Trauma Informed Pedagogy and its Implications for Nursing Education

On March 6, 2022 By teachingadventuressiteIn Instructional Techniques and Theory, reflections, Trends in Adult EducationLeave a comment

Inherent to the art of nursing is the establishment of the therapeutic relationship within which the 3C’s of nursing, compassion, communication and caring (Motter, Hassler & Anthony, 2021, March 26) can be realized. Engaging in compassionate care with a patient who has experienced trauma, however, can induce vicarious trauma in the nurse (Isobel & Thomas, 2021). Vicarious trauma has a significant impact on nurses and is an important consideration to nursing educators who, by providing a positive learning environment in the form of a trauma informed approach, can reduce the impact of vicarious trauma on student nurses during clinical practicums and simultaneously help them to develop strategies to alleviate the its long term effects. This paper will investigate three articles: Potentially Perilous Pedagogies: Teaching Trauma Is Not the Same as Trauma-Informed Teaching (Carello & Butler, 2014); Risky teaching: developing a trauma-informed pedagogy for higher education (Harrison, Burke & Clarke, 2020); and, Abolitionist Pedagogy in the Neoliberal University: Notes on Trauma-Informed Practice, Collaboration, and Confronting the Impossible (Whynacht, Arsenault & Cooney, 2018) to ascertain key points, implications for innovations in teaching and learning, determine article strengths, weaknesses and significance and finally, implications for nursing education.

Key Points from Articles

The authors of all three articles assess the impact that teaching trauma-related content has on students and instructors. It is noted that students dealing with trauma are more at risk of being re-traumatized. Existing trauma among students is high. “By the time youth reach college, 66% to 85% report lifetime traumatic event exposure and many report multiple exposures” (Carello, & Butler, 2014, p. 157).

Harrison, Burke and Clarke (2020) discuss that there are serious risks to students’ mental health when using teaching strategies that are intended to induce an emotional connections between the learner and the people involved with trauma related content. Some teachers believe that activating emotional responses in students is good teaching (Carello, & Butler, 2014) and can lead to transformational learning when in fact, it could be re-traumatizing them. Whynacht, Arsenault and Cooney (2018) note that in a course based on abolitionist pedagogy, traumatizing course content lead to students disclosing past traumas to instructors, leaving instructors at risk for vicarious trauma (Carello, & Butler, 2014). The articles conclude that meaningful learning can occur when teaching trauma-related content, without re-traumatizing or inducing vicarious or entirely new traumas in students, if established processes like that of trauma informed pedagogy are in place.

Implications for Innovations in Teaching and Learning

Taking a risk to create emotional connections to generate compassion between the learner and the people involved with trauma related content requires processes to ensure safety for learners and instructors (Harrison, Burke & Clarke, 2020; Whynacht, Arsenault & Cooney, 2018). These processes have not been historically established in the educational setting. Integrating trauma informed pedagogy into university courses is a vital innovation to support the mental health of students and instructors and to enable meaningful learning (Carello, & Butler, 2014; Harrison, Burke & Clarke, 2020).

The processes of trauma informed pedagogy are still evolving. Presently, these include; trauma awareness – prevalence, signs and symptoms, paths to recovery (Harrison, Burke & Clarke, 2020); the prioritization of student safety and an awareness that risky teaching does not lead to transformational learning (Carello, & Butler, 2014); the establishment of a collaborative community of practice (Whynacht, Arsenault & Cooney, 2018); access to professional mental health support (Carello, & Butler, 2014); and, the development of curriculum that is culturally competent and trauma aware (e.g., limit exposure to traumatic content, vary the intensity of traumatic content, provide information on self care) (Carello, & Butler, 2014). The implementation of these processes in the university setting is achievable. I believe that trauma informed pedagogy is a critically important innovation that should be implemented in educational settings.

Articles’ Strengths, Weaknesses, and Significance

The articles highlight that trauma is common and that there is a risk of re-traumatizing or creating direct and indirect trauma when using pedagogies to creating emotional connections between learners and trauma survivors or trauma related content. The articles provide a variety of perspectives that ranged from a compilation of data of emotional responses from learners engaging with a trauma survivor (Harrison, Burke & Clarke, 2020), a narrative account from instructors of a social justice course (Whynacht, Arsenault & Cooney, 2018) and research into how engaging with trauma-related content or using trauma inducing practices such as trauma exposure or forced disclosures can have detrimental impacts on students (Carello, & Butler, 2014). The articles offer a variety of perspectives from both students and instructors. This offers depth and provides insights into the complexity of trauma in the classroom. The principles for trauma informed practice that are outlined are applicable to the Eurowestern university setting. Whynacht, Arsenault and Cooney (2018) highlight the importance of contextual influences on the implementation of actions in their discussion of how they tried to build a community of practice among students in their course but had challenges due to the university’s culture of high levels of competition among students.

A weakness for the articles is that they are all are from the Eurowestern perspective. The lack of diversity among the articles limits insights into what trauma informed practice would be in other cultures. While the articles offer some general actions that instructors can take, they do not provide overarching principles to guide the delivery of trauma informed pedagogy. Carello and Butler (2014) state “. . . more interdisciplinary research is clearly needed in this area, as most of the available literature is anecdotal and based on clinical training, and it does not explicitly adopt a trauma-informed framework” (p. 163).

