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• Volume 26 - 2021
• Number 1: January 2021

Crisis in Competency: A Defining Moment in Nursing Education

Dr. Kavanagh is Associate Chief Nurse for Education and Professional Development, The Cleveland Clinic Foundation in Cleveland, Ohio. She leads the integration, standardization, and advancement of nursing education and professional development for the more than 30,000 caregivers in the Cleveland Clinic Nursing Institute. A former medical-surgical faculty member, Dr. Kavanagh's research addresses quantifying and mitigating the preparation-to-practice gap. In 2013, Kavanagh developed and launched Cleveland Clinic’s first New Graduate Registered Nurse (NGRN) competency-based residency program. The residency program, accredited with distinction by the American Nurse Credentialing Center, is designed to 'meet the learner where they are' and has received national attention as an exemplar in supporting transition-to-practice.

Dr. Sharpnack Is Dean and Strawbridge Professor, The Breen School of Nursing and Health Professions of Ursuline College in Cleveland, Ohio. She has held leadership roles in academia and service for over 40 years. She has extensively published and presented at national and international conferences regarding creative academic strategies for clinical education and transition to practice. A Masters TeamSTEPPS ® Trainer, she serves as a member of the Advisory Board for the American Hospital Association. She is an immediate three term Past-President of the Ohio Board of Nursing and is currently the Board Supervisory Member and Chair of the Nursing Education Advisory Committee.

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Advancing the mission of nursing education for a future we cannot yet fully conceive is a daunting task. The rapidly changing healthcare landscape is an exciting world of innovation, digital transformation, and accelerated knowledge creation that offers hopeful, and infinite possibilities to improve patient care, safety, and outcomes. New data suggest a continuing decline in the initial preparedness of new nurses at a time when preparation is most needed. We must adapt and embrace pedagogies relevant to a new generation of learners. In this article, we first describe the digital disruption informed by innovation moving at warp speed, catalyzing necessary and long overdue change not only in healthcare, but in how education is conceptualized and delivered. Leading and promoting the paradigm shift needed for this change is not discretionary as nurse educators strive to enhance the competency of new registered nurses . Leaders in nursing education have initiated efforts to appraise the state of the academy and find approaches to lessen the transition gap, such as competency-based education. We discuss current trends at this defining moment in nursing education, and strategies to leverage the tipping point as educators mobilize to prepare future nurses for successful collaborative artificial intelligence-infused, clinical practice.

Key Words: nursing education- future of education, preparation-to-practice gap, transition to practice, Performance Based Development System (PBDS), entry-level competency

This new world order shift from sick care to health care generates continued and critical opportunities for nurses to play a vital role... The rapidly changing healthcare landscape is an exciting world of innovation, digital transformation, and accelerated knowledge creation that offers hopeful, and perhaps infinite possibilities to improve patient care, safety, and outcomes. The exponential rate of progress in Artificial Intelligence (AI) and machine learning, along with advances in genetics, genomics, and dramatic enhancements in wearable and implanted sensors, are pressurizing and shifting tectonic plates in every industry ( Marx & Padmanabhan, 2021 ). In healthcare, the changes are massive and, in many instances, long overdue. Reforms include the move from volume to value; from process to a focus on quality and outcomes; from episodic to life cycle care; and from acute care to population health. This new world order shift from sick care to health care generates continued and critical opportunities for nurses to play a vital role in patient safety, advocacy, education, and leadership, regardless of the setting and focus of care.

In this article, we first describe the digital disruption informed by innovation, and the paradigm shift needed for change, particularly to address the continued decline in initial competency of new registered nurses. We discuss current trends at this defining moment in nursing education, and strategies to leverage the tipping point as educators mobilize to prepare future nurses.

Digital Disruption

The worlds of big data, discovery, and innovation are moving at warp speed... The worlds of big data, discovery, and innovation are moving at warp speed, catalyzing necessary and long overdue changes. Changes are happening not only in healthcare, but in how education is conceptualized and delivered, creating opportunities to live and learn in a whole new way ( Carroll, 2021 ; Remtula, 2019 ; Thomas & Rogers, 2020 ; Weston, 2020 ). Klaus Schwab ( 2017 ), Executive Director of the World Economic Forum, has named this epoch of AI, digitization, and biotechnological advances as "The Fourth Industrial Revolution." Schwab ( 2018 ) admonishes that many of our current education systems are already disconnected from the needed competencies to thrive in today's workforce and that the rate of technological innovation and change threatens to widen the gap between education and the demands of practice if we do not respond.

Advancing the mission of nursing education for a future that we cannot yet fully conceive is a daunting task... Advancing the mission of nursing education for a future that we cannot yet fully conceive is a daunting task, but leading and promoting change is not discretionary. To understand digital disruption, the impact on patient care, and the implications for education, we need only look at the worldwide evolution of care delivery already enabled by technology and supported by AI. Digital tools have become ubiquitous and invaluable partners in care; from sensors providing critical patient data, to the Internet of Things (IoT) connecting devices and sensors, to entire hospitals without patients, where interprofessional healthcare teams remotely monitor and care for individuals with complex health challenges in their homes ( Allen, 2018 ). These advances provide a glimpse at the present-day, seemingly futuristic, and evolving skills and competencies necessary to harness technology and enhance the quality of care.

Although healthcare has been relatively slow to integrate robotics, that is rapidly changing. With an aging population, an aging workforce, and a global nursing shortage, the use of robots to perform routine tasks has captured the interest and financial backing of the Japanese government, who generously support technology research that might decrease the high demand for nurses ( Carroll, 2021 ). It is estimated that by 2025 there will be 1.5 billion commercial and industrial robots and that by 2030 industrial robots will replace 50 to 70% of existing jobs ( King, 2016 ).

What an exciting and engaging way to prepare the next generation of nurses! While robots will never replace the registered nurse, they can already support care, follow algorithms, suggest plans of action supported by AI, and perform routine tasks. The Duke University schools of nursing and engineering have previously revealed that Rethink Robotics' Baxter robot could accomplish more than twenty simulated nursing tasks ( Carroll, 2021 ). In The Future is Faster Than You Think, Diamandis and Kotler ( 2020 ) remind us that emerging technology can not only promote optimal patient care, but allows us as educators to create an infinite range of immersive, multi-sensory, experiential teaching-learning environments. What an exciting and engaging way to prepare the next generation of nurses!

