Nurse educator’s guide to best teaching practice

Nurse Educator’s
Guide to Best
Teaching Practice
A Case-Based Approach
Keeley C. Harmon
Joe Ann Clark
Jeffery M. Dyck
Vicki Moran

123


Nurse Educator’s Guide to Best Teaching Practice



Keeley C. Harmon • Joe Ann Clark
Jeffery M. Dyck • Vicki Moran

Nurse Educator’s Guide
to Best Teaching Practice
A Case-Based Approach


Keeley C. Harmon, PhD, RN
Our Lady of the Lake Regional
Medical Center
Baton Rouge, LA, USA
Jeffery M. Dyck, MSN
British Columbia Institute of Technology
Burnaby, BC, Canada

Joe Ann Clark, EdD, RN (Retired)
Our Lady of the Lake College
Baton Rouge, LA, USA
Vicki Moran, PhD, RN, CNE, APHN-BC
Saint Louis University
St Louis, MO, USA

ISBN 978-3-319-42537-5
ISBN 978-3-319-42539-9
DOI 10.1007/978-3-319-42539-9

(eBook)

Library of Congress Control Number: 2016948212
© Springer International Publishing Switzerland 2016
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First, I dedicate this book to the many
educators I have known over the years who
have worked tirelessly to develop teaching
methodologies which would more effectively
meet their student’s needs. Second, I
dedicate this book to my daughter Keeley
Harmon who encouraged/pushed her mom to
become a part of this endeavor. For this, and
her constant encouragement, I thank her.
—Joe Ann Clark.
I dedicate this book to my understanding and
loving family: To my children, Nicholas and
Elise, and to my mother, Joe Ann. Nothing I
do in this life could be accomplished without
their love, patience, and support. This book
is also dedicated in loving memory of my
dearest father and late husband, Alan. I feel
their guidance and support in a heavenly
way. I also dedicate this book to the
hardworking nurse educators who work
diligently and strive to provide our future
nurses with an education focused on
promoting the best patient care outcomes
through our constantly changing healthcare
environment.
—Keeley C. Harmon.

Heartfelt thanks to my patient and
understanding family, who so often have to
report, “Dad’s at his computer again!” I am
sincerely indebted to the leaders in the
nursing department at the British Columbia
Institute of Technology, who have shown
remarkable flexibility, foresight, and empathy
in allowing me to craft a unique working
arrangement. Finally, I dedicate this work to
the many students whom I’ve had the
privilege to teach and who are so eminently
worthy of not only sustaining, but growing,
this fascinating profession.
—Jeffery M. Dyck.
I am truly inspired by many people in my life
to which I dedicate this book. First and
foremost to my husband, who has supported
and created a culture in our family to reach
for the stars and if you work hard enough,
you will achieve what you deserve. Second,
to my five children, who think I am always
texting people! Finally, to the many nursing
educators that I work with. The ability to
transform this profession starts with how we
create critical thinking, compassion, and
care in the classroom and clinical setting
with the students.
—Vicki Moran.

Preface

It is the belief of the authors that nurse educators are important people! This statement is not true just because the authors, who happen to be nurse educators, proclaim it, but because it is also documented in the literature. The National League for
Nursing (NLN), in its 2002 statement on the preparation of nurse educators, stated:
“Nurse Educators are the key resource in preparing a nursing workforce that will
provide quality care to meet the health care needs of our population” (NLN Board
of Governors, 2002). Halstead (2011) writes that nurse educators “influence the
future of the profession through the quality of the nurses they prepare to practice”
(p. 357). “Key resource in preparing the nursing workforce”—“influence the future
of the profession”! Those are strong statements that emphasize the importance of
what nurse educators do. Indeed, they make the faculty role tempting to the nurse
who wishes to be a part of the process.
However, there is also evidence indicating that teaching is not easy. Brookfield
(2006) describes it as “an activity full of unexpected events, unlooked-for surprises
and unanticipated twists and turns that takes place in a system that assumes that
teaching and learning are controllable and predictable” (p. xi). Brookfield’s description of teaching certainly applies in nursing, whether in a classroom, laboratory,
online, or clinical environment. All are fertile ground for unexpected surprises,
twists and turns.
It is sometimes implied that because nurses teach patients and staff, it follows
that teaching nursing students comes naturally. “All nurses are teachers” is a familiar—but dubious—adage. The role of the nurse educator is intricate. Over time,
nursing education has moved from the service sector to college and university settings, and the role of nursing faculty has evolved and become increasingly complex
(Finke, 2009, p. 3). It requires the knowledge and application of teaching methodologies in varied learning environments with nontraditional students. Educators
work with students from diverse cultures and backgrounds with different learning
styles. Educators construct and analyze tests and counsel students. They are role
models in terms of demonstrating caring, not only for patients and families, but for
students as well. They need to walk a fine line between expressing their concern for
their students and not fostering dependence. Above all, they are expected to prepare
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Preface

