A Reader’s Guide to "Educating Nurses: A Call for Radical Transformation"
Part 1 in The Carnegie Professional Education review series
This is one of five reader’s guides for the Carnegie Foundation for the Advancement of Teaching’s “Preparation for the Professions” series. If you don’t have time to read each book, each article should still give you a quick overview of relevant concepts that you can apply to your own teaching context.
Introduction
Reading Educating Nurses, I was forced to consider, with deep horror, all the times I’ve built classroom content that completely failed the learner. My training and instructional design background mostly came from corporate America, which means I worked in a world where the easiest way to communicate progress is to list how many learning modules you’ve built, how many hours of training a team has delivered, and the average student assessment scores. These metrics are a lot easier to communicate on a status report than, say, whether your students are building new mental models, and executive often care less about a student’s long-term professional growth than they do the cost of the time to build each job aid. Could we point to a library of training materials cleanly stored in a sleek LMS? Yes? Great, job done.
By contrast, the core message in Educating Nurses how important it is to connect the knowledge taught in the classroom to applied experience. For a nursing student to be successful, they must understand what the abstract science they learned tells them about the patient in front of them, and how to act according to that inference.
It takes much, much longer to build content that forces a student to make mental connections between the theoretical and the practical than it does to write down a bunch of facts and decorate them in an aesthetically pleasing way. You can’t hand off training to a low-paid offshore team; you can’t ask ChatGPT or other AI tools to generate a quick introductory video. But it can be surprisingly difficult to distinguish the between these two types of trainings – sometimes even to the learner. A beautiful template can go a long way towards disguising low quality, and a student who is getting A’s on the exam might not immediately realize there’s a deeper mental model they’ve failed to grasp.
As we’ll see, Educating Nurses teaches many lessons: the power of coaching and reflective learning, the importance of guiding students in developing a sense of salience, even the risk of expecting students to magically pick up on skills that aren’t explicitly named or taught in a curriculum. Yet what I loved most was its fierce demand that we take the time and care required to build content that helps students build new mental models and advance as creative thinkers. In an environment where it’s easier and faster than ever to generate content, we can’t lose focus on what make learning content truly valuable.
Why nursing education is so fascinating
The nursing profession has quirks that make nursing education particularly fascinating – and challenging:
Instructors have relatively little control over what types of patients a nursing student sees: it ultimately depends on which patient with which problem shows up in the clinic that day.
Nursing students can’t always pause and slowly reflect on the best way to handle a situation. If a patient is going into cardiac arrest, they can’t turn to a teacher to first review the steps of CPR.
Students need to practice new social norms: it’s normal to help someone with a bedpan or to have intimate, probing conversations about sex lives or drug use. How do you teach a brand-new nurse to become comfortable with unpleasant odors?
Nursing requires highly technical skills that take extensive practice – placing an IV or an NG tube; giving potentially fatal medications – but which also must remain subservient to seeing the patient as a person and building a strong human connection.
This last challenge highlights the crux of nursing education, which is to develop a sense of salience: an understanding of what’s important and what isn’t, what to pay attention to and when. This can’t be put on a lecture slide. It happens over years, as a student masters more and more skills and watches others in practice and makes mistakes and tries again and has developed their own “clinical and moral imagination” with a keen pattern recognition. It happens as a student slowly integrates everything they’ve learned to build their professional identity as a nurse.
This means nursing education has to figure how to tightly link classroom knowledge and discussions with the clinical care happening at the bedside of the patient. The repeated and harshest critique this Carnegie report had of nursing education today is that students are left struggling to connect what they hear in the classroom (lists of symptoms, pathophysiology of organ systems, memorized facts) into something they can use while interacting with a very sick patient.
It’s not a challenge unique to nursing. As I’ve said above, given the easy with which content can be generated these days (hello, AI), it’s so much easier to regurgitate large amounts of information onto slides or into a video and assume you’ve taught.
Best Practices: Learning Tools from Nursing Education
Luckily nursing education also provides solutions. When it’s at its best, we can look to nursing education’s andragogy to teach us how to successfully facilitate experiential learning, how to integrate the theoretical classroom knowledge with what happens in the real world, and how to help students cultivate a sense of salience and professional identity.