The Paradigm Shift

Densen ( 2011 ) accurately predicted that by 2020, medical knowledge would double every 73 days. Today, awash in accelerated knowledge creation and sweeping innovation, professionals in the healthcare and higher education find themselves facing isomer-like challenges to provide value, positive outcomes, access, and affordability for their consumers--or become obsolete ( Kavanagh, 2019 ). This opportunity necessitates a paradigm shift in education that moves us from cohort-based teaching and learning to personalized adaptive learning (AL), focused not on time but competency. The Landscape of Change paradigm shift can be visualized in the Figure 1 .

Figure 1. Landscape of Change

Preparing future nurses as knowledge workers is the required and essential pivot...

Adaptive learning (AL) platforms deliver customized instruction to students based on past knowledge and adjust delivery of content based on distinct preferences and variances in knowledge acquisition ( Hinkle, Jones, & Saccomano, 2020 ; Sharma, Doherty, & Dong, 2017 ). Preparing future nurses as knowledge workers is the required and essential pivot, supported by technology and underpinned by AI. The burgeoning world of AI is positive, disruptive innovation and creates the ability for educators to envision and design individualized AL experiences that will accelerate the pace of learning and potentially, knowledge use ( Hinkle, Jones, & Saccomano, 2020 ; Samadbeik et al., 2018 ).

Strategies such as spaced learning, bridging, and chunking of information are excellent examples of evidence-based tactics to decrease cognitive load and promote memory and learning ( Kelter, Steward & Zamis, 2019 ). Yet, despite the substantial evidence that brain-based, active learning in educational design leads to students engaged in deeper thinking and learning, the move to consistently apply cognitive neuroscience to education remains in the nascent phase of adoption ( Carr & O'Mahony, 2019 ; Deslauriers, McCarty, Miller, Callaghan, & Kestin, 2019 ; Pilcher, 2017 ; Remtula, 2019 ). The thought that these innovative technologies will guide educational transformation assumes that educators will accept and use the evidence, and these technologies, to engage learners.

Research findings have indicated that educators do not quickly accept new technologies. Research findings have indicated that educators do not quickly accept new technologies. Even when they do, they are used to support prevailing teaching practices, rather than to develop new pedagogies ( Grainger, Liu, & Geertshuis, 2020 ). In just a few short years, the digital revolution fueled by AI will be commonplace; but will we be ready? The time is now to embrace digital disruption, including immersive learning technologies that can transform education.

Virtual reality (VR), augmented reality (AR), and mixed reality (MR) technologies enable users to interact with and control virtually displayed components within virtual and physical environments ( Carroll, 2021 ; Remtula, 2019 ; Weinstein, Madan & Sumeracki, 2018 ). These rich, immersive technologies will continue to evolve as powerful and essential tools in clinical education. This shift requires a holistic view of education and pedagogies that empower both students and faculty as life-long learners. Education scholar Dennis Shirley ( 2017 ), author of The New Imperatives of Educational Change , reminds us of the power of the present moment. There is cause for hope and optimism, but past success does not entitle us to future success; we must plan for success and move quickly.

Declining Initial Competency of New Registered Nurses

Jim Collins ( 2001 ), famed author of Good to Great , cautions that if success is ones' goal, one must first ask, what are the brutal facts - not what are our opinions, but what are the facts? If we do not confront the facts, they will surely rise-up and confront us. While we continue to appreciate the many in-roads and tangible signs of excellence in the evolution of teaching and learning, from flipped classrooms to simulation and standardized patients; from monologue to dialogue and Socratic method; to makerspaces and virtual learning, there remains substantive work yet to be considered ( Forneris, 2020 ).

...practice is evolving faster than education can respond As educators, we must address the brutal facts of failing to prepare graduates as residency-ready and confront the issue that the academic, or preparation-to-practice gap, is increasing despite current efforts. While we continue to explore and research how best to prepare nurses for practice, Ironside ( 2008 ) conceded long ago that practice is evolving faster than education can respond. Our current educational model, developed in the 19th century, is obsolete ( Gidley, 2016 ). Gidley ( 2016 ) argued that we are unable to solve tomorrow's problems with yesterday's thinking.

We suggest that tomorrow's problems are already here. Transforming nursing education to meet the technologically savvy, digital native students of today requires embracing the capacity of technology to transform education ( Clark, Glazer, Edwards, & Pryse, 2017 ). We must shift to a post-formal pedagogy to prepare students for the higher-order thinking and knowledge work required for today's clinical practice ( Forneris & Fey, 2018 ).

New data suggest that we are continuing to lose ground in the preparedness of New Graduate Registered Nurses (NGRNs) at a time when it is needed most. Initial competency of NGRNs is declining at an alarming rate, slightly exacerbated by the impact of the COVID-19 pandemic as many traditional in-person clinical and classroom experiences have been adapted or abbreviated. In her seminal work, del Bueno ( 2005 ) shared aggregate national data on initial NGRN competency for all hospitals utilizing Performance Based Development System (PBDS), an assessment del Bueno designed to identify growth opportunities in critical thinking and provide insight into the thought processes of the NGRN. Del Bueno ( 2005 ) reported that 35% of NGRNs assessed as safe or in the acceptable range. Kavanagh and Szweda ( 2017 ) documented a decline in initial competency with assessments of more than 5,000 NGRNs from 2011-2015, from more than 140 nursing programs in 21 states, with 23% scoring in the acceptable range for a novice new nurse. Current aggregate assessment data utilizing the same PBDS assessment collected between 2016-2020 on more than 5000 NGRNs indicate that 14% of them demonstrated entry-level competencies or readiness for residency , and 2020 YTD graduate data (n=1222) from 200 unique schools of nursing display an even more disturbing decline, with only 9% of NGRNs in the acceptable competency range for a novice nurse.

A decade of PBDS assessments...reveals an alarming year-over-year decline in initial competency A decade of PBDS assessments representing more than 10,000 NGRNs reveals an alarming year-over-year decline in initial competency. PBDS assessments are administered post-hire but prior to orientation to ensure that results are indicative of the time before patient care initiation and that orientation and residency are not cofounding variables in the assessment results. Although the assessment is only one data point, it captures a snapshot of NGRN initial competency after graduation and, in most instances, post successful completion of the NCLEX.

The PBDS assessment is a valid and reliable tool ( del Bueno, 2001 ). The tool has not changed over time, other than updating clinical scenarios to reflect modern equipment and technology. The subjects in data collection from 2016-2020 included 60% holding a BSN; 35% an ADN; 1% a diploma; and 1% were MSN graduates. Consistent with earlier findings from del Bueno ( 2005 ) and Kavanagh and Szweda ( 2017 ), there was no difference in assessment ratings regardless of the type of nursing program. Site-specific aggregated PBDS assessment data is depicted in the Table . Aggregate data (2016-2020) indicated 14% of NGRNs assessing in the acceptable range; 29% failing to recognize urgency or a change in a patient's status; and 57% demonstrated opportunities for growth in the management of patient problems, including selecting the proper nursing interventions, communication of relevant data to the Licensed Independent Professional (LIP) and rationale for nursing actions.