graduates who can function safely and competently in an ever-changing healthcare
environment. These skills are very different from the skills that one learns when
becoming a nurse!
The qualifications of nurses who decide to enter nursing education vary. Many
are advanced practice nurses who have a background of rich clinical experience but
scant teaching experience. Novice educators may have experience in teaching, but
little clinical experience. These groups may be very different but they have one need
in common—tools for becoming more skilled teachers.
It is not the purpose of this book to be a compendium of all that is known about
the topic of teaching in nursing. Rather, it is the premise of the authors that there is
a need for a resource to assist nurse educators, the novice and the more experienced,
in working through some of the issues and challenges they are likely to encounter in
their day-to-day teaching experiences.
This book is designed to be an easy-to-use handbook of essential teaching skills
and tools for nurse educators. Preceded by a discussion of the principles of teaching
and learning, it explores topics such as classroom teaching, clinical experiences,
teaching in the simulation laboratory, and online learning. Each chapter begins with
information about the basics of teaching and learning in that specific environment,
followed by scenarios that focus on the issues most commonly encountered by faculty in that environment. The scenarios present a variety of actions the faculty member may take and describe rationales and/or potential problems that result from
these actions. The chapters also include specific tools and information designed to
assist the reader in preparation for the teaching role, such as examples of course
syllabuses and activities in the clinical area. This information is derived from the
experiences of the authors, each of whom started teaching as a novice and over the
years has developed tools and techniques designed to assist both the faculty member
and the learner. This book is our opportunity to share our knowledge and experience

and thereby assist nurse educators who are just getting started and trying to “figure
out” how to begin as well as other more experienced faculty who would like to try
other approaches to enhance their teaching.
Baton Rouge, LA, USA
Baton Rouge, LA, USA
Burnaby, BC, Canada
St. Louis, MO, USA

Keeley C. Harmon, PhD, RN
Joe Ann Clark, EdD, RN
Jeffery M. Dyck, MSN
Vicki Moran, PhD, RN, CNE, APHN-BC

References
Brookfield, S. (2006). The skillful teacher: On technique, trust, and responsiveness in the classroom. San Francisco, CA: Wiley.
Finke, L. (2009). Teaching in nursing: The faculty role. In D. Billings, & J. Halstead (Eds.),
Teaching in nursing: A guide for faculty (3rd ed.). Philadelphia, PA: Saunders.


Preface

ix

Halstead. (2011). The realist adjusts to sails: A commitment to transform nursing education models. Nursing Education Perspectives, 32(6), 357.
NLN Board of Governors. (2002). Position statement: The preparation of nurse educators.
Retrieved May 24, 2016, from />


Contents

1

Issues and Trends in Nursing Education ................................................
An Educator’s Perspective ..........................................................................
Joe Ann Clark..........................................................................................
History of the Development of Nursing Education ....................................
Educational Pathways to Become an RN....................................................
Regulation of Nursing Schools ...................................................................
NCLEX-RN History ...................................................................................
Student Population ......................................................................................
Faculty Role ................................................................................................
Conclusion ..................................................................................................
References ...................................................................................................

1
1
1
7
9
9
10
12
13
14
14

2

Principles of Teaching and Learning.......................................................
An Educator’s Perspective ..........................................................................

Vicki Moran ............................................................................................
The Seven Principles of Good Practice in Undergraduate Education ........
Additional Principles of Teaching Nursing .................................................
Student Centeredness ..................................................................................
Scenario One: Student Engagement........................................................
Reflective Practice ......................................................................................
Scenario Two: Reflection ........................................................................
Teaching Philosophy ...................................................................................
Team ............................................................................................................
Vulnerability ...............................................................................................
Learning Environment ................................................................................
Scenario Three: Learning Environment ..................................................
Adult Learners ............................................................................................
Scenario Four: Developing Reciprocity and Cooperation
in Students...............................................................................................
Conclusion ..................................................................................................
References ...................................................................................................

17
17
17
18
20
20
20
21
21
22
22
23

23
24
24
25
26
26
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4

Contents

Classroom Teaching ..................................................................................
An Educator’s Perspective ..........................................................................
Keeley Harmon .......................................................................................
Scenario One: The Basics .......................................................................
Scenario Two: Classroom Engagement ..................................................
The Flipped Classroom ...............................................................................
Scenario Three: Helping the Student Who Is Failing
a Nursing Course.....................................................................................
Scenario Four: Incivility in the Classroom .............................................
Scenario Five: Choosing Appropriate Test Items
for Course Examinations.........................................................................
Scenario Six: Academic Integrity: Cheating on Examinations ...............
Methods Used by Students to Cheat ...........................................................

