A New World of Health Care

Preparing Nurses to Succeed in a Complex Environment

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"Bedside nursing has had to respond to a rapidly changing health care environment. As a result, nursing education is changing with it,” said Irma Jordan, MSN, APRN, FNP-BC, instructor in the current BSN program. “From an illness standpoint, the acuity level is so much higher in hospitals today than in years past. Patients enter the hospital sicker and have a shorter length of stay than anytime in history; this dichotomy requires nurses who are capable of meeting the needs of complex patients in a complex environment.” Jordan’s perspective spans 30 years in the nursing profession, and she’s watched health care change up close and personal.

Jordan, along with five other instructors on the College of Nursing faculty, bring highly seasoned experience to the classroom, the laboratory and the bedside as they prepare entry-level nursing students for a whole new world of health care.

Teresa Britt, MSN, RN, director of the Clinical Simulation and Nursing Lab, underscored the situation succinctly, “Today, patients who used to be in ICU are now on the floor.”

A Broader Role

trainees practice on mannequins in hospital bedsBSN Seniors Marcia Enggano, Russell Jones and Jerri Wilson monitor computerized mannequin patients that talk and breathe and cost $8,000 to $9,000 each.

“The role of nursing has expanded,” explained Alise Farrell, MSN, RN, instructor, “Our students must learn to be leaders and critical thinkers because they are caring for more complex patients.” The typical patient today is older and in the hospital with multiple health problems. For example, a patient might be admitted with pneumonia but also have coronary artery disease, type 2 diabetes and be obese. This one patient may require multiple medications, a wide variety of tests and be under the care of an endocrinologist, a cardiologist, as well as a general practitioner.

“We need to be able to help patients through the health care maze,” noted Cindy Adymy, MSN, instructor. “In the old days, nothing was done on an outpatient basis. Now patients are in the hospital for three days instead of 10, and there’s so much more we have to do to get them ready for discharge. We literally have to educate them on their medications and, in most cases, help them prepare for permanent lifestyle changes.”

“Today the entire family is more involved and is part of the decision making,” said Sandra Madubuonwu, MSN, RN, instructor, adding, “Before they would sit in the waiting room with no clue about what was happening to their loved one. Patients and their families are more empowered by the information we are able to give them, and their involvement reduces the patient’s hospital stay.”

Technology Advances and Complicates

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Technological advances can lead to medical miracles but they also lead to a more complicated role for the nurse. Hallie Bensinger, MSN, instructor, commented that nurses today must continuously learn and adapt to new technology in every arena. “Labor and delivery used to depend upon internal fetal monitoring to determine short-term variability, but advances today allow external short-term variability monitoring that is just as accurate. This approach is less invasive, thus a safer way to monitor fetal well-being.”

Over her 20-year career, Bensinger has seen new wound care technology, porta-catheters for delivering meds and chemotherapy delivery systems, just to name a few advancements. “As a case in point,” she illustrated, “Hormone shots used to be given intramuscular with a 1 ½ inch needle. Now we do it subcutaneously with a ½ inch needle,” and emphasized that nurses are navigating much more complex machinery than ever before. “It’s just one more thing we have to cram into our cranium.”

“We don’t have the time with the patient we used to have, so today there’s more need for case coordination, and they rely on the nurses to do it,” said Adymy, summarizing, “We’re the patient’s advocate.”

Safety and Quality A Top Priority

Shorter hospital stays and more complex patient illnesses require even greater attention to quality and safety. Starting October 1, the federal government will up the ante and not pay for some treatments related to medical errors.

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Brittany Cardell, MSN, CNL, BC, clinical director of an inpatient unit at Le Bonheur Children’s Hospital in Memphis, is also a preceptor and adjunct faculty for UTHSC College of Nursing students. “We have to get so much more done, and done right, in a short period of time,” she explained. “Hospitals are taking quality and safety to a whole new level across the nation, and as the last stop before reaching the patient, nurses are hugely responsible for catching errors and preventing them from occurring.” Cardell pointed out that even with numerous double-check processes in place to catch errors, for example, in the medication pipeline, some still fall through the cracks, and the nurse must catch them before they reach the patients. “We can never stop thinking,” she emphasized.

The Heart of Nursing Education

Britt photoTeresa Britt, MSN, RN, director of Clinical Simulation & Nursing Lab: “I teach because I feel I can benefit more patients by preparing students to go out and take care of patients.”

“Clinical instructors and preceptors are not only the heart of nursing education, when it comes to preparing new nurses, they ARE nursing education,” said Dean Donna Hathaway, PhD, FAAN. “We continue to prepare bedside nurses and are fortunate to have such an experienced staff, as well as a wide variety of health care settings in which to educate them.” St. Jude Children’s Research Hospital, Methodist University Hospital, the Regional Medical Center (The MED), Le Bonheur Children’s Hospital, and the VA Medical Center are all practice sites for College of Nursing students.

