow for practical application” (p. 65). The traditional teaching pertains to lectures and discussions in the classroom.How to Structure an Environment that Fosters Learning The old school system used to teach nurses “to be obedient, dependent and fearful in caring for patients”, however, the complexities of today’s health care environment drove the nursing curricula to teach students to be “empowered and to be treated as valued members of the profession” (Rowles, 2012, p.

259). The new generation nurses are independent critical thinkers that can provide individualized, evidence-based and patient-centered care for multiple patients with various acuities in a holistic nursing model KSA that leads the interdisciplinary team to deliver optimal care.The computer technology and integration of nursing informatics have influenced the learning environment, but the element of human touch and intellect are invaluable and irreplaceable. There are tons of innovative strategies out there, but two remarkable strategies in promoting competencies in patient safety, evidence-based practice and communication and collaboration are selected.

They are problem-based learning [PBL] and simulation. The instructors or facilitators can introduce those core competencies in an integrated manner. In the classroom, PBL strategies can be implemented through group collaboration like assignment projects, case study analysis, written reports, dialogues/discussions, etc. The instructor prepares challenging scenarios that exercise the students’ critical thinking and clinical judgments.PBL is usually used as an approach to the entire curriculum; rather than focusing on separate disciplines or nursing specialties, in PBL clinical problems and professional issues are used as the focus of integrating all of the content necessary for clinical practice” (Rowles, 2012, p. 273).

The students’ actual clinical experiences and the instructors’ own experiences, et al. are immense sources for clinical questions and case study materials that makes PBL effective. (Winters & Echeverri, 2012) Secondly, the use of role playing is widely applied at the clinical laboratories.Simulation by role playing promotes group collaboration. Research shows that inadequate communication and poor working relationships are common causes of safety events and near misses incidents (Sherwood & Drenkard, 2007). An illustration of incorporating effective communication is through role playing exercises of Call-Out and SBAR [situation, background, assessment and recommendation].

These are standardized communication tools that are implemented in conjunction to the National Patient Safety Goals from the Joint Commission (JC).These tools are core competency components in TeamSTEPPS, an evidence-based team building model from the collaboration projects of Agency for Healthcare Research and Quality (AHRQ) and Department of Defense (DOD) applying the team sport model to health care with the aim to improve communication among health care providers (Johnson, Hamilton, Delaney & Pennington, 2011) The scenario of role playing in Call-out and Time Out practice is in the operating rooms.The students are divided into groups of five or six that create the surgery teams of doctors, nurses, technicians, etc. , then the circulating nurse actor calls out the team’s attention for a quick huddle.

The nurse say out loud the following information: the name of the patient, the procedure, the correct site, the anesthesia and surgery team to update the rest of the team about the procedure, the anticipated equipment, the plan, et al.The practice of this communication tool improved team collaboration and accountability with less errors. Another critical exercise to role play is the use of SBAR to practice of endorsing report. SBAR is borrowed by civilians from the Navy operational system of communication.

SBAR is useful in guiding nurses and other health care providers with giving reports during transfer process of patients to procedures, other units or other facilities. SBAR should be “concise, clear and timely” (Johnson, et al, 2011, p. 87).It can be a brief note or a hand off verbal report either face to face or by phone at the time of transfer. Communication outcome findings of literature review by Reising, Carr, Shea & King (2011) shows that use of high fidelity simulation [HFS] in an Advance Cardiac Life Support or ACLS code scenario provided the important value of role differentiation in the team collaboration, wherein the word ‘autonomous’ and ‘independence’ were numerously used in the students’ descriptions of the experience.

The use of simulation strategies help the students gain an in-depth understanding on the importance of effective communication skills which boost their confidence and assertiveness that they can integrate in actual clinical practice. (Zavertnik & et al, 2010) In the arena of EBP, the article of Odell & Barta (2007) emphasizes the importance of teaching graduating students with data mining and interpretation; data warehousing and data collection.These KSAs can be reinforced with practice of PICOT [Population of interests, Intervention or area of interest, Comparison intervention or group, Outcome and Time] format in clinical questionings that starts from simple to complex information. (Winters & Echeverri, 2012) PBL and Simulation can be applied in exercising the use of PICOT format either by group collaboration practice and individual essay writing. EBP’s data collection, mining and interpretation facilitate improvement in objective evaluation of web-based health information that is useful for patient and/or family teaching.

Lastly the KSAs related to EBP assist in collections of best practices from the seasoned nurses at the bedside which are reliable as long as the practices are supported by peer reviewed research journals. The debriefing discussions and dialoguing are great evaluation tools for feedbacks and lesson learned information. The common philosophy of “work smarter not harder” is practically the incorporation of EBP to actual practice, which impact patient safety and quality of care.