What are the tools nursing education deploys particularly well that we can (and should!) translate to our own practices?
Emphasize framework cultivation over fact memorization
There is too much medical knowledge for a nursing student to master in three years. Even what they do learn is rapidly out of date as new studies, drugs, and fields of knowledge rapidly emerge. Rather, nursing schools focus on giving students a framework for thinking: creating lifelong, intentional learners who know how to assess the new information they will inevitably receive and integrate it with/update what they already know.
A strong nursing curriculum will teach students:
How to recognize when they know and don’t know something – to self-identify their own knowledge gaps and where more study or research is needed
To observe what they’re paying attention to and (critically) why they think it’s important
How to move beyond mastering technique to “exercising flexible judgment and taking astute, context-dependent action in an undermined situation” (Benner et al., 179).
Successful nursing schools teach cognitive processes as much as scientific facts and think about how to intentionally include these elements in their curriculum.
Extensive use of self-reflection
Self-reflection is one of the most common tools in nursing education. All nursing schools use the post-clinical conference, where students share what they observed or practiced and reflect on what they plan to do differently the next day.
Importantly, “having a bad day and reflecting on it and then successfully managing to do better the next day was far more useful to the student’s development than to have an uneventful day with no challenges,” (Benner et al. 122). Learning came through making an error or finding opportunities to improve, not doing the work to perfection. Instructors try as hard as they can to allow fully think through a procedure, stepping in to avert a potentially dangerous mistake only at the last possible minute and then coaching the student to evaluate where they went wrong. Students want each other to learn from their experiences: during group clinical reflections, they frequently volunteer (unprompted) to share the tales of these near-misses with their peers so they can avoid making the same mistake.
This emphasis on reflection serves two purposes. One, it ensures the experiential nature of nursing education is actually effective: “Experiential learning is facilitated by an open climate of learning in which students can discuss and examine transitions in understanding, including their false starts or misconceptions in actual clinical situations. This is a lifelong habit of the mind-set needed by all professionals if they are to become experts” (Benner et al. 124). Experiential learning is not about getting everything right; it is learning through trying, doing, and reflecting. Two, reflection gives students an opportunity to learn from patients they didn’t see. Not every student can care for every patient or see every medical situation before they graduate; by hearing their peer’s experiences and reflection, they can still get exposed to the knowledge.
Nursing also uses clinical journals, where students document not just what happened and what was learned but their feelings about it. This gives the space to explore things the student might feel odd or even badly about, without any judgment. The instructor will write back and, if needed, help re-frame the experience.
This last piece is particularly important: self-reflection is only useful when tightly linked with feedback from teachers and coaching on the correct approach. No amount of self-reflection can address, for example, a fundamental misunderstanding of a clinical phenomenon or how to complete a complicated procedure. Recognizing what you don’t know or areas where you struggled then needs a teacher’s help to address those gaps.
Linking lecture and classroom teaching
All of this learning depends on the instructor’s ability to link lectures with classroom teaching. This was something many nursing educators failed at (it was highlighted as both a strength of nursing education and a thing that needed improvement), but when done well, it’s the cornerstone of mastery.
When giving feedback or helping a student reflect on learning, a strong nursing educator focused their questions on helping a student link what they observed in the patient, back to what was talked about in the classroom. In order to do this, teachers also needed to have an awareness of what students were learning both in the clinical setting and the classroom setting.
Interestingly, nursing educators sometimes misunderstood where a student’s uncertainty was coming from:
"For the student who has been asked to memorize catalogues of information rather than learn the knowledge in meaningful context, the cognitive leap is great. Nursing educators told us that they understand the students' uncertainty as 'lack of confidence' and encourage them to become more assertive. In fact, as interviews and survey responses consistently revealed, the students are uncertain about their knowledge of physiology, pharmacology, and other areas of nursing science. The students know that their grasp of the relevant knowledge is weak, which means that simply being more assertive is not enough."" (Benner et al. 152)
Worth pausing to consider the next time you have a classroom full of uncertain learners. Are they unsure of themselves? Or is there too much cognitive challenge to take what they’ve memorized and apply it to actually doing the job?