Implications for Nursing Education

Trauma among students is common. As part of their therapeutic engagement with patients, nurses are at an additional risk of experiencing vicarious trauma at the workplace (Isobel & Thomas, 2021). Trauma can manifest as a wide range of complex emotional responses (Harrison, Burke & Clarke, 2020) and may not always be identified as being a trauma response. As a nurse educator, I need to realize that all students are at risk and that at anytime in a course, a student could be experiencing direct or vicarious trauma. I must also recognize that I too have both direct and vicarious trauma from my personal and professional life. “To use trauma-informed pedagogy requires a communal recognition of trauma—both acknowledging its existence and acknowledging the traumas we each have faced individually or as a group, and then responding to that through both action and curriculum (Whynacht, Arsenault & Cooney, 2018, p. 151).

Emotional safety is a necessary adjunct to learning (Carello & Butler, 2014). I need to ensure that the students and I establish a community of practice in which we collaboratively build a trauma-informed space. I need to provide students with information on what trauma is, ways of coping with trauma (Whynacht, Arsenault & Cooney, 2018), and means of emotional self-regulation. Students need to be aware how to access professional mental health counseling and be able to recognize when they require professional support. I need to understand that learner performance may be impacted by trauma (Carello & Butler, 2014) and that I need to reach out to students that are encountering challenges with assignments. I need to develop curriculum that is trauma aware and culturally competent. I must ensure that I am engaging with the students during their clinical and allow for them to have time away, with support provided as needed, from the clinical to process exposures to traumatic events and narratives of survivors. I need to ensure that course content is balanced and that modules do not have a sustained focus on trauma-related content. I need to understand that students with trauma are vulnerable to people in authority (Carello & Butler, 2014) and that “ . . . supportive relationships are created through trust, which is gained through honesty, responsibility, and dialogue” (Whynacht, Arsenault & Cooney, 2018, p. 148).

Conclusion

Trauma among students is common. Nursing students are particularly vulnerable to the development of vicarious trauma by virtue of the establishment of the therapeutic relationships with patients who have experienced trauma. Vicarious trauma has a significant impact on nurses and is an important consideration to nursing educators who, by providing a positive learning environment in the form of a trauma informed approach, can help student nurses develop strategies to alleviate the long term effects of vicarious trauma. This paper investigated three articles: Potentially Perilous Pedagogies: Teaching Trauma Is Not the Same as Trauma-Informed Teaching (Carello & Butler, 2014); Risky teaching: developing a trauma-informed pedagogy for higher education (Harrison, Burke & Clarke, 2020); and, Abolitionist Pedagogy in the Neoliberal University: Notes on Trauma-Informed Practice, Collaboration, and Confronting the Impossible (Whynacht, Arsenault & Cooney, 2018) and ascertained key points, implications for innovations in teaching and learning, determined article strengths, weaknesses and significance and finally, outlined implications for nursing education.

References

Carello, J. & Butler, L.D. (2014). Potentially Perilous Pedagogies: Teaching Trauma Is Not the Same as Trauma-Informed Teaching. Journal of Trauma & Dissociation,15,153–168. Taylor & Francis Group, LLC.

Harrison, H., Burke, J. & Clarke, I. (2020): Risky teaching: developing a trauma-informed pedagogy for higher education. Teaching in Higher Education, 1-15. Routledge. DOI: 10.1080/13562517.2020.1786046

Isobel,S. & Thomas, M. (2021). Vicarious trauma and nursing: An integrative review. International Journal of Mental Health Nursing. 1-13. John Wiley & Sons Australia, Ltd. DOI: 10.1111/inm.12953

Motter, T., Hassler, D. & Anthony, M.K. (2021, March 26). “The Art of Nursing Becomes a Celebration of Nurses.” OJIN: The Online Journal of Issues in Nursing 26(2). DOI:10.3912/OJIN.Vol26No02PPT72 https://doi.org/10.3912/OJIN.Vol26No02PPT72

Whynacht, A., Arsenault.E. & Cooney, R. (2018). Abolitionist Pedagogy in the Neoliberal University: Notes on Trauma-Informed Practice, Collaboration, and Confronting the Impossible. Social Justice, Vol. 45(4), 141-162.

Adult Education in the 21st Century Reflection Series: Foundations for Canadian Nursing Education– Part 6

On February 24, 2022February 24, 2022 By teachingadventuressiteIn Critical Thinking, Instructional Techniques and Theory, reflections, Trends in Adult EducationLeave a comment

Are there any innovations in nursing education that can be offered to help with the crisis in nursing?

Government policy innovations

• Reinvest in community nursing and community programs. Keeping people in community will alleviate the stress on hospitals. (My experience is that nurses are more likely to stay in community nursing as they like the autonomy and the hours of work).
• Invest in more seats for undergrad, specialty post-RN programs and nurse practitioner education. Note: BC has just funded an additional 602 seats to an already 2000 existing seats for undergrad programs and nurse practitioner education (Smart, 2022, Feb. 20).

