Nursing School Curriculum – Time for an Update?

September 3, 2022

Many colleges of nursing have not significantly updated their curriculum, leaving their graduates in the proverbial lurch when it comes to in the trench nursing.  In fact, certain curricula are intensely cattywampus with overlapping repetition of some information and still rife with unnecessary courses to “separate the wheat from the chaff”, as it were, discouraging a lot of otherwise serious and enthusiastic students from pursuing nursing. Conversely, some important items are neglected or ignored.  Some changes must take place. Here are a few on my list.

In 2005 the NLN (National League of Nursing) opined that there should be major paradigm shift in nursing to a Concept Based Curriculum (CBC). Not only the NLN, but also the Institute of Medicine, American Association of Colleges of Nursing, and the Carnegie Foundation – have all pressed for major changes in nursing schools’ curricula to address the realities of modern-day health care. CBC is a tool to teach students the material they need for the job and to equip them with the critical thinking and collaboration skills they will need to deliver superior patient care. A nurse today needs to be able to transfer his or her knowledge from one bedside situation to another.

CBC fosters critical thinking, better application, improved application of facts, rather than rote memory and being able to apply what learned. It helps develops astute clinical judgement and teaches students how to categorize & organize information.

While still very much relevant today as it was in the beginning of nursing as a profession.  “Assess, Diagnose, Plan, Implement, Evaluate”, flies in the face of “nurses don’t diagnose” and needs to be defined with care and in minute detail.

According to NANDA-I, the official definition of the nursing diagnosis is: 

“Nursing diagnosis is a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes. A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable.”

The use of the word “diagnosis” or “diagnosing” in step two of how nursing process is typically taught infers that only a NANDA-I nursing diagnostic statement can be used to identify the nursing priority. This is simply not how it works in clinical reality.

Consider this scenario. A home care nurse arrives at a patient’s house, only to find him with weakness in the face, arm, or leg on one side of the body; confused, trouble speaking, or difficulty understanding speech, trouble walking, dizziness, loss of balance, or lack of coordination. Do you really expect her to form a nursing diagnosis when she calls 911 and the doctor?

“A stroke rarely comes with a neon sign announcing its presence, yet a quick, correct diagnosis is essential to preventing brain damage and saving lives. The first contact, most often a nurse, needs to be able to make the call”, says Kelly Gleason, a nurse clinician at Johns Hopkins Hospital since 2014 and a PhD candidate at the Johns Hopkins School of Nursing.

Gleason continues during an interview with John Hopkins Nursing Magazine, (What Nurses Need to Know: Diagnostic Error 12/12/17) “Triage, an early stage of diagnosis, has always been part of the nurse’s responsibility. We are there more often. We are the sentinels. It is who we are fundamentally.”

The article goes on to succinctly give 8 reasons why nurses must have a more prominent role in medical diagnoses heretofore the physician’s private domain.

1. Misdiagnoses are the most common and deadly of medical errors.

2. The first recommendation of National Academy of Medicine’s report “Improving Diagnosis in Health Care” is to “Facilitate more effective teamwork in the diagnostic process among health care professionals, patients, and their families.” The report specifically recommends interprofessional teamwork, including nursing engagement, in the diagnostic process.

3. Historically, there has been an explicit distinction between nursing and medical diagnoses that makes it abundantly clear to providers that the medical diagnostic process is not a nursing role function, limiting opportunities to actively engage nurses in improving diagnostic safety and quality.

4. Nurses have always played important, tacit roles in medical diagnosis. When triage nurses identify chief complaints and assess illness severity, they are playing a critical role in accurate and timely emergency department diagnosis. Likewise, when hospital nurses on a surgical floor decide whether to call for a physician to assess a patient with pain (rather than treating the patient symptomatically with pain medications), they are playing a critical role in accurate and timely post-operative diagnosis.

5. There are heavily ingrained barriers to full nurse participation in the diagnostic process that must be overcome through innovative changes to nursing education, culture, operations, and logistics.

6. Despite the sociocultural barriers, nurses are ready and able to effectively use diagnostic reasoning skills as full members of the diagnostic team.