...there was no difference in assessment ratings regardless of the type of nursing program The 2020 aggregate PBDS data includes an n of 1222, with less than 10% assessing in the acceptable range. When further subdivided to isolate the April/May 2020 graduates who experienced the impact of limited clinical experiences (sample size of 626), 7% assessed in the acceptable range for a novice nurse and 40% assessed in the lowest domain, failing to recognize urgency or a change in a patient's condition. In sum, evidence supports a continued decline in the competency of HGRNs.

Table 1. Site-Specific PBDS Assessment Data

Leveraging the Tipping-Point

The crisis in initial competency of NGRNs must not become a portent of patient safety challenges and NGRN success. In a day when we can transplant a face, a heart, or a uterus, we can certainly design and create processes and grow cultures where patients come first and safety always is a living breathing testament to our great profession's commitment to patients and nurses alike. Whether one's primary role is in academe or practice, five critical sub-narratives demand our reflection and re-evaluation. These sub-narratives include an acceptance of the chasm between academe and practice and the resultant challenge deemed inherent and inevitable in transition-to-practice (TTP); accountability for success and what NGRN residency-readiness requires; speed of learning, education transformation, and moving innovations to scale; the impact of digital disruption, and finally, the divide and inequality in education.

We need only look to the past ten months to marvel and celebrate the victories, the quick pivots in unchartered territory. In this, the International Year of the Nurse and Midwife ( WHO, 2020 ), the challenges before us are vast and complex. However, we argue that these challenges are ours to embrace. This is our moment, our time! As nurse leaders, we have the power to either build excitement and anticipation about change, about ongoing and much-needed education transformation, or potentially contribute to stress, anxiety, and even disengagement. We need only look to the past ten months to marvel and celebrate the victories, the quick pivots in unchartered territory. Most academic programs moved from in-person to virtual learning, from in-person clinical to virtual simulations mapped to the curricula within just a few days! Technology was readily incorporated and enhanced remote student classroom experiences introduced as the new normal in instructional design. Agility by fire, and yet we prevailed!

Despite each of these successes, the COVID-19 pandemic added to the chasm in NGRN preparedness. While no one can predict the longitudinal consequences of the pandemic with certainty, there is no question that healthcare and education responded in a profound and remarkably swift way. The demonstration of agility in a time of crisis dissolves long-held assumptions about how much time progress takes ( Berwick, 2020 ), particularly in higher education. The success of an agile and thoughtful response in a time of crisis, albeit not perfect, brings honor to us all and hope for the future.

The demonstration of agility in a time of crisis dissolves long-held assumptions about how much time progress takes... Leaders in nursing education have initiated efforts to appraise the state of the academy and find approaches to lessen the transition gap. Nursing education reform is indebted to the iconic work of Dr. Patricia Benner, whose contributions from the Carnegie Foundation Preparation for the Professions research fueled the celerity of education reform ( Benner, Sutphen, Leonard, & Day, 2010 ). In the past few years, we have seen increasing attention addressing the development of critical thinking, clinical judgment, and clinical reasoning in our pre-licensure nursing students. Significant trends in higher education that foster higher-order thinking include moving from structured, cohort-based education to a personalized, individualized, adaptive learning approach, such as smart book technology and virtual on-screen simulation like NovEx, that adapts information to the learner's progression ( Santos, 2013 ; Hooper-Kyriakidis, Ahrens, & Benner, 2017 ; Benner, 2020 ).

Another major trend gaining traction is the severing of time, measured in credit hours, from learning and competency. In a traditional academic environment, programs of study are delineated by credit hours that equate to time spent either in class or online. The credit hour, initially conceived a century ago by the Carnegie Foundation to describe educators eligible for pensions, grew into an easily understood and adopted method to track academic progression, financial aid, and faculty workload. However, no evidence exists that the credit hour and time spent in class or online equates with learning ( Laitinen, 2012 ; Kirst & Stevens, 2015 ; Robinson, 2018 ). The 2015 Carnegie Foundation report on the 'Carnegie Unit,' concluded that although flawed, the credit hour remains a necessary model. Laitinen ( 2012 ) urged that the credit hour is negatively impacting our nation's workforce and that, as the cost of education soars, federal policy needs to shift from paying for and valuing time to paying for and valuing learning.

Leaders in nursing education have initiated efforts to appraise the state of the academy and find approaches to lessen the transition gap. Competency-based education (CBE) is gaining momentum buoyed by the 2013 Department of Education Experimental Sites program success, which allowed select institutions to grant credit through competency-based assessments ( Cunningham, Key & Capron, 2016 ; Silva, White & Thomas, 2015 ). Although CBE and direct assessment are in the earliest phase of development, the transition from time-based to competency-based assessment is a movement whose time has come ( Johnson, 2017 ; Josiah Macy Jr. Foundation, 2017 ; Robinson, 2018 ). To date, the United States Department of Education has granted approval for almost 200 universities to offer some form of CBE, and the Higher Learning Commission has embraced CBE as the future of academic preparation ( Nodine, 2016 ; Silva et al. 2015 ).

The magnitude and significance of Benner's ( 2010 ) call for radical transformation and her innovative work to elucidate the current science of teaching and learning has been compared to Abraham Flexner's report ( 1910 ) on medical edition. Benner's findings spurred leaders from national nursing organizations to examine the current state of academia and initiate much needed change efforts. The National League for Nursing's (NLN) strategic educational resources, the National Council of State Boards of Nursing's (NCSBN) work to design a psychometrically sound and legally defensible Next Generation NCLEX ( Dickinson, Haerling & Lasater, 2019 ) to assess higher-order thinking better and thus, preparedness for practice of new graduates, and more recently, the American Association of Colleges of Nursing's (AACN) call for reformation of nursing education are substantial attempts to mitigate the NGRN competency gap.

Competency-based education is gaining momentum... The AACN Vision for Academic Nursing ( 2019 ) white paper addresses fundamental academic failings. It proposes an action plan to meet the needs of a dynamic, global society and a diverse patient population ( AACN, 2019 ). The report identifies several trends and changes that inform nursing education. These include a changing higher education climate; competency-based education; learners who hail from diverse backgrounds and generations; advances in neuroscience that have resulted in the development and adoption of innovative educational technologies; a rapidly evolving healthcare system with a shifting workforce; an aging faculty; and the ongoing evolution of regulatory bodies ( AACN, 2019 ). The overarching goals described in the AACN vision statement align with the changing healthcare landscape and accountability for residency-ready graduates. Strengthening academic-practice partnerships, accelerating diversity and inclusion through holistic admission policies, improved faculty development through a greater understanding of the neuroscience of learning, efficient use of resources, and competency-based education and assessment are central to these recommendations.