Adymy photoCindy Adymy, MSN, A-CNS-BC, instructor: “It’s very rewarding when all of a sudden it all comes together for the students; I love watching them take off.”

Managing the day-to-day running of the program for pre-licensure students is Tommie Norris, DNSc, RN, director of the Professional Entry Program. “Our last class of BSN-RN professional entry students entered in July 2008, and the first class of MSN-RN professional entry-Clinical Nurse Leader students will begin their program next summer,” she noted. In nursing education since 1986, Norris has seen major shifts in health care and works to ensure that the curriculum prepares student nurses to meet today’s complex new requirements for skilled nursing care. In preparing for licensure, students meet in traditional and online classes, practice in the skills and simulation lab on campus, and shadow nurse preceptors in the real world of local hospitals.

“Safety and quality concepts are introduced the very first term and threaded throughout the curriculum for all three terms of the program,” Norris explained. In addition to more traditional courses such as adult health, mental health, pediatrics, and reproductive health, students today also have classes in clinical anatomy, genetics, informatics, pharmacology, pathophysiology, evidence-based practice and acute care of complex patients.

“Today we must teach more holistically because we must prepare the patient for home care after a hospital stay,” Farrell observed.

“We must prepare our students to care for the total patient,” added Jordan. “Nurses must see their patient not just in the traditional sense but also as a family and as a community. The net effect is that nursing education today is so much more in-depth and all encompassing. Nurses must be prepared to care for the particular needs of a patient and identify resources to meet those needs.”

Evidence-based Practice

Farrell photoAlise Farrell, MSN, RN, instructor: “I enjoy watching the huge growth curve in students, when they go from being afraid to see patients to going right into the room and caring for them.”

“Nursing research supports why we do what we do,” said Adymy. “That is why today’s student must become familiar with an abundance of research. We must know exactly and precisely when a certain procedure is needed and why it works. For example, we turn patients every two hours because research says it prevents bed sores.”

Madubuonwu, a nurse for 18 years and a clinical nurse specialist, pointed out that research has advanced nursing practice in nearly every area of patient care. For example, evidence has shown that a safety measure called “the six rights of medication administration,” which the nurse has to observe before giving any medication, has substantially reduced medication errors. “We used to do something just because that’s the way it had always been done,” she said. “Now, we teach evidence-based practice and expect nurses to be familiar with it or at least know where to go to find the answer before making a critical decision.”

“Evidence-based practice assures we are performing for the optimal level of patient benefit,” summarized Christine Purchase, preceptor and staff nurse at Methodist Germantown Hospital.

High-Tech Simulation and Skills Training

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“More than ever, nurses must develop and use assessment skills and work in collaboration with the physician,” said Madubuonwu. “If the patient’s status changes, the nurse doesn’t have to wait for the doctor to arrive; her assessment of symptoms should be thorough enough that the doctor can give the order over the phone.” Nursing students learn these kinds of skills in the simulation lab where computerized mannequins can speak and “breathe,” and have recorded human bowel sounds, heart sounds, blood pressure and pulses.

“A mere 15 years or so ago, we used a mannequin to learn to bathe patients and give injections; but computer simulation has advanced at the same fast pace as computer technology,” said Britt, director of the simulation lab. “Every year we see more bells and whistles added. We can preprogram the simulator with 50 different medical surgical scenarios.” A “pregnant” mannequin that actually delivers a baby and a newborn simulator that moves, cries and changes color also help students learn the intricacies of childbirth.

“Our lab can be configured to replicate many different health care settings. We can take our students to a higher level of complexity and problem solving before they have to face real patients,” explained Britt.

Clinical Preceptor – A Guide for the Real World

students study laptop

“As a preceptor, my primary responsibility is to role model appropriate behavior again, again and again. We can’t just tell students what to do,” emphasized Le Bonheur’s Cardell.

“Preceptors have to set the example and model professionalism,” added Purchase, “We must convey the concept that patients always come first.”

Alfe White, BSN, RN, preceptor at Methodist South, works on the medical surgical floor and helps students focus on the diagnosis, noting “We train according to each patient; it’s a lot of work but we must be dedicated because it makes a difference with the students.”

“The world that clinical instructors and preceptors are preparing students for is vastly different than the world most of us encountered as students. The challenge facing today’s faculty is to prepare students to step immediately into a highly complex environment that demands mastery of sophisticated technical skills coupled with a high degree of critical thinking and problem solving. At the same time, faculty must think futuristically and prepare their students to be lifelong learners in an ever-changing health care environment. “Without doubt, the contributions of our clinical faculty and preceptors are key to the future of nursing and the health of our nation,” concluded Dean Hathaway.