Institutional program innovations

• Stay the course with the professional model.
o Increase the number of seats in universities for specialty programs.
o Develop accelerated specialty programs that combine theory and clinical in one semester.
o Liaise with hospitals and health authorities to provide specialty programs that will meet their needs and provide a solid background in nursing theory.
o Create a program that provides 2 years of general nursing education and clinical overview followed by a 2 year specialty focus in hospital based or community care.

• Encourage the development of nursing theory from the standpoint of diverse voices by providing scholarships and financial support for Indigenous, minority, immigrant, ability diverse and LGBTQIA2S+ community members.
• Hire Indigenous, minority, immigrant, ability diverse and LGBTQIA2S+ nursing instructors.
• Provide scholarships and financial support for Indigenous, minority, immigrant, ability diverse and LGBTQIA2S+ students.
• Have instructors use self-evaluation tools to assess for inclusivity in the classroom. Below are a few example tools.
o Primary /secondary
• https://inclusiveschools.org/wp-content/uploads/2017/10/ISN-Self-Assessment-PDF-2.pdf
• https://www.doe.mass.edu/edeval/guidebook/2d-teacherselfassess.pdf
o University
• https://provost.tufts.edu/celt/files/Inclusive-Assessment-Chart-1.pdf
• Support faculty – both tenured and sessional – to bring in innovative practices into the classroom by providing resources, instruction and mentorship.
o Celebrate as a team when teachers implement new innovations into their programs.
o Highlight how these innovations supported student achievement, improved inclusivity and celebrated diversity.

Individual program innovations

• Address diversity issues in the curriculum and in the classroom. Utilize inclusive teaching strategies.
• Use curriculum that is grounded in nursing theory that offers a holistic framework to guide student actions in the clinical area.
• Offer curriculum that provides a balance of both the art and science of nursing. Discuss with students why the art of nursing matters.
• Ensure alignment between curriculum and clinical learning outcomes.
• Use curriculum that develops creative thinking skills and demonstrates how they can be applied to the clinical area.

Innovations that I will incorporate into my courses

• I created an accelerated perinatal specialty program (Fall 2021) during which students complete their theory and clinical in 1 semester. Feedback so far from health authorities, unit managers and students is positive.
• I am continuing to look at barriers to inclusivity in the curriculum and in the classroom. I will try this self-evaluation tool that is designed for teachers of college students.
o I am also looking at how I can integrate a trauma informed approach with my students

• I do not explicitly address a specific nursing theory in courses except to reference nursing diagnosis for the clinical area. I will investigate this further. I will also bring attention to the elements in the curriculum that reflect the art of nursing in class discussion, and how these can integrate the principles of trauma informed practice , Family Centred Maternal and Newborn Care and culturally safe practice
• I am integrating the skills and behaviours required for creative thinking into the curriculum and during weekly classroom sessions.
• I will continue to seek feedback from students and fellow instructors on ways I can improve my courses, address my own biases and assumptions and support student learning.

Reference

Smart, A. (2022, Feb. 20). Province to add hundreds of post-secondary nursing seats to address skills gap. CBC News. https://www.cbc.ca/news/canada/british-columbia/nursing-seats-added-bc-1.6359029

Adult Education in the 21st Century Reflection Series: Foundations for Canadian Nursing Education– Part 5

On February 23, 2022February 24, 2022 By teachingadventuressiteIn Instructional Techniques and Theory, reflectionsLeave a comment

What lessons can we learn from the past?

Photo Credit: Wikipedia. (1955). Two nurses with baby in nursery at Toronto East General and Orthopaedic Hospital, Toronto, ON. License: Public Domain https://en.wikipedia.org/wiki/Nursing_in_Canada#/media/File:Two_nurses_with_baby_in_nursery_at_Toronto_East_General_and_Orthopaedic_Hospital,_Toronto,_ON.jpg

American educators influenced Canadian nursing educational programs

American influences from the contemporary educational theorists in the US prompted Canadian nursing educators to take an educational approach versus a medical approach to nurse training (Bramadat & Chalmers, 1988, October).

• Interestingly, ongoing nursing shortages and cut backs are causing some American nursing educational programs to eliminate nursing theory courses. They are instead going back to a medical model for nursing education (Kikuchi, 2003).
• The American influence on Canadian nursing education continues. I am seeing American based nursing modules being bought and used for hospital based and even some university based specialty training in BC. These modules are grounded on the medical model. I am concerned that the importance of nursing theory, culturally safe practice, Family Centred Care and Trauma Informed Practice that contribute to the well being of patients and communities will be ignored if these modules continue to be used.

The apprenticeship model increased the supply of nurses in the hospital but lead to worse outcomes for patients

We have seen that outcomes are worse for patients when they are not cared for by university prepared RNs (Canadian Nurses Association, 2015). We cannot go back to the exclusive use of this model.

• Nursing shortages have been an issue for 100 years (Duncan, Scaia & Boschma, 2020). Switching the model of educational training to the professional model from the apprenticeship model did not create the current nursing shortage. I do feel, however, that it may have exacerbated it by reducing the number of seats available for students and by increasing the time to graduation from 2 to 4 years.

The professional model was geared to provide training for community based care and leadership in administration and education

• As a result of government policies in the 1950’s and 1960’s that emphasized hospital based care over community based care, the primary employer for RNs is the hospital. This has lead to a mismatch between the educational needs of RNs.