7. If nurses are encouraged to practice to the full extent of their training, education, and experience and key barriers are removed, they will be perceived (and will perceive themselves) as integral diagnostic team members.

8. Nurses have been a driving force behind major quality improvement and patient safety efforts, and must take part in helping lead efforts to reduce diagnostic error.

NANDA is not a teaching tool. It is a nursing language and does not represent how a nurse in practice thinks.  This may be one reason why our allied health collaborators rarely read our notes.  It contributes to “failure to rescue” by the nurse when the status of a patient changes and there is no NANDA statement to identify a change of status or care priority.

NANDA is a needed foundational level of thinking that is best suited for beginning students and stable patients with expected outcomes. But just as foundational skills are first taught and then more complex skills are built upon that foundation in nursing education, clinical reasoning is developed into “professional nurse thinking” with the appropriate use of NANDA. Educators should look to see if it's relevant.

It would be interesting to know if the NCLEX contains NANDA related questions!

When doing clinical & teaching how to teach patients, students need to be aware that teaching of patients begins the moment they enter hospital. Unfortunately, most educators & students think patient education begins at discharge. There lies the problem with communication. If we don't communicate properly and in an ongoing fashion with the patient, it only promotes recurring patterns of events or problems after discharge. Teaching and learning should begin through all phases of hospitalization.

Problems frequently occur with transfer from hospital to home care or hospice. New nurses are frequently in the dark about what the transition involves and how to prepare the patient. Nurses need communication skills more than ever, to function as unit between the hospital, hospice, home care, physicians, nurse practitioners, and physician assistants. Hospital nurses need to be informed about resources for lay caregivers & clients.

They should know what equipment will be need in home before discharge. Who pays for it? Most seniors have Medicare which usually pays 80%, leaving 20% for the patient to pay if deductible is met. Part B of Medicare covers certain DME (durable medical equipment) such as wheel chairs, crutches, canes, hospital beds, and walkers. Ironically, Medicare won’t pay for a safety alarm! Medicaid brings in a whole other facet to the cost for eligible patients. Once the inviolate realm of social workers and physical therapists, a patient’s financial well-being falls partially in the bailiwick of the nurse.

Most curricula revolve around nursing in a hospital setting with perhaps a basic course in community nursing. Nurses who work in home care or hospice have accumulated the skills they need while on the job. According to the Centers for Medicare and Medicaid Services (CMS), $102.2 billion was spent on home healthcare in 2018. CMS expects that to increase by about 7% a year by 2027, up from the 4-5% annual increases of the past few years. Some analysts see the industry more than doubling in size by the end of the decade.

Home care nurses should be able to instruct caregivers on how to arrange a room, such as placing the bed within view of a window so they can see the outdoors, changes in weather and day or night; a calendar so they can keep track of the date; organization of equipment arranged so no one trips over it. Will an alarm (bed or chair exit or fire) be necessary? What about a help alarm system? Also, how to get the patient safely out of the room in an emergency (fire, tornado, earthquake).

There needs to be an extra layer of safety provided to nurses, caregivers and educators. Safety in home care situations have changed greatly for the nurse in the last twenty years before everyone carried a cell phone. In the hospital, there are codes for everything. What about home care? With the cell phone, that is now possible if the nurse is facing a dangerous personal situation or her patient is in trouble. Also, with the advent of hidden cameras, the nurse should know she may be recorded during every interaction.

Students need to be informed of what awaits them on the other side of graduation and then vocalize to the school what subjects they’d like to see covered in more detail. After all, even a state-run college is not educating you for free. You are paying for a product and if that product doesn’t meet your needs, it’s time to speak up or look into other schools. 

One of the problems is that there are not enough qualified instructors to teach the number of students applying for admission to nursing schools and the ones we do have are among the aging population. This is in part due to the low pay scale ascribed to college instructors. Again, the answer is to speak up to your school, promote higher wages for our teachers and start campaigns to encourage new grads to choose teaching as their main interest.

There are many more changes I’d like to see in nursing education. It is my opinion that we are creating yet another generation of nurses unequipped to handle the myriad of hurdles they will face once they leave the fairytale-land of school.

© 2022 Guiomar Goransson