Trends in Registered Nurse Education Programs:
A Comparison Across Three Points in Time

INTRODUCTION

The purpose of the study was to document how the practices, methodologies, and strategies used in nursing education changed in the past five years and to identify changes expected to occur in the next five years. Because the survey was completed in the fall of 1999, the study provided a perspective on nursing education over the 1994 – 2004 decade. A secondary study purpose was to obtain pilot data to use as the basis for a national study addressing these same issues.

METHODOLOGY

A literature review (see Bibliography) was completed to identify published trends and changes in nursing education. When categorized, the reviewed nursing education changes clustered into six domains: 1) curriculum design/focus/framework/ program objectives/outcomes, 2) teaching methodologies/approaches, 3) evaluation methods/approaches, 4) clinical experiences and use of the laboratory, 5) faculty dimensions of program design/implementation, and 6) student recruitment/retention/enrollment.

Curriculum and Objectives/Outcomes (hereafter referred to as Curriculum) trends and changes related to the structure, design and organizing framework of a program, the nature of support/cognate courses, when nursing courses were initiated/ offered in the curriculum, the availability and nature of nursing courses and/or electives, and course content. In this domain was objectives and outcomes of curricular efforts.

Teaching Methods/Approaches (hereafter referred to as Teaching) focused on innovative strategies to facilitate student learning, such as the use of focus groups, problem-based learning, collaborative learning, interdisciplinary experiences, and service learning. Also included were student research experiences or participation with faculty in research, use of technology, and distance learning.

Evaluation Methods/Approaches (hereafter referred to as Evaluation) trends related to innovative use of evaluation techniques to include tests, creative projects, dyad testing, care plans, and computer adaptive learning.

Clinical Experiences and Use of the Laboratory (hereafter referred to as Clinical/Laboratory) changes encompassed diverse clinical sites, non-traditional times for clinical experiences, the use of preceptors and adjunct faculty, placements in nurse-managed clinics, and the integration of diverse and alternative laboratory equipment and techniques.

Faculty Dimensions of Program Design/Implementation (hereafter referred to as Faculty) changes included faculty demographics and the use of non-traditional faculty, rank and tenure issues. Scope of faculty responsibilities and aspects of faculty development were included.

Student Recruitment/Retention/Enrollment (hereafter referred to as Student) included recruitment strategies, retention strategies, changing student demographics, meeting the needs of an increasingly diverse student population, success-oriented strategies, and admission, progression and graduation standards.

A 16-page questionnaire was designed to reflect trends in each of the six domains (Appendix A). The questionnaire also included three pages of program information, such as type of institution (public or private), Carnegie classification, type of RN programs offered, accreditation status, and size of the program.

The questionnaire contained a total of 160 items: 40 in the “Curriculum” area, 40 in the “Teaching” domain, 15 related to “Evaluation,” 37 that focused on “Clinical/Laboratory,” 15 that addressed “Faculty,” and 13 in the “Student” domain. Some of the 160 items reflected only subtle differences; however, all were included in the questionnaire, because the goal was to develop an exhaustive, rather than a limited or selective, item list.

Nursing program respondents were asked to answer two questions about each of the 160 items: 1) “Compared to 5 years ago, is today’s emphasis on this item more, less, or the same?” and 2) “5 years from now, do you expect the emphasis on this item to be more, less, or the same?” Respondents were asked to select the one response for each item that best described how their program addressed that item.

A response of “More” indicated that the program put a greater focus/emphasis on the item in 1999 than in 1994 (“5 years ago” at the time of the survey), or expected more of an emphasis on the item in 2004 (“5 years from now” at the time of the survey). A response of “Less” meant that there was less focus/emphasis on the item in 1999 than in 1994 (five years previously), or that the program expected less emphasis on the item in 2004. A “Same” response indicated that the focus/emphasis on the item was similar to what it was 5 years ago (1994) or that the program expected the emphasis to remain unchanged five years in the future (2004). For each item, “Never” was also a response option. “Never” meant that the program did not address the item in 1994 or in 1999, or the program did not address the item in 1999 and did not expect to address it by 2004.