The overarching goals described in the AACN vision statement align with the changing healthcare landscape and accountability for residency-ready graduates. While the recommendations are intended to be realized as a compendium, it will take time to fully engage the academic community in these initiatives. Innovative thinking and approaches to preparing the nursing workforce of tomorrow are critical if nursing education is to meet the public demands for graduates to be able to know and do the work of nursing ( AACN, 2020 ). The Essentials: Core Competencies for Professional Nursing Education, the framework proposed to supersede the current BSN, MSN, and DNP Essentials documents, is informed by the lived experiences of nursing practice where there is a fusion of knowledge and action ( AACN, 2020 ).

The foundational elements of the new recommendations are built upon nursing as a discipline, the underpinning of a liberal arts education, and competency-based education principles. While considering the vital preparation for a residency-ready graduate, additional elements have shaped the proposed essentials document. These include diversity equity and inclusion, spheres of care, academic partnerships, systems-based practice, technology and informatics, consumerism, and career-long learning ( AACN, 2020 ). The goal is to prepare a generalist who can practice in any setting through mastery of competencies. Scaffolding and measuring these competencies will require nurse educators to foster higher-order thinking. Common competencies for NGRNs will demonstrate the effectiveness of educational programs and assure the public of a graduate's capability.

The goal is to prepare a generalist who can practice in any setting through mastery of competencies. Advances in teaching-learning technologies and strategies, shifting learning styles of students, and the push for outcome-based education all point to the necessity of competency-based education ( AACN, 2020 ). Public demand for accountability in the health professions is propelling the shift toward CBE ( Englander et al., 2013 ). Nevertheless, there exists no common taxonomy for domains of competence for health professions. Methods to best measure competency in nursing education need further exploration and a design that will challenge students and prepare them for practice. Rigorous quantitative and qualitative research must be conducted to determine the reliability and validity of CBE ( Gravina, 2017 ).

Public demand for accountability in the health professions is propelling the shift toward CBE Bridging the gap between CBE, practice, and implementation of knowledge, skills, and attitudes, has been explored by implementing Entrustable Professional Acts (EPAs) in medical education ( Wagner, Dolansky, & Englander, 2018 . Entrustable Professional Acts are units of professional practice, defined as tasks or responsibilities, to be entrusted to the unsupervised execution by a trainee once they have attained a specific competence. They are not an alternative for competencies but a way to translate competencies into clinical practice ( Cate, 2016 ). Similar to the revised Healthcare Quality Competency Framework that guides academic institutions to reduce variability in quality competencies and supports workforce readiness and effectiveness in healthcare quality ( NAHQ, 2020 ), sequencing domains of competence of increasing difficulty, risk, or sophistication can serve as a practical approach to integrate competencies in nursing.

They are not an alternative for competencies but a way to translate competencies into clinical practice Competency-based education will require novel approaches to enhance nursing education using technology. Integrating technology into nursing curricula improves efficiency and enhances student experiences, accomplished primarily through active learning and interactive learning designs ( Luo &Yang, 2018 ). The development of augmented, mixed, and virtual reality simulation offers an opportunity for focused application-based learning ( Fertleman et al., 2017 ). Foronda and colleagues ( 2017 ) argued that using these realities may influence the length of the learning curve, reduce practice time, and enhance learning outcomes ( Foronda et al., 2017 ). Augmented or mixed reality tools such as Microsoft HoloLens ® , and virtual simulations such as vSims ® created through a partnership with Laerdal ® , Wolters Kluwer Health ® , and the NLN have already been integrated into nursing programs to augment existing teaching-learning practices.

AI is being used to create virtual patients (VP) scenarios that improve interactions with patients, the interprofessional team, and nursing colleagues. These scenarios enhance self-efficacy and confidence in effective communication skills. Academe must support the technological and digital transformation to foster student success, improve the TTP outcomes, and provide foundational and advanced faculty development that fosters the adoption of a new educational paradigm.

...the requirement to strengthen interprofessional educational opportunities intensifies the prerequisite of a common language for outcomes for each discipline. Finally, the requirement to strengthen interprofessional educational opportunities intensifies the prerequisite of a common language for outcomes for each discipline. The Joint Commission ( 2017 ) has cited communication failures among interdisciplinary team members as the most common root cause of sentinel events and pronounces the inability to communicate and work effectively in teams as a significant threat to patient safety. Foundational competencies commonly understood by all professionals will support appropriate role expectations and predictable outcomes and, arguably, improved teamwork and collaboration.

The 2010 Institute of Medicine report argued that entry-level nurses must be able to efficiently transition from their academic preparation to a range of practice environments, with an increased emphasis on community and public health settings ( IOM, 2010 ). Ten years have elapsed without discernable change in our outcomes, based upon quantifiable outcomes of preparedness for practice or residency. Given the COVID-19 pandemic, one could contend that we lost ground. Despite advances in technology, in practice, and accessibility, nursing education struggles to own the outcomes of the graduate nurse.

We have an unprecedented opportunity to become architects to advance nursing education in a digital age! The initiatives proposed by AACN may provide an opportunity to re-examine our efforts. Nurse educators must mobilize to prepare future nurses for successful, collaborative, AI-infused, clinical practice. The call for transformation is more robust because of the pace of change and obvious gaps that can no longer be tolerated. We must adapt and embrace pedagogies relevant to a new generation of learners and a new world order replete with quantum leaps in technology, addressing each student as a unique learner ( Hopkins et al. 2018 ; Presti & Sanko, 2019 ). Risling ( 2017 ) warns that the evolving technological advances will necessitate responses and navigational shifts, unlike any that we have ever negotiated. The time is now. We have an unprecedented opportunity to become architects to advance nursing education in a digital age!

Ludvik reminds us that the requisite demonstration of whether learning can be applied in "real-life" contexts requires collaboration with the professionals who will either hire the students or admit them into ongoing professional or academic degree programs ( 2018 , p. 13). Whether our primary role is practice or academe, we are called to evolve from the perspective that an educator's job is just one part of the whole, to the belief that the job is a system. Practice and academe must work together as a system supporting student success and that of the eventual NGRN, a collaborative belief long held but infrequently realized. Almost five decades ago, Myrtle Aydelotte ( 1972 ), founding Dean and Professor at the University of Iowa College of Nursing, shared: "What is needed is a reexamination of nursing leadership and a new thrust forward. Nursing leadership must reorient itself and restructure itself in such a way that nursing education and practice are inseparable, are symbolic, and are united in purpose" ( 1972 , p.23). That defining moment is now.