Radical Transformation: Improving Nursing Education
I’ve highlighted some of the best practices of nursing because they give me ideas and understanding I can apply to my own unique practice. However, Educating Nurses was written as a critique of nursing andragogy, and its goal was to make recommendations on what can be improved. And – just as the nursing students who learned best from their mistakes or challenging days, not their successes – I think we also have a lot to learn from what nursing education needs to change.
Educating Nurses calls for four fundamental shifts in the thinking around nursing education:
“… (1) from a focus on decontextualized knowledge to an emphasis on teaching for a sense of salience, situated cognition, and action in clinical situations; (2) from a sharp separation of classroom and clinical teaching to integrative teaching in all settings; (3) from an emphasis on critical thinking to an emphasis on clinical reasoning and multiple ways of thinking that include critical thinking; and (4) from an emphasis on socialization and role taking to an emphasis on formation.” (Benner at al. 112)
What does all of this mean in practice?
Give students a wider array of clinical scenarios that better reflect what they’ll see in the real world. Almost all nursing clinicals happen in a hospital environment, but in today’s healthcare system, more than half of patient care is provided outside the hospital. Students aren’t practicing in an environment that matches their real world.
Key takeaway: Make sure your hands-on activities mirror the environments your students will actually work in – not just what’s easiest to coordinate administratively.
Examine how you keep clinical mechanisms closely tied to the patient’s experience. Rather than simply teach the structure of the heart, make sure every piece of knowledge shared has the scaffolding in place to let students link that knowledge back to their job as a nurse.
Key takeaway: Intentionally design ways to connect what you just lectured about to how your students need to be able to use that information. Don’t assume it’s intuitive.
Diversify how performance is assessed. Avoid over reliance of multiple-choice exams or writing a patient care plan just because they’re easy to grade: neither of these assesses how a student actually performs with a patient or whether they’re developing a clinical imagination.
Key takeaway: Consider how you’re assessing mastery of your students and what that tells you. Are you testing their ability to recite back facts, or in how well they can now perform the task in the real world? Can you tell what mental models they’re building?
Some challenges in nursing education need to be addressed at the systems level. This report found fundamental administrative and policy issues with how nursing was taught that aren’t within one teacher’s control. These ranged from needing more educators, educators needing better pay and training on how to teach, and a need for more clinical sites.
Key takeaway: There are factors at work beyond your instructional design that affect your learner’s success. For those of us in the corporate world, this means not only examining your pedagogy design but organizational structure itself and how it does or does not value training as a whole. And TRAIN YOUR EXPERTS IN HOW TO TEACH!!!! Educating Nurses takes a pretty strong stance that nurses should be the one teaching nurses, but only if they receive support in how to teach.
People in Glass Houses: Improving My Own Instructional Design
What changes do I want to make to my own instructional design practices after reading this book?
Spend more design time thinking about linking classroom content to experiential learning: The true value in curriculum design comes from figuring out how to help student bridge theory with practice. For example, if you’ve got a room full of call center workers learning how to help people enroll in health insurance, they need to know how to assess the widely variable needs of their callers, not parrot back facts about health insurance. The latter is easier, and faster, to build a learning unit on, but it’s low-value learning if you want outcomes of callers feeling supported and insured.
Build in more time for meaningful self-reflection: I admit, this isn’t a tool I use very often – it’s one of those things that seems ‘nice to have’ but quickly gets cut when you’re trying to jam-pack a lot of information into a short time period. Going forward, I plan to include self-reflection as a core pillar of the curriculum, not something tacked on later.
Create train-the-trainer programs that emphasize how to teach cognitive skills: Most train-the-trainer programs I’ve seen emphasize initial mastery of the knowledge to be taught and then sometimes add in things like public speaking tips and how to manage a digital classroom. What they should actually be teaching is skills like how to help students scaffold, develop a sense of salience, and effective ways to give feedback (if I hear ‘the sandwich method’ one more time…). Teaching is a skill that can and should be taught, rather than expecting new instructors to simply intuit their way through what works.
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If you’re still reading, thanks for getting all the way through this behemoth of an article! I hope it was helpful to your own instructional design practices. But I’ll also say, this article was a pale shadow imitation of the study itself
Works Cited
Benner, P., Sutphen, M., Leonard, V., Day, L. Educating Nurses: A Call for Radical Transformation. Jossey-Bass, 2010.
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