Keith Rischer, RN, MA, CEN, CCRN

TRANSFORMINGNursing EducationPractical Strategies to Prepare Students

for Professional Practice

Table of Contents

Preface:

Introduction:

Part I: Transforming the Educator

Chapter 1: My Journey

Chapter 2: Do You Have What it Takes to be a Nurse Educator?

Chapter 3: How to THRIVE not Merely Survive as a Nurse Educator

Chapter 4: Words of Encouragement from Experienced Educators

Part II: Transforming the Content

Chapter 5: Laying the Foundation: The “Art” of Nursing

Building Block #1: Caring and Compassion

Building Block #2: Holistic and Spiritual Care

Building Block #3: Professionalism and Reflective Practice

Chapter 6: Teaching Strategies to Lay the Foundation

Building Block #1: Caring & Compassion

Building Block #2: Holistic and Spiritual Care

Building Block #3: Professionalism and Reflective Practice

Chapter 7: Raising the Walls: The Applied Sciences of Nursing

Wall #1: Pathophysoiology

Wall #2: Nursing Pharmacology

Wall #3: Applying F&E to the Bedside

Chapter 8: Teaching Strategies to Raise the Walls of the Applied Sciences

Wall #1: Nursing Pharmacology

Wall #2: Fluids & Electrolytes (F&E)

Chapter 9: Building the Roof: Four Trusses of Nurse Thinking

Roof Truss #1: Nursing Process

Roof Truss #2: Critical Thinking

Roof Truss #3: Identifying Relationships of Clinical Data

Roof Truss #4: DEEP Understanding of Clinical Reasoning

Chapter 10: Tools and Strategies to Develop Nurse Thinking

Chapter 11…: Seven Sacred Cows that need to be Brought Down

Part III: Transforming Clinical

Chapter 12: Six Steps to Strengthen Student Clinical Learning

Chapter 13: Clinical Education that Prepares Students for Professional Practice

Chapter 14: Nuts & Bolts of Clinical Education

Chapter 15…Tools to Transform Clinical Education

Chapter 16: Clinical “Pearls” from Experienced Educators

Part IV: Transforming the Classroom

Chapter 17: One Educator’s Journey to Transform her Classroom

Chapter: 18: How to Transform the Classroom Step-By-Step

Chapter 19: How to Practice Nurse Thinking in the Classroom

Chapter 20 : Tools to Transform the Classroom

Chapter 21: Additional Strategies to Strengthen Classroom Learning

Chapter 22: Classroom “Pearls” from Experienced Educators

Chapter 23: How to Transform Your Test Questions

Part V: Transforming Nursing Education

Chapter 24: Transforming Academia by Promoting Civility

Chapter 25: Transforming Academia by Improving Retention of Male Students

Chapter 26: Next Steps: Following Florence

Final Thoughts

Acknowledgements

Appendices

A. Student Handouts to Strengthen the “Art” of Nursing

B. Student Handouts to Strengthen the Applied Sciences

C. Student Handouts to Strengthen Clinical Reasoning

D. Faculty Handouts to Transform the Clinical

E. Faculty Handouts to Transform the Classroom

Introduction

“To transform nursing education and meet the current and future needs of the clinical environment,

innovative methods of teaching and learning are required now.”

–Marsha Howell Adams, President of the National League for Nursing

“A major finding of our study is that a significant gap exists between today’s nursing practice and the

education for that practice…the quality of nursing education must be uniformly higher.”

–Educating Nurses: A Call for Radical Transformation, p. 4

Transforming Nursing Education is intended to be a practical resource for nurse educators. TMI (too

much information) in nursing education is counterproductive. It prevents students from recognizing what

content is most important. Using my lens as an expert nurse in clinical practice, I emphasize in this book

what content is most important so it can be deeply understood and applied to the bedside. Transforming

Nursing Education is filled with numerous innovative and outside the box strategies that are currently

needed to situate clinical reasoning in both the clinical and classroom settings. The ultimate objective can

then be realized; preparing students for practice as well as the NCLEX.