Joan M. Kavanagh, PhD, MSN, RN, NEA-BC, FAAN Email: [email protected]

Patricia A. Sharpnack DNP, RN, CNE, NEA-BC, ANEF, FAAN Email: [email protected]

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January 31, 2021

DOI : 10.3912/OJIN.Vol26No01Man02

https://doi.org/10.3912/OJIN.Vol26No01Man02

Citation: Kavanagh, J.M., Sharpnack, P.A., (January 31, 2021) "Crisis in Competency: A Defining Moment in Nursing Education" OJIN: The Online Journal of Issues in Nursing Vol. 26, No. 1, Manuscript 2.

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Educating the nurses of 2025: Technology trends of the next decade

Affiliation.

• 1 University of Saskatchewan, College of Nursing, 4218 Health Sciences Building, E-Wing Clinic Place, Saskatoon, SK S7N 2Z4, Canada. Electronic address: [email protected].
• PMID: 28049072
• DOI: 10.1016/j.nepr.2016.12.007

The pace of technological evolution in healthcare is advancing. In this article key technology trends are identified that are likely to influence nursing practice and education over the next decade. The complexity of curricular revision can create challenges in the face of rapid practice change. Nurse educators are encouraged to consider the role of electronic health records (EHRs), wearable technologies, big data and data analytics, and increased patient engagement as key areas for curriculum development. Student nurses, and those already in practice, should be offered ongoing educational opportunities to enhance a wide spectrum of professional informatics skills. The nurses of 2025 will most certainly inhabit a very different practice environment than what exists today and technology will be key in this transformation. Nurse educators must prepare now to lead these practitioners into the future.

Keywords: Curriculum development; Informatics; Technology.

Copyright © 2016 Elsevier Ltd. All rights reserved.

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7 Key Challenges Faced by Nurse Educators Today

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America is in the middle of a severe and long-standing nursing shortage. It is threatening the supply of registered nurses. The shortage has also affected the number of clinical preceptors and nursing faculty who prepare nursing students.

Nursing school enrollment cannot grow fast enough to meet the projected need. The shortage of nursing school faculty members has also limited enrollment numbers.

Nurse educators often are active clinicians, which is important to maintain quality nurse teaching . However, this also places a strain on educators with higher workloads, forcing them to work short-staffed in practice and education.

These stressors have led to a crisis in the profession. More nurses and nurse educators are seeking positions outside of nursing and feel less committed to their profession than in the past.

We interviewed several influential nurse educators who shared the challenges they face. We also explore the changes needed to improve the system and how nurses can advocate for those changes.

Nurse Educators Face Challenges Due to Nursing Shortage

The nursing shortage is expected to worsen as the baby boomer generation ages and more nurses retire. According to the American Association of Colleges of Nursing (AACN), faculty staff shortages limit student capacity at a time when growth is necessary.

There is a critical need to increase the number of nurse educators to meet the demand, but nurse educators are also under a lot of stress. To retain experienced educators and preceptors, it’s important to support their efforts.

Many challenges affect educators today. Nurse educators identified the following challenges that affect their ability to nurture and educate the future generation of nurses.

1. Lack of Resources

Nurse educators are well aware of a faculty shortage in programs around the country.

• Schools were forced to turn away 80,407 qualified students from undergraduate and graduate programs in 2019. This is an increase from the 68,000 turned away in 2014.
• In one survey of 892 nursing schools, 1,637 vacancies were identified. There is also a need to create an additional 134 positions to accommodate the rising demand.

Erica Jastrow has been a nurse educator for over 17 years and sees firsthand the lack of human resources in nursing facilities.

“In some schools,” she says, “faculty members manage all aspects for the nursing program from admissions, to advising, to instruction.”

This lack of human resources places additional stress on stretched-thin faculty members with limited time and resources. In addition to the faculty who have reached retirement age, other nurse educators are leaving the profession, furthering the issue.

Anne Dabrow Woods has witnessed and experienced the challenges facing faculty. She teaches in the graduate program at Drexel University and says it is imperative we address the issues faced by educators today.

Woods says we must:

• Increase nurse educator salaries and pay them what they are worth
• Provide learning opportunities for adjunct faculty
• Use academic and practice partnerships to develop and fund adjunct faculty programs.

2. Curriculum Challenges

Sherri Wilson, DNP, is the director of health career programs at Stride, a provider of tech-enabled education programs. She identifies several curriculum challenges that impact new nursing students and teaching faculty.

Students must overcome several barriers just to enroll in nursing programs. Once accepted, they face additional challenges to succeed in the program. Some students don’t have the tools they need, and others may not understand what the career involves.

Wilson suggests starting early by offering ways high school students can prepare for a nursing career . Students may learn more through classwork, clubs, mentorship, or dual enrollment.

“The sooner we can introduce students to the prerequisites, requirements, and opportunities in nursing and nurse education, the better,” she says.

Nurse educators also face curriculum challenges. Most programs are seeking faculty with doctorates. According to the Special Survey on Vacant Faculty Positions in 2019 reported by the AACN, 89.7% of faculty openings required or preferred a doctoral degree.

Wilson notes that doctorates are either research focused or clinical focused. Yet most programs do not include substantial academic coursework to prepare graduates for a teaching or faculty role, she says. It is necessary to reevaluate the curriculum used to teach future teachers.

3. Representation in Faculty and Training

Wilson also seeks representation of different cultural backgrounds in faculty and preceptors. A recent AACN study found that 93% of full-time faculty were female, and only 17% were from underrepresented groups.

“A more diverse nursing faculty can help to broaden the perspectives of nursing students and can provide sources of mentorship for minority nurses,” Wilson says.

The recent Future of Nursing Report 2020-2030 explored how the profession could develop different curricula. The goal would prepare nurses to reduce health disparities and inequities, like how nurses can address disparities in infant mortalit y, by using cost-effective strategies. These include technology and maintaining patient- and family-focus care.

To address these issues, there needs to be better representation in nursing and cultural competence in nursing . With a diverse workforce, nurses can serve communities better by understanding and identifying the social determinants of health.

“Finding ways to connect more nursing students to learning opportunities in the communities they serve will empower them to work with people of different backgrounds and from various life experiences,” Wilson says.