What About Cheating on Assignments? .....................................................
What Should You Do If You Suspect Cheating During
a Classroom Exam?.....................................................................................
Conclusion ..................................................................................................
References ...................................................................................................
Clinical Experiences..................................................................................
An Educator’s Perspective ..........................................................................
Keeley Harmon .......................................................................................
Scenario One: Being a Clinical Instructor for the First Time
—What Do I Do? ....................................................................................
Scenario Two: Supporting a Student Who Is Performing
a Skill for the First Time in Clinical .......................................................
Scenario Three: Unprepared Student ......................................................
Managing Clinical Unpreparedness When It Occurs..................................
Scenario Four: Not Enough Time—Spending Appropriate
Time with Each Student ..........................................................................
Scenario Five: Today’s Student...............................................................
Scenario Six: Proper Feedback on Summative Clinical
Evaluative Tools ......................................................................................
Scenario Seven: The Great Intimidator...................................................
Faculty and Student Behavior Considered to Be Uncivil ...........................
What About Faculty That Tip the Scale and Want
to Be Everyone’s Best Friend?....................................................................
Scenario Eight: Promoting Professionalism in Our Students .................
Conclusion ..................................................................................................
References ...................................................................................................

27
27
27

28
33
34
36
38
40
43
44
45
45
46
46
49
49
49
50
54
56
58
59
60
63
64
65
65
66
66
66

Contents

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5

Simulation ..................................................................................................
An Educator’s Perspective ..........................................................................
Vicki Moran ............................................................................................
Scenario One: Basics of Simulation Preparation ....................................
Scenario Two: Students that are Unprepared ..........................................
Scenario Three: Letting a Student Fail ...................................................
Scenario Four: Reducing the Anxiety of Simulation ..............................
Conclusion ..................................................................................................
References ...................................................................................................

69
69
69
74
76
76
77
78
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Online Learning ........................................................................................
An Educator’s Perspective ..........................................................................

Jeffery M. Dyck ......................................................................................
Scenario One: How Can I Best Get Up to Speed
on My School’s LMS? ............................................................................
Prevalence and Growth of Online Courses in Nursing ...............................
Instructors’ Perceptions of Feeling Unprepared..........................................
Scenario Two: Preventing a Lack of Engagement ..................................
Scenario Three: Promoting Community .................................................
Scenario Four: How Can I Prevent Academic Dishonesty? ...................
Scenario Five: How Can I Stay Connected with My Department
and My Colleagues When Teaching from a Distance? ...........................
Conclusion ..................................................................................................
References ...................................................................................................

81
81
81
83
85
86
92
96
101
105
108
109

Appendix A: Example Course Syllabus ........................................................ 111
Appendix B: Program Outcomes................................................................... 113
Appendix C: Exam Blueprint ........................................................................ 115
Appendix D: Example Case Study ................................................................ 117

Appendix E: Example Welcome Letter ......................................................... 119
Appendix F: Key Discussion Points During Advising ................................. 121
Appendix G: Clinical Organization Tool ...................................................... 123
Appendix H: Example of Clinical Syllabus .................................................. 125
Appendix I: Abbreviated Second Patient Form ........................................... 129


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Appendix J: Example of a Clinical Contract................................................ 131
Appendix K: Sample Action Plan .................................................................. 133
Appendix L: Sample of Debriefing Questions for Simulation .................... 135
Index ................................................................................................................. 137


Chapter 1

Issues and Trends in Nursing Education

An Educator’s Perspective
Joe Ann Clark
In the early stages of preparation for this book, the authors (who collectively have
about 80 years experience in nursing education) spent much time discussing their experiences as nurse educators. Their discussions focused on many of the issues in nursing
education, changes they had witnessed over the years, and challenges which impacted
them as nurse educators. We noted that as nurse educators we felt concern, especially
when we were first starting out, as we were ill-prepared for the role and had often
taught ourselves the skills we needed to get through the day. We questioned if we had
been as effective as we could in helping our students achieve their educational goals.

I started my nursing education in 1951 in a diploma program which was in the
earliest stages of transitioning into a baccalaureate program. When I entered the
program as a student, the requirements for admission were that you have “good”
grades in high school, pass the entrance examination, be at least 5 feet tall, and
weigh within “normal” range for your height.
Tuition at that time was $125.00 for the first year—that included room and board,
textbooks, uniforms, and laundry of uniforms. The second year, tuition was $50.00 and
the third year, $25.00. That was because during the second and third year students
were, in varying degrees, utilized as staff in the hospital. Almost all of the students were
young (a few of us had a couple of semesters of college), all were female, and most just
out of high school. No one was permitted to be married, and you could not marry while
in school. We were all required to live in the dormitory and obey all of its rules.
The hospital of those days was very different from the clinical environment in
which student learning takes place today. First of all, the patient units were composed of large rooms in which 20 or more patients were placed. There were typically two such large rooms per unit. The beds were the old “crank” type which
would elevate and lower the head and feet. That was all they were capable of doing!
© Springer International Publishing Switzerland 2016
K.C. Harmon et al., Nurse Educator’s Guide to Best Teaching Practice,
DOI 10.1007/978-3-319-42539-9_1