The crisis in health care we are currently facing is eerily similar to 100 years ago. Back then, nursing leaders saw the need for more nurses in community and responded by developing nursing theories and establishing a holistic approach for health promotion. I find it interesting that educational policy makers are responding to this pandemic by returning nursing education to a medical model, a model that is disease focused and singular in its approach to patients. This would certainly not be supported by what I have learned during my inquiry into the past. What is needed is some innovative thinking around nursing education so that we can meet the nursing shortage and not lose the holistic approach that nursing educators have worked hard to develop.

References

Bramadat, I,J. & Chalmers, K.I. (1988, October). Nursing education in Canada: historical ‘Progress’ — contemporary issues. Journal of Advanced Nursing, 1989, 1 4 , 719-726.

Canadian Nurses Association. (2015). Framework for the Practice of Registered Nurses in Canada. — 2nd ed. Canadian Nurses Association. https://hl-prod-ca-oc-download.s3-ca-central-1.amazonaws.com/CNA/2f975e7e-4a40-45ca-863c-5ebf0a138d5e/UploadedImages/Framework_for_the_Pracice_of_Registered_Nurses_in_Canada__1_.pdf

Duncan, S. M., Scaia, M. R. & Boschma, G. (2020). “100 Years of University Nursing Education”: The Significance of a Baccalaureate Nursing Degree and Its Public Health Origins for Nursing Now.” Quality Advancement in Nursing Education – Avancées en formation infirmière: Vol. 6: Iss. 2, Article 8.
DOI: https://doi.org/10.17483/2368-6669.1248

Kikuchi, J. (2003). Nursing Theories: Relic or Stepping Stone? CJNR 2003,Vol. 35 No 2, 3–7.

Adult Education in the 21st Century Reflection Series: Foundations for Canadian Nursing Education– Part 4

On February 23, 2022 By teachingadventuressiteIn Instructional Techniques and Theory, reflections, Trends in Adult EducationLeave a comment

What is nursing theory and how does it improve nursing care?

With the establishment of baccalaureate nursing degree programs, conceptual theories of nursing developed and evolved from those first proposed by Florence Nightengale. These nursing theories provide the framework for nursing care and range from abstract (metaparadigm) to concrete (practice level) (Wayne, 2021, July). Unlike the medical profession where the focus is on the treatment of disease, nursing theories focus on health promotion. By encompassing an awareness of the environmental, relational and personal (physical, emotional and spiritual) aspects of care these theories provide a holistic framework that is essentially considered to be the art of nursing.

In our readings this week, I was very interested in Martin’s (1987) article Transforming Moral Education. Martin (1987), feels that Eurocentric education is focused on the development of a rational, “. . . well-developed mind that is governed by reason” (Martin, 1987, p. 206); aspects that she considers to be masculine and productive in nature. Martin (1987) feels that this cultural view comes at the expense of the feminine, reproductive education, which embodies emotions in the form of generative love and the 3Cs of caring, connection and concern. Nursing is unique in that the feminine, reproductive components, the art of nursing, exist alongside the science of nursing, the masculine, productive components. The 3C’s of nursing practice, caring, compassion and communication (Motter, Hassler & Anthony, 2021, March 26) were taught to me in my hospital based program and are foundational to current BN and BSN programs.

Martin argues that a new construct for moral education is needed. One where “an emphasis on generative love transforms the entire landscape of moral education ” (Martin, 1987, p. 212). I feel the foundational nursing theories that nursing has developed validate the importance of the feminine and reproductive components in nursing education. What worries me is that with the ongoing nursing shortage and the focus in health care on concerns about risk management and the importance of scientific based care, the art of nursing is in danger of being lost. I believe that without the art of nursing at its core, patients and communities will be in jeopardy of no longer receiving holistic care.

The integration of emotional and rational that has been so beautifully captured by nursing theory is an innovation that cannot be lost. I will continue to ensure that my curriculum emphasizes the 3 C’s of nursing along with the synergistic principles of Trauma Informed Care, Family Centred Maternal Newborn Care and culturally safe practice. Nursing theories need to continue to evolve. I will encourage students to embark on this research. The nursing theories require more voices from different cultures, genders, and gender expressions.

References
Martin, J. R. (1987). Transforming moral education. Journal of Moral Education, 16(3), 204–213. 10.1080/0305724870160305

Motter, T., Hassler, D., Anthony, M.K., (2021, March 26). “The Art of Nursing Becomes a Celebration of Nurses” OJIN: The Online Journal of Issues in Nursing Vol. 26, No. 2 DOI: 10.3912/OJIN.Vol26No02PPT72 https://doi.org/10.3912/OJIN.Vol26No02PPT72

Robinson, S. (2014, April) Nursing 2022 – Volume 44 – Issue 4 – p 44-45
doi: 10.1097/01.NURSE.0000444533.58704.e5. https://journals.lww.com/nursing/fulltext/2014/04000/true_presence__practicing_the_art_of_nursing.11.aspx

Wayne, G. (2021, July). Nursing Theories and Theorists. Nurselabs. https://nurseslabs.com/nursing-theories/

Adult Education in the 21st Century Reflection Series: Foundations for Canadian Nursing Education– Part 3