4. Fostering and Maintaining Student Relationships

Student-teacher relationships are important from elementary school through graduate school. They lead to:

• Academic achievement
• Increased motivation to learn
• Professional student development

Yet, stressed and overworked faculty often have little time to build constructive and authentic relationships with their students.

The lack of student-teacher relationships may have an unfortunate trickle-down effect on some students’ future career development. It could discourage students from furthering their education and choosing a career as a nurse educator.

Strong student-teacher relationships can help bridge the gap and support students’ efforts. Some students are working in healthcare while completing their education. Mandated hours or extra shifts are obstacles to completing assignments, maintaining grades, and attending class.

“Showing a student that you care about them and are there to support them may make the difference between a student who drops out or fails in the program and one that is successful,” Jastrow says.

5. Pay Inequality

Pay inequality in nurse educator roles is a significant obstacle to attracting new faculty. According to the U.S. Bureau of Labor Statistics , the median salary for a nurse educator is $75,470.

Nurses with comparable education levels make far more than nurse educators, with nurse practitioners making $114,510 annually , on average. This pay deficit causes master’s- and doctoral-level nurses to not pursue nurse teaching.

It is crucial that the compensation for nurse educators match their experience and education. This will help to attract quality faculty to nursing programs.

H. Eva Hvingelby is a faculty member at Walden University and clinical advisor at Optum. She sees the challenges with pay inequality and the need for immediate change.

She says that higher educator pay and smaller teacher-to-student ratios will make training new nurses more attractive to clinicians. But these adjustments will not come easily.

“While it is difficult to implement these changes when there is already an acute shortage,” she says, “not doing so risks further loss of capable personnel, worsened patient outcomes, and higher healthcare costs.”

6. Lack of Preceptors

Nurse educators and nursing students are impacted by the lack of preceptors available to nursing students. The nursing shortage has meant that many nursing units work short-staffed with higher than normal staff-to-patient ratios.

Nursing preceptors are a guiding hand and a steady voice for nursing students. When there is not enough available or low staffing, it can impact the quality of a nursing student’s education or new nursing graduate.

Tony Anno is a core faculty member at Walden University. He says online and traditional classroom learning face challenges from the restrictions and lack of access to clinical sites and preceptors.

However, nursing programs have a role in addressing the shortage in innovative ways.

For instance, Anno notes that Walden University has identified areas where students could complete some or all of their clinical hours using telehealth nursing services .

7. Lack of Opportunity to Update Knowledge and Skills

The nursing shortage in academia and clinically has stretched nurse educators’ resources thin. Nurse educators do not have the time to update their knowledge and skills.

This lack of opportunity was the most frequently described frustration for clinical nurse educators in one study. Additionally, this can contribute to the rising levels of nursing burnout as it contributes to nurse educators’ acute and chronic stress levels.

One study confirmed what most nurse educators know: Nurses value professional development and believe it is integral to improving patient care standards.

Access to continuing education for nurses to update knowledge and skill levels helps maintain high standards of care. This is essential when educating and training the next generation of nurses.

“Universities, as well as hospital systems and other healthcare providers, should look for ways to continually upskill their existing workforce and faculty on the latest practices and technologies,” Wilson says.

Wilson stresses the need for continued education and skill development in the face of rapidly changing technology. Nurse educators are expected to possess these skills to advance quality and address emerging needs.

What Needs to Change and How Nurses Can Get Involved

Despite challenges during the pandemic, turning away thousands of qualified candidates, and a shortage of nurse educators, enrollment in nursing programs across the country was up by 5.6% in 956 programs surveyed. However, significant changes must be made to raise enrollment and fill open nursing positions.

The pandemic has highlighted long-standing issues in healthcare that have contributed to the nursing shortage. Wilson says nurses are currently “uniquely positioned to become involved in the policy process to advocate for resources to address this complex issue.”

Woods believes the answer lies in innovation, perseverance, and resilience.

“Given this landscape, investing in learning technologies is no longer a ‘nice to have’ for nursing education but truly essential,” she says.

With the increased adoption of educational technology, we will also see a shift in funding to address previous hurdles that nurse educators faced in accessing these technologies, Wilson says.

What Needs to Change to Increase the Nurse Educator Retention Rates

• Bridge the wage gap between clinical roles and educators, so salaries align with other nurses holding graduate and doctoral degrees.
• Reduce teacher-to-student ratios to improve education and make the nurse educator role more attractive to clinicians.
• Better prepare nurse educators in their master’s or doctoral programs with academic coursework to prepare them for a teaching role.
• Increase human resource support for admission and advising so faculty can focus on teaching.
• Value the time and effort necessary to foster better student-faculty relationships, which improves a student’s education and faculty job satisfaction.
• Provide recognition for faculty members within the nursing program.
• Offer nursing scholarships that encourage students to pursue positions as nurse educators.
• Improve clinical working conditions, staff ratios, and work-life balance for nurses and nurse educators.
• Give faculty the opportunity and time to update their knowledge and skills.
• Partner academic centers with healthcare systems to develop adjunct faculty training programs.
• Invest in better mental health resources for nurses and nurse educators.
• Invest in innovation technologies.

Nurse educators can advocate for change and promote ways for nurses to effect change in their profession. They can provide information and perspective from professionals working in the field through taking advantage of professional nursing associations and advocacy groups.

Often involvement does not require hours of time and energy but rather phone calls and emails to state legislators to support or defend policy change.

Nurse educators may also consider working with the administration in their program to use creative strategies to meet the needs of the students and faculty.

It can be challenging to push for change. Yet, many colleges and universities are now recognizing the need for innovation to reduce the nursing shortage and attract qualified nurses as teachers and faculty.

Meet Our Contributors

Sherri Wilson, DNP

Sherri Wilson oversees the development and implementation of curriculum and partnerships in the healthcare field as director of health career programs at Stride, Inc. – a provider of tech-enabled education programs. Prior to joining Stride, Wilson served as a public health administrator with Fairfax County.

Wilson earned her doctor of nursing practice from Johns Hopkins University, a master’s in public administration from Seton Hall University, and a bachelor of science in nursing from Hampton University. In 2021, Wilson was named president-elect of the Virginia Nurses Association.

Erica L. Jastrow, Ed.D., MSN, RN, CNE

Erica Jastrow has been a registered nurse for over 20 years and a nurse educator in higher education for over 17. She has led several prelicensure nursing programs and currently serves as an assistant professor and RN-to-BSN program director at William Peace University . She has a BSN from Lenoir Rhyne University, an MSN in nursing education from UNC-Greensboro, and a doctorate in education from Grand Canyon University.