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Issues and Trends in Nursing Education

Each patient had a bell to ring if they needed something—or they just yelled! There
were no “contour” sheets, so students were taught to tuck in the sheets, military

style, in such a manner that they would not move. The beds were placed along the
walls, with pull curtains which could be drawn to provide privacy. However, there
was no air conditioning, so it was very hot and when the curtains around the beds
were drawn, it was even hotter. One good thing about this arrangement (when the
curtains were open) was that you could take one look around the room and see what
was happening with every patient. Each of these nursing units also had one or two
private room for the very sick and/or new postoperative patients. There were no
recovery rooms or intensive care units. There were a few isolation rooms, but not on
every unit. The configuration of those rooms included an elaborate entrance/exit
area which contained all the supplies that a nurse would need to enter and exit the
room. Isolation was fastidiously maintained, a practice that predated the discovery
of antibiotics. There was rampant, active tuberculosis, all sorts of wound infections,
and hepatitis. Tuberculosis was so prevalent that I became positive for TB during
my first semester in school.
There was a very small nurse station which included space to pour medications
and equipment for treatments. Medications were kept in large bottles—no prepackaged medications. Nurses had to calculate how many pills to give or how to break
up the pills in order to provide the proper dose for their patients. The proper dosage
was put into a medicine cup, which was glass. After medications had been given the
cups had to be washed and sterilized.
Injections were a big part of nursing care. Almost everyone on medical–surgical
units was given penicillin three to four times a day. Syringes were glass and they
had to be washed and sterilized on the unit after each use. Needles were metal and
nurses had to check them before use and sharpen them when they were dull. The
needles also had to be cleaned after each use and sterilized in the small sterilizers on
each unit. IV bottles were glass; most tubing was rubber, although plastic was
beginning to be used. All rubber tubes on the unit (urinary catheters, gastric tubes,
etc.) had to be cleaned and returned to central supply to be autoclaved. Enema tubes
were washed after use and placed in a container to soak in a soap solution. Bed pans
were washed and after a patient was discharged, they were boiled. The fact at that
time was nothing was disposable!

Nurses had to prepare sterile normal saline, enema solutions, dermatology soaks,
and other solutions on the unit in the treatment room. They had to add medications
to IV bottles in this same room which was the setting for all sorts of tasks. For every
kit that was used, for example, a catheterization kit, the nurse or student had to clean
the equipment and then return it to central supply to be autoclaved. Rubber gloves
were kept on the units, to be used for “special things” such as dressings and catheterizations, but after each use, the nurse had to wash the gloves, put them on a rack
to dry, powder them when they were dry, and finally wrap them in linen to be
returned to central supply for autoclaving. For patients with diabetes, urine had to
be checked every 4 h for glucose levels. The nurse had to collect the urine and take
it to the treatment room where there was a metal tent to prevent the urine from splattering all over the room. The urine was placed in a test tube with Benedict’s solution
and boiled, which would turn the urine a different color depending on the amount of


An Educator’s Perspective

3

sugar present. The appropriate dose of insulin would then be calculated and given.
I will never forget the smell of cooked urine!
Nursing faculty taught in the classroom, clinical setting, and laboratory. In the
Nursing Fundamentals course, the faculty not only had to teach the procedure but
also the care of the equipment, calculation of medication dosage, etc. However, in
the following courses, faculty assigned students to clinical units to provide learning
experiences for the specific courses they were taking. Assignments on the units and
work schedules were made by the head nurse, who also evaluated the student’s
clinical performance. Each course was heavy with clinical hours, and after the first
semester, students’ clinical learning experiences were in reality “service hours.”
Upon completion of the first semester students were assigned not only to the day
shift but also to the 3:00 p.m. to 11:00 p.m. and 11:00 p.m. to 7:00 a.m. shifts including
weekends. The total number of hours students were assigned each week varied, but the