SAMPLE

The questionnaire was mailed to all RN programs included on the Fall 1999 list of programs approved by the Connecticut State Board of Nursing. At that time 14 RN programs were operational in Connecticut. Twelve of the 14 (86%) programs returned useable questionnaires: four were associate degree programs, seven were baccalaureate programs, and one was a generic master’s program through which students completed baccalaureate-level competencies and became eligible to sit for the RN licensure exam (Table 1). Seven of the 12 programs responding (58%) were public. All of the programs reported being accredited by the National League for Nursing Accrediting Commission and the New England Association of Schools and Colleges.

DATA ANALYSIS

The “More,” “Less” “Same,” or “Never” responses to each item for 5 years ago and 5 years into the future were tabulated. The investigators set the “significance” level as a trend or change that was found in more than 50% of respondents. This relatively low level of significance was set because the study was a pilot and designed for exploration. There were 12 responding programs, therefore, when more than seven showed agreement on an item, the item was designated as significant. Because of the large number of survey item, only trends identified as significant were reported in this manuscript.

Items Identified as Receiving More Emphasis

Curriculum (40 items). More than 50% of the programs reported six Curriculum items that received both more emphasis in 1999 than in 1994 and were predicted to receive more emphasis 2004 than in 1999 (Table 2). The six items were: 1) case management, 2) informatics/computers, 3) patient care outcomes, 4) health care cost/finance/financial management, 5) critical thinking, and 6) evidence-based practice. In addition to these six items, responding programs reported teaching more content in 1999 than in 1994 on management and delegation and the changing health care environment (e.g., managed care). A significant number of respondents predicted that by 2004 there would be increased emphasize on prevention, alternative therapies/holistic approaches to care, collaborative partnerships, health promotion/wellness care, and community-based care in non-traditional settings.

Teaching (40 items). A significant number of respondents reported six Teaching methods items that received both more attention in 1999 than in 1994, and were predicted to receive more emphasis in 2004 than in 1999. The six items were 1) use of simulation, 2) case study, 3) mentoring, 4) use of the Internet in courses, 5) use of CD-ROMs, and 6) use of e-mail. A significant number identified one other item -- use of learning groups -- that increased in emphasis between 1994 and 1999.

Significant numbers of responders estimated that another 10 Teaching items would receive more emphasis in the next five years (between 1999 and 2004): 1) problem based learning, 2) cooperative/collaborative learning, 3) interdisciplinary learning, 4) distance learning, 5) small group discussion/seminar, 6) active learning strategies, 7) interactive video, 8) Power Point presentations, 9) web-based courses, and 10) List Servers.

Evaluation (15 items). A significant number of respondents reported two Evaluation items that received both more emphasis in 1999 than in 1994, and were predicted to receive more emphasis by 2004. The two items were 1) critical analysis and 2) clinical case presentations. Respondents estimated that another Evaluation item -- using creative projects to evaluate student learning -- would receive more emphasis in 2004 than it received in 1999.

Clinical/Laboratory (37 items). Computer simulation was reported by a significant number of responding programs to both receive more emphasis in 1999 than in 1994 and was expected to receive more emphasis in 2004 than in 1999. No other Clinical/Laboratory item was identified by more than 50% of the respondents as receiving more emphasis in 1999 than in 1994; however, six additional items were predicted for increased emphasis between 1999 and 2004. The six items were 1) use of homeless shelters, 2) experiences in nurse-managed centers, 3) use of primary care clinics, 4) adopting a community, 5) using competency-based assessment, and 6) using critical elements.

Faculty (15 items). More than 50% of the respondents reported two Faculty items that received both more attention in 1999 than in 1994 and were predicted to receive more emphasis by 2004. The two items were 1) use of computers and 2) innovative teaching approaches. Two other items were projected to receive more attention by 2004: 1) re-tooling for community-based teaching and 2) grant writing.

Student (13 items). A significant number of responding programs identified one item -- recruitment of non-traditional age students -- as both receiving more emphasis in 1999 than in 1994 and estimated to receive more emphasis in 2004. Between 1994 and 1999, two additional items received more emphasis: 1) increased admission standards in nursing and 2) increased progression and graduation standards in nursing. In the next five years (1999 – 2004), 50% of respondents predicted that 1) recruitment/retention of diverse student populations and 2) recruitment in middle schools would increase in emphasis.