On February 22, 2022February 23, 2022 By teachingadventuressiteIn reflections, Trends in Adult EducationLeave a comment

Advantages and disadvantages of the professional model in nursing education

Historical Influences

At the time that the apprenticeship model of nursing was taking hold in hospitals in Canada, the professional model of nursing education was also taking root. Concerned about the lack of standardization and quality of nursing education in the hospital based programs, nursing leaders sought to establish an educational model that would ensure consistent educational standards, foster the growth of professional nursing organizations and promote licensing and registration of professional nurses (Bramadat & Chalmers, 1988, October). The desire for post-graduate nursing education for supervisors of nurse training schools led to alliances with American nursing universities (Bramadat & Chalmers, 1988, October). American influences from the contemporary educational theorists in the US prompted Canadian nursing educators to take an educational approach versus a medical approach to nurse training (Bramadat & Chalmers, 1988, October). The university programs that they designed focused on developing nursing leaders who worked independently in communities, taught, were superintendents of schools of nursing (Bramadat & Chalmers, 1988, October) and functioned as hospital administrators (Duncan, Scaia & Boschma, 2020).

Current influences

Health care policies from the 1950’s – 1960’s which prioritized hospital based care over community based care (Duncan, Scaia & Boschma, 2020), has impacted the focus of nursing degree programs from primarily nursing leadership in education, hospital administration and community care to mostly acute care. I spoke to recent BN RN graduates and some state that they did not do any community placements as they wanted to work acute so they only completed one leadership community based project. Duncan, Scaia and Boschma (2020) note that: “(t)he 2020 pandemic may well be surfacing the loss of emphasis on public health nursing contributions as schools of nursing struggle to locate practicum opportunities for nurses in acute care, while not fully appreciating the opportunities and promise of community and public health nursing roles as essential grounds of preparation” (p.4).

The pandemic has also brought to the forefront how years of cuts to community based programs in addition to a reduction in the scope of practice for Public Health Nurses (PHN) has greatly impacted the general public’s access to PHNs and community programs. I myself have attempted to have postpartum patients have their blood pressures taken by a PHN in community and was unable to do so as the Health Authority would not allow it. This is such a change from how it was. 36 years ago when I did a placement with a community health nurse in a rural community in Southern Alberta I was blown away by the impact one PHN was having on the community. People in the community would stop by the health unit for counseling on diet, blood pressure checks and baby care which often involved vaccination discussions. The PHN did health education in the schools, and was even spearheading a community fitness event which involved most of the community. This type of nursing leadership is no longer an option for PHN.

Advantages of the professional model in nursing education

• Standardization of educational standards, trained faculty and curricula.
o Health care outcomes for patients are improved when cared for by degree prepared RNs (Canadian Nurses Association, 2015).
o Sound educational theory is used to guide curriculum; critical and creative thinking and reflective practice are incorporated into the curriculum.
o Nursing theory in addition to medical information is provided in the curriculum.
• Leadership in nursing is emphasized.
• Provides education for community and home care nursing.

Disadvantages of the professional model in nursing education

• Lack of alignment between the historical foundation for the professional model (community based care, leadership in administration and education) and the current places of employment for most graduate RNs which is in acute care.
• Mismatch between meeting the continued demand for hospital based nurses and available seats for nursing degree programs.
• Mismatch between available seats for specialty education programs and demand.
• 4 year time span for training produces a lag time in producing graduate nurses.

My takeaways on the professional model for nursing education

The professional model improves outcomes for patients by ensuring standardized education. Its historical roots in community based care, leadership in administration and education are no longer in alignment with health care policy that emphasizes hospital based care.

References

Bramadat, I,J. & Chalmers, K.I. (1988, October). Nursing education in Canada: historical ‘Progress’ — contemporary issues. Journal of Advanced Nursing, 1989, 1 4 , 719-726.

Adult Education in the 21st Century Reflection Series: Foundations for Canadian Nursing Education– Part 2

On February 20, 2022February 23, 2022 By teachingadventuressiteIn Instructional Techniques and Theory, Trends in Adult EducationLeave a comment

Advantages and disadvantages of the apprenticeship model in nursing education

Historical Influences

Hospital administered nursing programs utilize the apprenticeship “on the job” model. These programs were the norm for nursing education in Canada up until the early 1990’s when all of the provinces, with the exception of Quebec, went to the professional model and implemented university provided, degree based programs. (Duncan, Scaia & Boschma, 2020). The apprenticeship model was desirable for hospital administrators as it provided a steady supply of student nurses who could attend to patient care (Bramadat & Chalmers, 1988, October). Shorter turn around for training (2-3 years for hospital based programs versus 4 years for university, professional programs ) was also deemed desirable for communities as it was seen as a way to deal with workforce demands (Duncan, Scaia & Boschma, 2020). This seemingly win – win situation lead to an increase in the number of hospital based programs in Canada from 200 in 1909, to 800 by 1930. (Bramadat & Chalmers, 1988, October). Unfortunately, the rapid proliferation in the number of training programs resulted in the lowering of admission standards and a reduction in faculty expertise. Without standardization, programs suffered from inadequate curricula and because of this “. . . being a ‘trained nurse’ might mean ‘anything, everything, or next to nothing’ “(Bramadat & Chalmers, 1988, October, p. 720).