rule seemed to be that the combined classroom and clinical hours could not exceed
40 h. Assignments were task oriented; students might be assigned direct patient care on
an acutely ill patient, or group of patients, or as “medicine” or “treatment” nurses.
On the evening shifts, night shifts, and weekends, there were no nursing faculty in the
hospital and students worked closely with the nursing staff. During their senior year,
especially on evenings, nights, and weekends, students often served as charge nurse.
Classroom teaching was scheduled during the day. Students could not be scheduled to work during classroom hours but those who did work evening or night shifts
were expected to be in class during the day. It was common, on the weekends when
students had no classes, to assign students “split shifts.” For example, on Saturday
and Sunday, the hours assigned often were 7:00 a.m. to 12:00 p.m. and 4:30 p.m. to
7:00 p.m. This assured that students were there to “pass” medicines, provide baths,
and give evening care (evening care at that time consisted of a back rub; brushing of
teeth and a face wash; smoothing or change of linens; and a little conversation). After
I completed the diploma program, and because I had previously completed the basic
education courses required for the degree, I was able to take an additional course, a
newly developed public health/community course required for the Bachelor of
Science in Nursing (BSN). I was one of the first of three graduates in the newly
developed BSN program. In 1955, after graduating and passing the national licensure examination, I was immediately recruited to become a faculty member at the
school. The reason for the program’s interest in me as a potential faculty member
was simple: the program was transitioning into a baccalaureate program, and it was
evident that the academic requirements for faculty would soon be the BSN. The fact
that I had absolutely no teaching or clinical experience was not a deterrent. I had the
required degree (not many nurses at that time did), so I was hired. Thinking back, I
don’t know what in the world made me feel I was prepared for this challenge!
For the first two semesters, I was assigned to work with a more experienced
faculty member and felt I was beginning to learn a little something about teaching.
I was assigned to teach very few of the classes and received little guidance about
how the class I was to teach fit in with the rest of the course. Also, the tests I was
provided had been written in previous years. I did not know this at first, so I had no
idea if the content I taught was appropriate to prepare the students for the test. There

was no real orientation to the practice of teaching in the classroom. My preparation


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Issues and Trends in Nursing Education

for clinical teaching was a directive to get the students as many procedures as possible and to be sure and check their charting.
When my more experienced faculty member resigned to pursue her master’s
degree in Texas, I became the senior faculty member for the fundamental nursing
course. I was responsible for all the classroom teaching, testing, teaching in the
laboratory, and for coordinating clinical supervision of students in the hospital. I
had someone to assist in all of this, but she had even less knowledge and experience
than I did. There was no faculty orientation or assistance, so I just taught as I had
been taught and as the faculty member before me had taught. In the classroom, I
lectured and attempted to encourage discussion among the students. It was difficult
to think about teaching strategies as I was preparing for lectures every night and just
barely staying ahead of the students.
The nursing laboratory experience was, to say the least, very interesting. The
teaching methods used were, I am sure, as old as nursing itself. Looking back on it,
I don’t know how in the world we got away with it. Today, the students would probably bring suit against us for doing invasive procedures on them! Demonstrations of
procedures were done first by the instructor. That wasn’t hard for me because I had
just been a student myself and did it in the same manner I had been taught. Following
the demonstrations, students were then expected to practice by doing a return demonstration of the procedure with one of their classmates acting as the patient. They
gave each other baths, provided evening care, took vital signs, drew blood, inserted
nasogastric tubes, and gave injections (sterile saline, of course). The rationale for
this teaching approach was twofold: (1) the student needed to have experience in the
laboratory before doing procedures on patients in the hospital and (2) students

needed to empathize with how the patient felt when receiving care. All of those
return demonstrations were very time consuming for both the student and faculty
member, but it certainly motivated students to practice!
In my teaching experience during that time, my biggest challenge was creating tests.
The tests had to be created a few days before the scheduled test date so that the secretary
could type and duplicate them. As a result, the test writing process was done in a hurried
manner with no time to really look at the test as a whole or to ask another faculty member to review it. Altogether, writing lectures and tests, doing the nursing laboratory
demonstrations and clinical assignments, supervision, and evaluations were overwhelming. Many of those early teaching experiences were difficult, frustrating, and scary.
I continued in my position as a nursing instructor for the next few years, at times
feeling more competent as a teacher in some areas but in other areas feeling inadequate and frustrated. After the birth of my second child in 1958, I took time away from
nursing education. During the 1970s, after our youngest child was almost ready to
start school, I decided it was time to return to nursing and, frankly, as a fairly young
couple, my husband and I needed the extra income. I recognized that I needed to
update my clinical skills and went to work in a hospital which had an orientation program for nurses who had been out of nursing for an extended period of time. There
was a nursing shortage at the time and hospitals were doing all they could to assist
nurses in making that adjustment. The hospital also had a diploma in nursing education program and after I had worked as a staff nurse for a short time, they recruited me
to return to nursing education. I was hesitant because I felt I needed more time to


An Educator’s Perspective

5

regain my skills, but was assured that I would be given all the support I needed. Again,
at this time, there was a real shortage of academically prepared nurses to teach and
even though I had been out of nursing for several years, I was hired. After a short time,
I again asked myself, “What in the world made you think you were really prepared to
teach?” It did not take long before I began to experience the same feelings of frustration and inadequacy that I had in my previous teaching experience.
Despite the passing of nearly two decades, teaching at this school was not all
that different from my previous teaching experience in the 1950s. In the early