The tools and strategies I share in the upcoming pages have been successfully implemented in

classroom and clinical settings by educators across the United States, and other countries including

Canada, Australia, and Great Britain. But before I posted my very case study online in 2012, I used my

case studies successfully in my own classroom as a novice nurse educator.

The transformation that is needed in nursing education is impossible by only changing methodology

and pedagogy to strengthen student learning. Transformation flows through the heart passions of the

EDUCATOR. Everything that the educator communicates is influenced by what the teacher IS. Teaching

is not merely the performance of an hour in class. It represents the outflow of the passions in the life of

the educator. It takes years of clinical practice to formulate and deliver a powerful and authentic lecture,

because it takes years in practice to make the nurse who is now the nurse educator. Authentic,

transformational teaching is an outflow of a person’s life.

Where are Nightingale’s teachings? They are long gone and have died with the students that she

taught over 150 years ago. But the woman who is Florence Nightingale is much greater than any of her

best lectures. She lives forever as a passionate and transformational nurse educator even today. Your

teaching is but a voice. What you have spoken, much will be forgotten. But the person that is you, who

communicates a passion for nursing and the value of serving others will live forever in the hearts of your

students if you live this out in academia, and use successful strategies to prepare students for practice. As

educators we must never forget that the learning of students — and ultimately, the patients they care for

— will be directly impacted if the quality of nursing education is not improved.

Educating Nurses: A Call for Radical Transformation (2010) summarized the Carnegie Foundation’s

research findings of nursing education in the United States. This book was a wake-up call to challenge the

status quo in nursing education. It is imperative that nurse educators do not forget the full title of

Educating Nurses. It is not a call for a few minor tweaks or a call to “flip” your classroom. It is “A Call

for Radical Transformation”! The educational research findings by the Carnegie Foundation contained in

Educating Nurses identified that nursing education needs to be RADICALLY TRANSFORMED by

implementing the following essential shifts of integration:

Shift from covering decontextualized knowledge and content (textbook) to

CONTEXTUALIZING classroom content so it is situated in clinical practice (at the bedside) so

students can see why the content is relevant.

Shift from sharp separation of classroom and clinical teaching to greater INTEGRATION of

classroom theory and clinical content. They should not be kept in largely separate orbits in

nursing education as it is typically taught.

Shift from an emphasis of critical thinking to an emphasis on CINICAL REASONING. Clinical

reasoning is the ability of the nurse to think in action and reason as a situation changes over time

by capturing and understanding the significance of clinical trajectories and grasping the essence

of the current clinical situation (Benner, Sutphen, Leonard, & Day, 2010).

In order to bring needed change and transformation to your program, no curriculum change is

required. Simply change the way you teach your current content (Benner, Sutphen, Leonard, & Day,

2010) by integrating clinical reasoning across the curriculum. So how do you practically integrate clinical

reasoning in your program? This is what many educators and programs struggle to do. This book

emphasizes “how to” implement and pursue a clinical reasoning curriculum that is in reality a practical

pedagogy to integrate clinical reasoning in the class and clinical settings. Practical strategies will be

discussed in detail in the following chapters and is the underlying premise of this book.

To see where you are at in your journey to realize this needed objective, use the following reflection

questions that capture the essence of what a clinical reasoning curriculum practically looks like:

1. Emphasizes relevance, NOT content. TMI (too much information!) is an ongoing problem in

nursing education.

Do you filter the content so that less content is really more?

2. Emphasizes DEEP learning of what is MOST important

A&P. Pathophysiology must be DEEPLY understood in order for students to make connections

to the relationships of essential clinical data in practice.

o Do you emphasize and contextualize A&P in each presentation?

F&E. What labs are most important and why? Applied understanding of F&E is more important

than memorizing the "hypo" and "hyper" of the most common electrolytes!

o Do you contextualize this essential content to the most common scenarios that nurses

may encounter?

Pharmacology. In order to safely pass the most common medications, students must not just

memorize, but UNDERSTAND the mechanism of action.

o Do you integrate the most common medications in your presentations and briefly review

the mechanism of action of these drugs?