Items Identified as Receiving Less Emphasis

No Curriculum items were identified by a significant number of responding programa as receiving less emphasis in 1999 than in 1994. One item -- history of nursing -- was predicted by a significant number to receive less curricular emphasis in 2004 than in 1999 (Table 3). One Teaching item -- lecture -- was identified as receiving less emphasis in 1999 than in 1994 and was predicted to receive less emphasis in 2004 than in 1999. Respondents identified no Evaluation, Faculty, Clinical/Laboratory, or Student items that received less emphasis in 1994 than in 1999; and none of these domain items were predicted for less emphasis in 2004 versus 1999.

Never Emphasized Items

A significant number of responding programs defined five items as “Never” emphasized between 1994 and 1999 (Table 4). In Clinical/Laboratory items, the strategy of having students “adopt” a community to address its health needs was never emphasized. In Faculty items, joint appointments were never emphasized. In Student items, the use of a full-time nurse recruiter, opening nursing courses to high school students, and offering summer camps for high school students were three strategies never used by more than 50% of the respondents. Between 1999 and 2004, “Never” was not selected for any item by a significant number of responding programs.

DISCUSSION

The results of the study documented that in the 1994 – 2004 decade, basic RN program faculty changed and expected to continue to change many aspects of nursing education. Curricular data reflected nurse educators’ commitment to integrate up-to-date patient content (e.g., patient care outcomes and evidence-based nursing). Further, most responding programs reported increased curricular emphasis on national emerging topics such as alternative therapies/holistic approaches to care and collaborative partnerships. Changes in teaching methods mirrored those written and discussed nationally, namely, problem-based learning, interdisciplinary learning, and technology-based methods.

As academe moved from evaluating knowledge to evaluating critical thinking and creativity over the past decade, so have nurse educators. Clinical/Laboratory sites kept pace with national trends and increasing awareness about the health care needs of marginalized populations, e.g., responding programs reported an increased use of simulation learning, use of alternative learning sites and increased experiences with vulnerable populations. Additionally, faculty members have and continue to expect to re-tool for community-based teaching. Program faculty worked both to recruit and retain non-traditional and diverse students, again mirroring national trends in United States education.

Despite the many changes in nursing education, faculty omitted few items from educational strategies and approaches. Only history of nursing, as a Curriculum topic, and lecture, as a Teaching methodology, were identified for less emphasis by 2004. The paucity of items identified for less emphasis suggested that respondents continued to add to curricula without taking items out.

Although the initial literature review showed that some schools used joint appointments with success, more than 50% of the respondents reported never using the strategy. The reason may be tied to the small sample size and the types of programs included in the study. Joint appointments may be used most extensively in academic health centers. In the sample there was only one RN program from an academic health center. The validity of this explanation can be tested in the national sample survey.

LIMITATIONS

Although the results are important in understanding the status of nursing education in the nation, the narrow sample -- RN programs in Connecticut -- and the small sample size (n = 12) limited generalization of the results. When the questionnaire was developed, no effort was made to define each survey item (e.g., interdisciplinary teaching, learning groups, etc.) or compress the number of items. Instead, investigators allowed respondents to define each item and decide how that item was represented in their nursing program. Although this approach was intentional, more items may have reached the “significance” threshold (i.e., emphasized by more than 50% of the respondents) if items were grouped and/or defined.

CONCLUSIONS AND RECOMMENDATIONS

The data analysis documented that in the studied programs, RN education was dynamic – changes occurred in the five years preceding data collection and were expected to occur in the five years following the study. Faculty were implementing new curriculum topics and new teaching methodologies. Although innovation and change are touted as desirable for nursing education programs, before adopting trends or changes, faculty should examine research studies that under-gird the innovations/changes. Changes should be made systematically with opportunities for faculty to understand and debate the documented effectiveness and efficiency of changes. In addition to relying on presented and published nursing education research for innovations, nurse educators should complete and may benefit from their successes and failures.

The findings suggested that programs continually added content or learning experiences, but rarely deleted items. The result could to be “congested” programs that overwhelm students with too much content and detract from learning.

With the alarming rate at which nursing information is expanding, the question becomes can nurse faculty continue to add to curricula without simultaneously making the difficult decision to delete content? And is there an optimal number of teaching methods for a course – when does too many modalities become disruptive to student learning?

Importantly, nurse educators must determine if trends found in the present study are extend across the country and are common to other types of programs. The study should be repeated on a national level so that the findings can be generalized beyond the Connecticut sample. In addition, a similar study of trends in practical/vocational and graduate nursing education would document significant changes in other program types.

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Table 1

Table 3