1970s, students were still very young and female, could not be married without
permission, and were required to live in the dormitory. Requirements for
entrance into the program were about the same as they had been in my previous
school. The applicant had to have good grades, pass an entrance examination,
and submit reference letters. Some years there were not enough qualified applicants to fill a class and other years there were more than enough. However, after
the nursing shortage became more severe in the 1970s, the number of applicants
grew every year; the entrance requirements became more and more stringent
and we began to have a lot more applicants than we had space for students. The
school had a very good reputation throughout the state and its pass rate on the
licensing examination was extremely high.
The hospital at that time had advanced—somewhat. There were recovery rooms
and acute care units, and the rooms were air-conditioned. Needles and syringes
came in various sizes and were disposable. Gloves were disposable as well, but used
only for special procedures. Plastic IV tubing was available but solutions still came
in bottles, with medications being added by the nurse, on the unit. Kits for purposes
such as catheterization and dressing changes came from central supply and had to
be cleaned and returned for autoclaving. Most of the rooms housed two patients,
though the beds, for the most part, were still the old crank-type. Overall, however,
technology and equipment were changing and advancing every year.
The minimum academic requirement for faculty was the Bachelor of Science Degree
in Nursing but the State Boards of Nursing was beginning to emphasize the need to
increase the minimum requirement. In the 1980s, due to pressure on the national and
state level, the Master of Science in Nursing degree was required for nursing faculty.
Teaching at this school in the 1980s was not all that different from my previous
teaching experience in the 1950s. Following a brief orientation to the curriculum
and school rules, I was assigned to teach with a more experienced faculty member
who, again, taught as she was taught: lecture in the classroom, laboratory demonstrations, and heavy clinical assignments. I was assigned certain lectures to present
and again did not know that test questions were already written. My major responsibilities were to assist in the lab. Because the lab was small we had to repeat sessions in order to accommodate all the students. I also had a group of students in the
clinical environment for 4 days a week.
The major difference in the clinical area was that students were no longer utilized

as staff and the faculty member was always present on the unit to supervise students.
One asset of the diploma programs of the day was the quantity of clinical experience. Students had clinical for 4 days or evenings a week in every course. In the
fundamentals course, students were assigned clinical for 4 h a day, 4 days a week.


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Issues and Trends in Nursing Education

The change in the student over the 4-day period was remarkable. The first day or
two, students were nervous and anxious but by the fourth day, for the most part, they
were confident and self-assured. They were expected to be well prepared—getting
their assignments the day before, visiting their patients, reviewing the chart, and
preparing a plan of care. As the courses progressed, the hours were longer and
patient assignments became more complex. Four day clinical assignments gave
them added confidence and expertise as they progressed through the program.
The curriculum was focused around the medical model and students were now
required to complete a course in anatomy and physiology that was taught by a professor from a nearby university. The content was the same as what he taught at the
university to the medical students.
Then, in 1978, everything began to change. The hospital moved into a new “stateof-the-art” facility. The school of nursing moved with the hospital—with classrooms
and a laboratory in the hospital but no dormitory—and we quickly became a commuter school. The student body began to change and became more diverse with a
higher number of nontraditional students (25 years and older). Some of these nontraditional students were married with children, some were single parents, some were
individuals seeking second careers, and, lastly, some were attracted to the profession
not because of their desire to serve, but solely because of the availability of jobs after
graduation. Most of the students held jobs outside the program and had little time for
anything they considered “busy work.” The State Boards of Nursing made it clear
that, within a designated period of time, the Master’s of Nursing Degree would be
required for nursing faculty. Therefore, most of the faculty, including myself, were

going back to school; I received my master’s degree in 1980.
In the early 1980s, as a result of the nationwide trend of moving diploma nursing
education programs from the hospital setting into institutions of higher learning, the
decision was made to establish a free standing college to offer an associate degree
(A.D.) in nursing and other allied health fields. This began a long process involving
visits to institutions offering the associate degree and accrediting agencies, choosing a curriculum model, and designing nursing courses. Consultants were brought
in to critique and assist the faculty’s efforts and to ensure that everything met the
requirements of the State Boards of Nursing and accrediting agencies. Faculty were
excited about the proposed changes and the fact that they were supported and
included throughout the process. Even though faculty were stretched very thin during this transition, developing the new A.D. program while still teaching in the
diploma program as it was being phased out, they went to great lengths to minimize
any negative impact on students. During this period, I enrolled in a program to complete a doctorate in higher education and graduated in 1990.
When the transition was completed, the new A.D. Program received full approval
from the State Boards of Nursing and full accreditation from the regional accreditation agency on the first try! Upon graduation, students in both the diploma and A.D.
programs scored high on the NCLEX-RN and student exit evaluations of the programs were very positive. We saw this as a tremendous achievement, made possible
because faculty felt a part of the process and were given the support and preparation
they needed.