3. EVERYTHING taught is contextualized to the bedside. Nursing is a practice based profession.

Therefore EVERYTHING that is taught must have a "hook" that contextualizes content to the bedside.

Content heavy lectures that regurgitate textbook content for students is hindering student mastery of

content that must be able to be applied, NOT memorized! If your program emphasizes concepts, then be

sure to contextualize your concepts!

When you lecture, do you contextualize content to the bedside using case studies or other active

learning strategies?

4. Emphasizes clinical reasoning as “nurse thinking.” Clinical reasoning is the ability of the nurse

to think in action, reason as a situation changes, recognize what clinical data is relevant and grasp the

essence of the current clinical situation (Benner, Sutphen, Leonard, & Day, 2010).

Do you teach other ways of nurse thinking besides nursing process and written care plans?

Do you provide opportunities for students to practice this essential nurse thinking skill in your

classroom?

Radical Transformation Defined

To fully comprehend the radical transformation that nurse educators must aspire to, let’s define two words

that were intentionally included in the title of Educating Nurses:

Radical. Very different from the usual or traditional way of doing things. It implies EXTREME changes

in existing views and what is practiced or taught (“Radical,” 2014)

Transformation. Complete or major change in the appearance or form of something (“Transformation,”

2014)

An excellent example of the radical transformation educators are called to emulate is similar to the

metamorphosis of a caterpillar as it transforms into a beautiful butterfly. Once the caterpillar hatches, it

must grow up to one hundred times its initial size. It must feed on the right food whenever possible. By

the end of summer the caterpillar begins turning into a pupa or chrysalis. The final step of metamorphosis

is the butterfly in all its beauty and splendor. Transformation realized!

Though it was a process that took time, it was worth the wait because something better and more

beautiful was ultimately created and realized. As educators, we can learn two things from this example in

nature to realize the necessary transformation that is needed in nursing education today. Just as the

caterpillar was required to feed on large amounts of food to make transformation from a caterpillar to

butterfly possible, educators need to be intentional about reading, reflecting, and assimilating resources

that will allow you to gain a deeper understanding of what is required to bring transformational change to

your program. I will refer to many essential resources throughout this book, including Educating Nurses

that cite best educational practices to lay a strong foundation for transformational change.

It is also important to give this process time! Rome wasn’t built in a day, and transformation of your

program will also be a work in progress. It will take time to develop. Even though there must be a sense

of urgency, do not rush this process. Take the time to get your faculty team on the same page by reading

Educating Nurses and this book—together. Have a team or department meeting to discuss next steps.

Remember the wisdom of the ancient Chinese proverb: A journey of a thousand miles begins with the

FIRST step. That is what matters. Take that first step today!

Because clinical reasoning must be emphasized in nursing education and mirrors the way a nurse

thinks and sets priorities in clinical practice, it is imperative that every nurse educator reflect and ask the

following question,

“What will be the ultimate consequence if a student in your program who graduates to be a nurse

in practice fails to clinically reason and think like a nurse by identifying a change in a patient’s status

until it is too late?”

A patient will likely have an adverse outcome and may even die as a result. This is why nurse

educators must not make the fatal mistake of seeing clinical reasoning as just another trendy pedagogy, or

active learning strategy that will “flip” your classroom. The inability of a new nurse to clinically reason

can potentially be a matter of life and death!

I See Dead Patients

“I see dead people” was a famous quote by Cole Sears from the hit horror

movie The Sixth Sense in 1999. Fortunately, it was only a movie.

Unfortunately, I have seen clinical situations as a rapid response nurse

that foreshadowed a patient death as a result of the primary nurse’s

“failure to rescue” and clinically reason when there was a change of status

that went unrecognized until it was too late.

Jenny was a newer nurse who graduated a year ago. She had an

elderly male patient named Ken. He had a perforated appendix, but it had

been removed successfully two days prior and he was clinically stable.

Around midnight, he became restless. His BP was slightly elevated at

158/90 and his HR was in the 100s. He had a history of mild dementia

and was not able to readily communicate his needs, so Jenny gave him 1

tablet of oxycodone, assuming he was in pain. Two hours later, he

continued to be restless and Jenny thought that she heard some faint wheezing. She noted that he was now

more tachypneic with a respiratory rate of 28/minute. He did have a history of COPD and had an albuterol

nebulizer prn ordered, so that was given.