Despite inadequacies in the hospital based programs and the availability of standardized university nursing degree programs, the apprenticeship model persisted through to the 1990’s as a way to meet continued labour demands. Additionally, health policies from the 1950’s -1960’s focused on the delivery of hospital based health care instead of community based health care programs. These policies, along with controlling influences exerted by the medical profession on nursing education, saw that hospital based skills were prioritized at the expense of university prepared RNs who were being trained to provide high quality community and home based care (Duncan, Scaia & Boschma, 2020).

Current influences

Hospital based programs that utilize the apprenticeship model are still being used for post-RN specialty training. The current nursing shortage is forcing nursing organizations, like the Oregon Center for Nursing to revisit this model as an innovative way to increase the supply of nurses.

Advantages of the apprenticeship model in nursing education

• Provides a consistent supply of nurses for hospitals.
• Nurses are job ready upon completion of their training.
• Trains nurses for a specific hospital setting (e.g., rural vs urban).
• Provides on demand specialized training for hospital based specialties.
• Provides training that supports the delivery of medical care in the hospital setting.

Disadvantages of the apprenticeship model in nursing education

• Lack of standardization of educational standards, trained faculty, curricula.
o Provincially run professional organizations like the BCCNM offer certifications but these are only for nurses that are functioning in autonomous practice (e.g. prescribing antibiotics in a STI clinic).
o Health authorities are taking on some of this training and are offering their own brand of specialty training (e.g. perinatal care, OR). Local hospitals are still providing this training as well.

• Does not provide education required for community and home care nurses.
• Focus on clinical skills may preclude education on nursing theory, critical and creative thinking, reflective practice.
• Influence of medical profession and hospital administration on curriculum may limit the voice that the hospital trained nurse has on health policy.

My takeaways on the apprenticeship model for nursing education

Due to ongoing and persistent demand for hospital based specialty trained RNs, the apprenticeship model for post-RNs continues to exist. Processes need to exist to ensure consistent standards, appropriately trained instructors and curriculum that develops critical and creative thinking, reflective practice.

References

Bramadat, I,J. & Chalmers, K.I., (1988, October). Nursing education in Canada: historical ‘Progress’ — contemporary issues. Journal of Advanced Nursing, 1989, 1 4 , 719-726.

Adult Education in the 21st Century Reflection Series: Foundations for Canadian Nursing Education– Part 1

On February 9, 2022February 24, 2022 By teachingadventuressiteIn Instructional Techniques and Theory, reflections, Trends in Adult EducationLeave a comment

Photo Credit: GetArchive (n.d.). *Interior of Toronto General Hospital, with nurse, 1913* [Online Image]. Wikimedia Commons. License: Public Domain. https://jenikirbyhistory.getarchive.net/amp/media/interior-of-toronto-general-hospital-with-nurse-1913-12dcc5

I realize that this may sound alarmist, but as a frontline RN, I feel that the pandemic has so severely challenged the already precarious health care system that it is in danger of collapsing. Nursing shortages are at critical levels across BC as well as across the country. Without nurses, the current system is not able to function safely. Causes of the nursing shortage are multifactorial. Ensuring that there are enough graduated nurses ready to enter the profession is one of the solutions to the crisis. To figure out where we need to go, I will need to start at the beginning. How does the historical educational foundations for nursing education impact how registered nurses are educated now? Is it time for a change?

Training for registered nurses typically involves a 4 year undergraduate degree. Admission standards are stringent and waitlists exist for students with a 93% high school graduation grade. Governments are scrambling to add more seats and are offering condensed programs for students with existing degrees.

It wasn’t however, always this way. The professional model of nursing is only one of the educational models that existed for nursing. The apprenticeship model – the hospital based program – trained nurses up until the early 1990s until all the provinces, with the exception of Quebec, went to the professional, degree based program. (Duncan, Scaia & Boschma, 2020).

I am a hospital trained RN. I completed 2 years of university courses towards a general science degree thinking that I would go into medicine. Realizing that medicine was a long haul prospect and with little financial and social supports, I decided that the best option was for me to go into nursing. The university I was going to had a BN program. When I reviewed the degree requirements I was not happy with the limited amount of clinical time that was provided. Nursing to me was about being technically proficient with equipment and having the confidence and ability to perform necessary skills. Nursing theories like Levine’s 4 Conservation Principles and terms such as emancipatory nursing praxis did not sound like skills I needed for dressing changes and IV starts.

Consequently, I headed over to the local school of nursing program at the tertiary centre in my city and completed a diploma in nursing. The 3 year program had me in the clinical area from the onset. It combined theory with concurrent clinical time. When I graduated I felt ready to tackle hospital based care. This was a contrast to my professionally educated peers who seemed to struggle at first with the tasks of the clinical area simply because they did not have as much time on the units as I had had.

In July 1920, Ethel Johns stated: “Physicians and the public accuse us of educating nurses away from nursing and rendering them unwilling to perform ordinary nursing duties. I leave it up to you to say whether or not there is some truth in this accusation. They urge us to lower our standards, to give shorter courses, to do something to get nursing attendance for people who need it” (Street, 1973, p. 135 as cited in Duncan, Scaia & Boschma, 2020, p. 5).