Tony Anno, DNP, ACNPC-AG, AGACNP-BC, CCDS, CEPS, RDCS, FHRS

Tony Anno is a core faculty member in Walden University’s master of science in nursing program. Anno currently practices in cardiology/electrophysiology at the Kansas City VA Medical Center and volunteers as the sole provider for Health Partnership Clinic. The clinic provides healthcare to patients regardless of income or insurance status.

Anno is certified by the International Board of Heart Rhythm Examiners as a certified cardiac device specialist and certified electrophysiology specialist. He is also a registered cardiac diagnostic sonographer.

H. Eva Hvingelby, Ph.D., ACNP

H. Eva Hvingelby is a faculty member in Walden University’s master of science in nursing program and a clinical advisor for Optum. She has 21 years of experience as a healthcare clinician. In addition, she spent seven years with the federal government researching and supporting outreach to marginalized populations. Hvingelby consults on strategies to improve clinical communication and collaboration across disciplines.

Anne Dabrow Woods, DNP, RN, CRNP, ANP-BC, AGACNP-BC, FAAN

Anne Dabrow Woods is the chief nurse at Wolters Kluwer, Health, Learning, Research and Practice . She drives the strategic development of evidence-based solutions for nurses and nursing institutions. A nurse for over 37 years and a nurse practitioner since 1998, Dabrow Woods currently practices as an acute care/critical care nurse practitioner at Penn Medicine, Chester County Hospital. She also teaches in the graduate nursing program at Drexel University as clinical adjunct faculty.

Dabrow Woods earned a bachelor’s from West Chester University, a master’s from LaSalle University, a postmaster’s certificate from Drexel University, and a doctor of nursing practice from Texas Christian University. She is also a fellow in the American Academy of Nursing.

Page last reviewed December 16, 2021

• Open access
• Published: 15 August 2024

Nurturing ethical insight: exploring nursing students’ journey to ethical competence

• Sylvia Hansen   ORCID: orcid.org/0009-0003-8733-6892 1 ,
• Elisabeth Hessevaagbakke 1 ,
• Katrin Lindeflaten 1 ,
• Kaja Elvan 1 &
• Daniela Lillekroken 1  

BMC Nursing volume  23 , Article number:  568 ( 2024 ) Cite this article

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Metrics details

Ethical competence is a key competence in nursing and the development of the competence is a central part in nursing education. During clinical studies, nursing students face ethical problems that require them to apply and develop their ethical knowledge and skills. Little is known about how ethical competence evolves during students’ initial clinical placements. This study explored the development of ethical competence in first-year nursing students during their first clinical placements in nursing homes.

This exploratory-descriptive qualitative study used focus group interviews to collect data and a phenomenological hermeneutical method for analysis. Twenty-eight first-year nursing students participated in six focus groups. The data were collected between March and April 2024 at Oslo Metropolitan University in Norway.

The naïve reading of the data involved an awareness of the students applying their prior knowledge, modifying their prior knowledge and developing skills that allowed them to manoeuvre ethical practices that, in some cases, appeared excellent and, in other cases, grim. The structural analysis identified three themes: (i) ethical competence forges in practice, (ii) ethical competence evolves at the intersection of knowledge and skills and (iii) ethical competence unfolds through meaningful discussions. A comprehensive understanding of the data was formulated as ‘Being on a journey towards ethical competence’. This presents a metaphor illustrating that nursing students embark on a journey towards ethical competence; from their point of departure, their clinical experiences forge the essential waypoints along their path, knowledge and skills fuelling their navigation in rugged terrain towards their destination.

Conclusions

Nursing students’ ethical competence evolved in intricate ways during their initial clinical period. Being informed bystanders or participants in the care of nursing home residents in situations of ethical tension may be a unique position enabling students to evaluate care options differently from those immersed in the ward culture. The findings indicate that organised professional development in nursing homes needs to focus on more reflexively driven ways of supervising students in their first clinical study period. Educational institutions need to continue and further develop reflection-based learning activities and meeting points with students and their peers during their clinical placement periods.

Peer Review reports

Ethical competence is at the core of nurses’ integrity [ 1 ]. The overall aim of nursing is to deliver proficient healthcare services. However, the assessment of how services are delivered requires value-based and ethical inquiry [ 2 ]. Practicing nursing with integrity amid the complex moral choices and pressures that nurses confront on a daily basis is challenging [ 3 ]. Not living up to the ethical standards of nursing puts patients’ well-being at risk and is associated with human costs on patients’ behalf [ 4 ]. Furthermore, violating the ethical standards of nursing is also associated with moral injury [ 5 ]. To ensure high ethical standards in nursing, it is essential to enhance ethical training in the curriculum [ 6 , 7 , 8 ]; this training aims to cultivate moral qualities in students, preparing them for their roles as nurses. Being a ‘good’ nurse requires not only procedural skills and clinical reasoning but also strong moral qualities and ethical reasoning.

Improvements in nursing students’ ethical competence can positively affect appropriate and timely clinical outcomes [ 7 ]. The ways in which nursing and other healthcare professions educational institutions organise and implement learning activities to promote students’ ethical competence vary, and different approaches may yield diverse results [ 9 , 10 , 11 , 12 , 13 , 14 ]. However, the experiences students in the healthcare professions gain through their clinical studies substantial impact their learning outcome [ 15 , 16 ]. According to Mezirow [ 17 ], encountering a real ethical problem initiates an inner process that is essential to the development of ethical competence. The process consists of two steps. First, one identifies the problem at hand. Then, the essence of the problem is mirrored in the self, and ethical reflection and assessment starts as an attempt to identify just solutions.

In Norway, although learning activities vary from institution to institution, a key requirement in the curriculum for a bachelor’s degree in nursing is that graduates are qualified to reflect on and handle ethical problems in their professional roles. Additionally, they must be qualified to plan and implement respectful, collaborative and comprehensive interactions with patients and the patients’ next of kin [ 18 ]. By their nature, these qualifications are related to clinical skills. Therefore, training and guidance to achieve mandatory qualifications cannot be separated from clinical studies, which make up 50% of the total study hours in nursing education in Norway.

In the bachelor’s programme in nursing at Oslo Metropolitan University [ 19 ] in Norway, nursing students’ ethical training during clinical studies emphasises developing ethical competence through a discursive model of ethical reflection. This model, which is known as the Center for Medical Ethics model, or the CME model [ 20 ], is extensively utilised across interdisciplinary settings in Norwegian health service settings. The application of ethical decision-making models is a widely used method for systematic training as a way to enhance ethically justified reasoning and well-grounded decision-making [ 21 ]. The CME model equips students with a practical and applicable tool for developing ethical competence. The model is considered to be well suited because of its relatively simple structure and ability to apply knowledge and assessment directly to subject matter and practical solutions. Furthermore, using the model enhances discourse and diversity in the structured process of addressing ethical and legal problems.