History of the Development of Nursing Education

7

In summary, as I look back, I have seen many changes in nursing education. To
name a few:
• The movement of nursing programs into institutions of higher education
• Changes in healthcare delivery
• Changes in curriculum design to more effectively prepare students to function in
the health care environment
• An increasingly diverse and nontraditional student population

• Changes in technology, both in education and health care
• Increased requirements for approval by the State Boards of Nursing and for
accreditation by national accrediting agencies
• Changes in academic requirements for nursing faculty
However, an unfortunate constant in my observations is the lack of preparation
for nursing faculty in the basic skills of teaching. This book is designed to provide
practical, simple, and effective guidelines for the beginning nurse educator. The
book begins with a history of nursing education, information about the regulation of
nursing schools, the ever-changing student population, and the faculty role. Further
chapters contain content relating to principles of teaching and learning, classroom
teaching, teaching in the clinical environment, simulation, and online teaching.
Each chapter contains basic information related to the chapter content, followed by
scenarios which illustrate a variety of teaching situations which includes potential
actions and rationale for each action.

History of the Development of Nursing Education
The first nurse training programs in the USA were established in 1872. Women’s
Hospital in Philadelphia and New England Hospital for Women and Children were
nurse training programs staffed with women physicians who sought quality nursing
care (Kalisch & Kalisch, 2004). Three more nurse training programs supported by
hospitals opened in 1873. Bellevue Hospital Training School in New York,
Connecticut Training School in New Haven Hospital, and Boston Training School
in Massachusetts General Hospital opened with the support of laywomen. The
majority of schools established before the 1900s were on either the east or west
coast, with just a few training schools elsewhere in the country (Kalisch & Kalisch,
2004). By 1900, 490 nurse training schools had been established in the USA. Many
of these schools were specifically created to care for patients with the prevalent illnesses of the time, such as mental illness and tuberculosis (Kalisch & Kalisch,
2004). Hospital administrators found that it was more economical to have an internal nurse training program than hiring nurses from outside the institution. In general, students worked 12-h days and many of their classes were canceled when their
services were needed within the hospital.
Nursing leaders soon recognized the need to establish standards for college and

university nursing faculty programs. In 1919, the Rockefeller Foundation funded


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Issues and Trends in Nursing Education

The Committee for the Study of Nursing Education to study nursing education in
the USA. The committee charged Josephine Goldmark, a social worker, to lead the
investigation and it resulted in the publication of Goldmark Report in 1923. The
committee’s original mandate was to “examine the proper training of public health
nurses” (Committee for the Study of Nursing Education, 1923, p. 7). However, the
focus broadened to research “the entire problem of nursing and of nursing education” (Committee for the Study of Nursing Education, 1923, p. 7). The report highlighted the fact that other professions, like medicine and law, had moved away from
an apprenticeship model. In contrast, nursing had been directed by “organizations
created and maintained for the care of disease, rather than for professional education” (Committee for the Study of Nursing Education, 1923, p. 17). The report’s
recommendations included the establishment of a university-based school of nursing with a separate governing board and financing separate from hospitals. University
education also was recommended for future nursing educators. The report called for
the standardization of nursing education and the extrication of nursing education
from American hospitals (Ruby, 1999).
The Society of Superintendents of Training Schools, which later became the
National League of Nurse Education (NLNE), attempted to establish a standard curriculum for nursing programs. The league believed the standardization of curriculum would ensure that nurses were taught similarly and to a high standard in all
schools of nursing (Committee on Curriculum of the National League of Nursing
Education, 1937, p. 4). The Standard Curriculum for Nursing Schools was published in 1917 by the Education Committee of the NLNE under the leadership of
Adelaide Nutting. The curriculum was divided into two major sections. The first
section outlined the physical facilities, financial resources, and administrative control of the schools. This section also addressed the qualifications of the students and
faculty, guidelines for student life, and recommended methods of teaching. The
second section was a detailed curriculum plan with objectives, content, methods,
resources, and operational schedules (Education Committee of the National League

for Nursing Education, 1917). However, the standard curriculum was merely a
guideline and not adopted in its entirety by all nursing schools.
After the Goldmark Report of 1923, two revisions were made to the original curriculum publication and it was retitled A Curriculum Guide for Schools of Nursing.
The final revision in 1937 identified “well-supported suggestions and recommendations in relations to desirable objectives, sources, content, methods, and organizations” (Committee on Curriculum of the National League of Nursing Education,
1937, p. 10). The authors sought to provide a framework for schools of nursing, and
A Curriculum Guide for Schools of Nursing was intended as a handbook to be used
by an individual school in building its own curriculum. The authors believed nursing education should be in harmony with the principles and methods of modern
science (Committee on Curriculum of the National League of Nursing Education,
1937). This was a chalenging necessity due to the rapid changes in the health care,
science, and social arenas.
Another famous report on nursing education was published in 1948. Ester Lucille
Brown’s report entitled Nursing for the Future recommended that schools of nurs-


Regulation of Nursing Schools

9

ing be placed in colleges and universities, similar to the Goldmark Report (Brown,
1948). The Brown Report also supported the release of nursing education from
hospitals and a standard curriculum (Ruby, 1999).