Nursing is once again in crisis. As I am in the business of providing nursing education, I have some questions that I would like to investigate.

What are the advantages and disadvantages of the apprenticeship and professional models of nursing education?

What is nursing theory and how does it improve nursing care?

What lessons can we learn from the past?

Are there any innovations in nursing education that can be offered to help with the crisis in nursing?

See Parts 2-6 for my investigations and reflections to these questions.

Reference

Duncan, S. M., Scaia, M. R. & Boschma, G. (2020). “100 Years of University Nursing Education”: The Significance of a Baccalaureate Nursing Degree and Its Public Health Origins for Nursing Now.” Quality Advancement in Nursing Education – Avancées en formation infirmière: Vol. 6: Iss. 2, Article 8.DOI: https://doi.org/10.17483/2368-6669.1248

Adult Education in the 21st Century Reflection Series: Creativity and Nursing – Part 3

On February 6, 2022February 22, 2022 By teachingadventuressiteIn Critical Thinking, Instructional Techniques and Theory, Student Motivation, Trends in Adult Education1 Comment

Teaching strategies that will engage nursing students’ creative processes and establish (hopefully!) creative behaviours in the clinical setting

Process: Develop background knowledge and experience.
- Teaching strategies:
  - Review key concepts at the start of the class.
  - Have students identify all the pertinent medical data involved in the case study.
  - Have students identify additional data relevant to the case study:
    - alternative perspectives and actions;
    - environmental; and,
    - their own somatic experience – what they saw, felt, heard, smelled.
      - Acknowledge that students may be best at finding creative solutions to clinical problems when they are physically in the space that they work (embodied simulation).
Process: Reflection activities that examine the creative process.
- Teaching strategy:
  - As part of the student reflections on the case study presentation that they submitted with each case study I will include the following questions:
    - What was the biggest challenge you encountered with this case? (Yang, 2017).
    - What did you do to overcome these challenges?
Process: Develop cognitive flexibility (the ability to adapt to new situations).
- Teaching strategy:
  - Following student led case study presentations I will ask the class:
    - What would you would do in this case?
      - Have them change perspectives and have them look at it from the view of another care provider or patient.
Process: ‘Connect the dots’ between theory and clinical situations.
- Teaching strategies:
  - Theory: Link theory with data and over all patient presentation collected in case study.
  - Mental models: Make visible with the class what the different health care providers and patient/family mental models may have been through examination of actions taken based on the data and the sharing of reflections on the case.
  - Practice standards: Discussion with the class the practice standards that are applicable to the case.
  - Actions: Examine actions taken and explore factors that contributed to these actions.
Process: Create a safe and positive learning environment.
- Teaching strategies:
  - Allow for self-direction in creating case studies.
    - Students will develop own case studies based on clinical experiences.
  - Create a supportive, respectful and collaborative community of practice.
    - Feedback to peers for case studies is grounded in Appreciative Inquiry.
  - Role model honesty and acceptance of mistakes.

References

Brewster, A.L., Lee, Y.S.H., Linnander, E. & Curry, L.A. (2021, August, 17). Creativity in problem solving to improve complex health outcomes: Insights from hospitals seeking to improve cardiovascular care. Learning Health Systems. https://onlinelibrary.wiley.com/doi/full/10.1002/lrh2.10283

Chan, Z.C.Y. (2012). A systematic review of creative thinking/creativity in nursing education. Nurse Education Today. http://dx.doi.org/10.1016/j.nedt.2012.09.0

Cheraghi, M. A., Pashaeypoor, S., Mardanian Dehkordi, L. & Khoshkesht, S. (2021). Creativity in nursing care: A Concept analysis. FNJN Florence Nightingale Journal of Nursing, 29(3), 389-396. https://fnjn.org/Content/files/sayilar/211/389-396.pdf

Khalil, R., Godde, B. & Karim, K.A., (2019, March, 22). The Link Between Creativity, Cognition, and Creative Drives and Underlying Neural Mechanisms. frontiers in Neural Circuits. https://www.frontiersin.org/articles/10.3389/fncir.2019.00018/full

Leschziner, V. & Brett, G. (2019, August). Beyond Two Minds: Cognitive, Embodied, and Evaluative Processes in Creativity. Social Psychology Quarterly. DOI: 10.1177/0190272519851791

Yang, R. (2017, November, 29). How to Reveal the Creative Process Through Reflection. The Art of Education University. https://theartofeducation.edu/2017/11/29/revealing-creative-process-reflection/

Adult Education in the 21st Century Reflection Series: Creativity and Nursing – Part 2

On February 2, 2022February 22, 2022 By teachingadventuressiteIn Critical Thinking, Instructional Techniques and Theory, Intelligence, Student Motivation, Trends in Adult EducationLeave a comment

In order for me to be able to use teaching strategies that will support creative thinking in the classroom, I need to have a good grasp of the processes of creativity and the creative behaviours that are part of problem solving.

Creative Processes

Creative thinking is the result of the interplay between complex cognitive, emotional and hormonal systems (Khalil, Godde & Karim, 2019, March, 22).