Two hours later, Jenny called me as the rapid response nurse to come and take a look at her patient.

She was concerned but was unable to recognize what the problem could be and wanted a second opinion.

After Jenny explained the course of events that transpired to this point, I took one look at Ken and

realized that he was in trouble. He was pale, diaphoretic, and his respirations had increased to 40/minute

despite the nebulizer two hours ago. He was not responsive to loud verbal commands. The last BP was

still on the screen and read 158/90. I asked, “When was the last BP checked?” Jenny stated it was four

hours prior. While obtaining another BP, I touched Ken’s forehead. It was notably cold, as were his

hands. The BP now read 68/30.

Recognizing that Ken was in septic shock, and that IV fluids and vasopressors would be needed to

save his life, I looked for an IV and found only one, a 24 gauge catheter in the left hand. This is the

smallest size IV catheter and is typically used with infants and small children.

Realizing that Ken needed a central line and that there was little that could be done to initiate even the

most basic life-saving treatments to rescue Ken on the floor, he was emergently transferred to ICU.

Within thirty minutes Ken was intubated, a central line was placed, and three vasopressors --

norepinephrine [Levophed], phenylephrine [Neosynephrine] and Vasopressin -- were required to get his

systolic blood pressure greater than 90 mmHg.

After this transfer was completed, I asked Jenny a simple clinical reasoning question: “What was the

most likely complication that Ken could experience based on his reason for being hospitalized?” Jenny

admitted that she hadn’t thought about it because she was so focused on getting all of the tasks done with

her four other patients.

Had Jenny asked herself this question while caring for Ken, but more importantly answered it, she

would have been thinking like a nurse by vigilantly looking and assessing for EARLY signs of the most

likely complication Ken could experience because of his perforated appendix…SEPSIS. Although early

signs of sepsis were present at midnight, it was not recognized until it was too late for Ken. He died the

next day.

This story illustrates the tragic consequences of failure to rescue. This is WHY students must be

practically prepared for real-world practice. Like soldiers being prepared for the battlefield, nursing

education needs to intentionally and practically prepare students for real-world clinical practice by

integrating the paradigm shifts from Educating Nurses that include an emphasis and integration of clinical

reasoning in the class and clinical settings. To think, or not to think like a nurse, is a matter of life and

death. Nursing education does not need to remain broken. All it takes is nurse educators who are willing

to resist the current "status quo" and step out regardless of your fears and do things differently to bring

needed change. When content is contextualized, clinical realities are brought to class, and clinical

reasoning is the foundation of your program, you can be confident that you are not only preparing your

students for the NCLEX, but more importantly real-world clinical practice!

I have organized this book to follow a logical progression. I begin by sharing my journey to bring

needed change and then taking a deeper look under the hood to examine the struggles of faculty as well as

students in nursing education. In subsequent chapters I discuss how to thrive, not just survive as an

educator. I will present a new way to envision nursing education using a metaphor of a “living house” that

each student represents. Just as a house has a foundation, walls, and a roof that ties the structure together,

the student’s “living house” is comprised of a foundation, walls, and a roof. Practical strategies to build

each component into your students will be discussed by emphasizing what content is most important and

why.

Once the big picture of the “living house” is understood, “sacred cows” must be brought down that

hinder student learning and prevent needed change in nursing education. Best-practice strategies to

transform clinical and classroom learning will be presented as well as clinical “pearls” from experienced

educators. Finally, the last two chapters address “big picture” transformation issues that continue to exist.

This includes talking about incivility, the “elephant in the room” in nursing academia and clinical practice

that continues to be all too prevalent. Did you know that men in nursing continue to have one of the

highest failure to complete rates of any demographic in nursing education? What are the unique struggles

men continue to experience in nursing education and more importantly, what can be done to support the

unique needs of male students will be discussed.

So let’s get started. But before anything can change, we need to start with the key to successful

transformation in any program…YOU!