Educational Pathways to Become an RN
Today, there are three educational pathways to become a registered nurse in the
USA: the Associate Degree in Nursing (ADN), Associate of Science in Nursing
(ASN), and Bachelor of Science in Nursing (BSN). Graduates of all the pathways
are eligible to take the NCLEX-RN. Typically, ADN or diploma programs are
approximately 3 years in length and mimic the original hospital-based training programs (AARP, 2010; Institute of Medicine, 2011). The Associate of Science in
Nursing [ASN] program originated following the end of World War II in 1945.
Advances in health care and dramatic increases in the number of new hospitals from

the Hill-Burton Act of 1946 increased the demand for nurses and a shortage of hospital nurses ensured (Orsolini-Hain & Waters, 2009). In response, a 2-year nursing
program was created and was offered at junior and community colleges. Graduating
students received an ASN and qualified to test for licensure as a registered nurse
(RN) (Matthias, 2010). Currently, ASN programs require 2 years of nursing instruction and are typically offered by community colleges (AARP, 2010; Institute of
Medicine, 2011).
The Goldmark Report of 1923 and the Brown Report of 1948 encouraged colleges and universities to cultivate baccalaureate nursing programs in institutions of
higher education. The number of such programs has grown steadily since that time
(Orsolini-Hain & Waters, 2009). Currently, about 55 % of the American RN workforce holds a bachelor’s or higher degree (Health Resources and Services
Administration [HRSA], 2013). Differentiation of graduate competencies among
the entry-level education programs—ADN, ASN, and BSN—may exist, but differentiation of nursing practice among entry-level prepared RNs do not (Matthias,
2010).

Regulation of Nursing Schools
The regulatory body mandated to oversee and approve education in each state and
territory in the USA is the State Boards of Nursing (SBON) (NCSBN, 2004). Each
SBON either approves or accredits nurse education program in schools and universities (NCSBN). SBON program approval/accreditation is for the purpose of protecting the health, safety, and welfare of the public (NCSBN). Each state or territory
has a Nurse Practice Act (NPA) enacted by the state legislature. The Boards develop
rules and regulations to clarify aspects of the NPA, including the establishment of
standards for pre-licensure education. These standards vary from state to state on


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Issues and Trends in Nursing Education

issues such as required curricular content, types and number of clinical experiences,
faculty qualifications, and ratios of students to faculty members (Glasgow,
Niederhauser, Dunphy, & Mainous, 2010). The SBNs evaluate nursing schools by

comparing the NCLEX-RN pass rate of the school to the national average.
National nursing accreditation is a voluntary, nongovernmental peer-review process to assure that schools of nursing are meeting standards (NCSBN, 2004). There
are two major nationally recognized accreditation agencies for nursing programs.
The AACN developed the Commission on Collegiate Nursing Education [CCNE] in
1998 and accredits baccalaureate and graduate degree including doctorate of nursing practice programs (AACN, 2014). The National League of Nursing Accreditation
Committee [NLNAC], formed in 1996, accredits diploma, associate, and baccalaureate programs. As a result of the continued demand for accreditation services, the
NLNAC changed its name to the Accreditation Commission for Education in
Nursing or ACEN in April 2013 (ACEN, 2013). “The purpose of the ACEN is to
provide specialized accreditation for programs of nursing education, both postsecondary and higher degree, which offer either a certificate, a diploma, or a recognized professional degree (clinical doctorate, master’s, baccalaureate, associate,
diploma, and practical)” (ACEN, 2013, p. 1). Both agencies require a self-study for
accreditation, focusing on identified standards set by each accrediting agency. Both
agencies use NCLEX-RN pass rates as one measure for approval in the accreditation process. In most cases, schools follow the accreditation process every 10 years.

NCLEX-RN History
Nursing has the potential to cause harm to the public if practiced by unprepared or
incompetent practitioners. Licensure is a method put into place to assure the public
that a nurse has obtained the necessary skills to practice in each state or territory in
the USA An individual qualifies for licensure by completing a nursing program and
by passing the NCLEX-RN examination (NCSBN, 2016).
The test plan of the NCLEX-RN is a set of content categories that define nursing
actions and competencies across all settings for all clients (NCSBN, 2016). The
NCLEX-RN is developed and revised by NCSBN based on extensive analysis of
the practice requirements of an RN (NCSBN, 2013). The NCLEX-RN test plan is
categorized by the client needs presented in Table 1.1. This table also identifies the
percentage of items on the examination from each of the categories and subcategories for the 2016 NCLEX-RN test plan.
The NCLEX-RN examination uses a variety of types of questions, including multiple response, multiple choice, fill in the blank items, hot spot items (where the
candidate needs to locate an anatomical point on a diagram or body), ordered
response items, chart and graph items, and items that use computer technology
(Lavin & Rosario-Sim, 2013). NCLEX-RN test items are written at a higher level of
thinking in order to test the applicant’s ability to process complex patient care issues.

Bloom’s taxonomy is a way to categorize the hierarchy of cognitive processes using