Creative cognition:

Includes flexibility, fluency, reflective skills, the ability of the working memory to take in divergent information and then screen out irrelevant data so that the important data can be focused on (part of working memory updating) and originality (Khalil, Godde & Karim, 2019, March, 22).

Creativity requires knowledge and experience in the domain (Cheraghi, et al., 2021).

Emotional influences:

Includes motivation, mood, regulatory focus (motivation with a promotion or prevention focus) and rewards ( Khalil, Godde & Karim, 2019, March, 22).

Body and sensory knowledge:

Researchers are beginning to investigate how body and sensory knowledge – embodied simulation – also contributes to creativity (Leschziner & Brett, 2019, August).

Environmental Factors

A supportive environment (Cheraghi, et al., 2021).

Creative Behaviours

Brewster, Lee, Linnander and Curry (2021, August, 17), identify 3 behaviours that hospital based cardiovascular care teams use to foster the ‘ecological view’ which provides an understanding of the entire patient’s care processes and the environment within which these occur. The researchers note that this view is essential for creative problem solving. These behaviours are (located in Results):

collecting new and diverse information;
accepting (rather than dismissing) disruptive information; and,
employing empathy (ie, to understand or feel what another person is experiencing from within their frame of reference, that is, the capacity to place oneself in another’s position).”

My takeaways

Creative processes

Develop teaching strategies that will engage students with cognitive flexibility (the ability to adapt to new situations).
Develop teaching strategies that will help students ‘connect the dots’ in clinical situations.
Ensure that the students have enough knowledge and experience to be able to develop creative solutions for problems.
Provide reflection activities that examine the creative process.
Create a safe and positive learning environment.
Support intrinsic motivation by designing assignments that allow for autonomy, encourage mastery and provide purpose.
Acknowledge that students may be best at finding creative solutions to clinical problems when they are physically in the space that they work (embodied simulation).

Creative Behaviours

Have students collect diverse and disruptive data (alternative perspectives, nontraditional approaches) in addition to the usual data collection of the standard medical views and approaches for case studies.
Have students integrate alternative and standard views into case studies.
Have students imagine taking a stand from an alternative view.

See Part 3 for specific problem solving and teaching strategies that I will try out for supporting creative thinking in the classroom.

References

Chan, Z.C.Y. (2012). A systematic review of creative thinking/creativity in nursing education. Nurse Education Today. http://dx.doi.org/10.1016/j.nedt.2012.09.0

Davis, J. (2020, June 16). How Creativity Builds Resilience in Times of Crisis. Psychology Today. https://www.psychologytoday.com/ca/blog/tracking-wonder/202006/how-creativity-builds-resilience-in-times-crisis

Leschziner, V. & Brett, G. (2019, August). Beyond Two Minds: Cognitive, Embodied, and Evaluative Processes in Creativity. Social Psychology Quarterly. DOI: 10.1177/0190272519851791

Adult Education in the 21st Century Reflection Series: Creativity and Nursing – Part 1

On January 27, 2022February 22, 2022 By teachingadventuressiteIn Critical Thinking, reflections, Trends in Adult EducationLeave a comment

Creativity is the foundation upon which innovation is built. While actively engaging the nurses that I teach with the processes of innovation in the workplace may not be suitable at this time, what about having Registered Nurses that are taking specialty education engage with the processes of creativity? What are the benefits in including creativity in the curriculum? To begin my investigation, I will begin with myself. How do I personally feel about creativity as a frontline nurse? What has been my experience with engaging students with creativity in health care?

First of all I will define what creativity, as applied to this context, means to me.

Creativity: the state in which an individual, with the ability, resources and the inclination to do so, engages in the generation of ideas, concepts and/or physical products that are original in nature and/or application and can be used to solve problems in health care.

As a frontline nurse I am constantly coming up with creative ways to provide individualized care to patients that have a wide range of needs, a behaviour that is typical of nurses (Chan, 2012; Cheraghi et al., 2021). Chan (2012) notes that creative thinking and critical thinking are interrelated skills, both of which are critical for rural nurses who deal with the challenges of providing care in a low resource site. Additionally, “. . . ethical decision making is positively correlated with creative thinking . . .” (Chan, 2012, p. 1).

When working with students, I have found that nurses are very comfortable with suggesting alternative approaches to find ways to make something work. When I work with interdisciplinary teams, the same holds true, and, as there is a team to provide ideas, solutions to problems are often quite comprehensive.

Including creativity into the curriculum looks like it will also benefit patient care through improved problem solving skills and ethical decision making. Research also shows that there are direct improvements to the mental health of people who engage in creativity including:

An increase in self-esteem and self-confidence (Cheraghi et al., 2021);
Increased resilience (Davis, 2020, June 16);
The development of mental flexibility, empathy and openness (Brewster, Lee, Linnander & Curry, 2021, August, 17); and,
Increased positive emotions (Davis, 2020, June 16).

Creativity is definitely something I need to be engaging students with. See Parts 2 and 3 for a look at the processes of creativity, a summary of the creative behaviours that are part of problem solving and teaching strategies for supporting creative thinking in the classroom.

References

Chan, Z.C.Y. (2012). A systematic review of creative thinking/creativity in nursing education. Nurse Education Today. http://dx.doi.org/10.1016/j.nedt.2012.09.0

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