Over the years, researchers have conducted studies to better understand the concept of ethical competence in healthcare professionals. A review conducted by Kulju et al. [ 22 ] aimed to analyse the concept of ethical competence in the context of healthcare. Based on the results, ethical competence can be defined in terms of character strength, ethical awareness, moral judgement skills and willingness to do good. Virtuous professionals, the experience of professionals, human communication, ethical knowledge and supporting surroundings can be seen as prerequisites for healthcare personnel to develop ethical competence.

In an integrative review, Lechasseur et al. [ 23 ] aimed to clarify the concept of ethical competence, identifying six distinct yet interconnected components related to the concept: ethical sensitivity , the ability to recognise ethical tension; ethical knowledge , the integration of philosophical, normative, deontological and practical knowledge; ethical reflection , a continuous process evaluating alternatives to ethical issues; ethical decision-making , choosing responsibly among options; ethical action , contextually adapted action driven by reflection; and ethical behaviour , embodied moderation and respect. These components elucidate how ethical competence evolves among healthcare personnel and students.

Understanding the concept of ethical competence and its development in nursing students in different learning contexts is still challenging. The various studies addressing ethical competence in nursing students often target one of the six components identified by Lechasseur et al. [ 23 ], the relationship between two or more of the components or one of the components related to other phenomena. For example, Hakbilen et al. [ 24 ] found that students had medium ethical sensitivity after courses, highlighting the need to integrate ethical issues into all nursing education content to improve students’ ethical sensitivity. The results from a study conducted by Chen et al. [ 25 ] indicated that both moral sensitivity and professional values had a positive effect on the improvement of ethical decision-making in Chinese nursing students. Park et al. [ 26 ] reported that senior students had greater moral sensitivity in patient care and conflict than freshmen students and that more hours of ethics education were linked to higher principled thinking scores among seniors. The findings from another study [ 27 ] demonstrated that nursing students’ ethical sensitivity includes perception, affectivity, cognitive processing and cooperation. Using these categories, an educational framework for teaching ethical sensitivity was developed, detailing the purpose, content and methods. Albert et al. [ 28 ] conducted a review to understand nursing students’ ethical dilemmas in clinical settings; they found that dilemmas arose when students had to choose between providing ethical care or accepting unethical practices, staying silent about neglect or reporting it, and offering quality care or adapting to the culture because of a lack of autonomous decision-making. Heggestad et al. [ 29 ] explored the link between affective and cognitive empathy and students’ moral sensitivity, finding that affective empathy was a strong driver of students developing moral sensitivity. Students valued emotions for empathy and feared becoming indifferent. Moe [ 30 ] examined the relationship between ethical knowledge and action choices among graduating nursing students; she found a significant correlation between ethical knowledge and students’ actions after accounting for factors such as ethics courses, healthcare decision experience and general healthcare experience. ‘Action’ was measured by students’ likelihood of implementing behaviours in a list of nursing interventions across eight patient care vignettes. Ramos et al. [ 31 ] studied the ethical conflicts perceived by nursing students in their sixth semester and described their decision-making process. The students used a three-stage strategy: realisation, reflection and intervention. Reflection served as a mediator, drawing on individual insights, others’ input, academic knowledge and context, hence helping students choose the best response to ethical issues.

As the research literature has demonstrated, as a comprehensive concept, ethical competence has been underexplored. As a result, the concept has not yet been operationalised across different contexts and various healthcare settings, particularly in the context of first-year nursing students’ clinical practice in nursing homes. First-year nursing students often start their first period of clinical practice with limited formal ethical knowledge and experience; therefore, more knowledge of the evolution of ethical competence in them is necessary.

Aim of the study

The aim of the present study was to explore the development of ethical competence in first-year nursing students during their first clinical placements in nursing homes.

The current study employed an exploratory-descriptive qualitative (EDQ) design [ 32 ] and used content analysis to analyse the empirical data based on focus group interviews with students.

Recruitment

All five researchers contributed to recruiting the participants. They provided information both face to face and via email to students during and after the clinical period. To be included, students had to (i) be enrolled in the academic year 2023–2024, (ii) have completed the clinical period at a nursing home, (iii) voluntarily participate in the study and (iv) agree to be recorded during the interviews. Students who wished to participate in the study contacted the researchers to arrange a date and time for the interviews.

Participants and study setting

For the present study, purposive sampling was deemed appropriate for selecting participants who could provide the necessary information to address the study’s aim. Sandelowski [ 33 , 34 ] suggested that, in qualitative research, it is crucial to ensure that the sample size is sufficient to obtain the quality of the information needed. A total of 113 first-year students were invited to participate in the study, and 28 agreed to participate. Among those who agreed, only three were men. The participants’ ages ranged from 19 to 31 years. At the time of the interviews, their work experience in healthcare services ranged from 0 to 8 years.

During the fall semester of 2023, the students attended a two-hour lecture and a three-hour seminar on ethics in nursing aimed at enhancing their theoretical ethical competence. The study was conducted at the Department of Nursing and Health Promotion, Oslo Metropolitan University, following the students’ completion of a six-week clinical period in a nursing home as part of their first-year curriculum during their bachelor’s degree in nursing.

Data collection methods

The data were collected through focus group interviews using a semistructured interview guide. This data collection method is both time- and resource-efficient, allowing for the exploration of a wide variety of perceptions. Additionally, the participants can build upon each other’s responses, generating new insights and information [ 35 ]. The interview guide was developed for this study by the first author following the five phases recommended by Kallio et al. [ 36 ]: (1) identifying the prerequisites for using semistructured interviews; (2) retrieving and using previous knowledge; (3) formulating the preliminary semistructured interview guide; (4) pilot testing the guide; and (5) presenting the complete semistructured interview guide. After pilot testing, small adjustments to the questions were made to enhance the clarity and relevance of the interview guide. For the interview guide, see supplementary file 1 .

Six focus groups were conducted between March and April 2024. The number of participants varied across the groups: two groups had three participants, two groups had five participants, and two groups had six participants. The interviews were held in a classroom or seminar room and lasted between 30 and 50 min.

Ethical considerations

The present study was approved by the Norwegian Agency for Shared Services in Education and Research (SIKT, project number 334855). Approval to conduct the study was given by the head of studies at the Department of Nursing and Health Promotion at Oslo Metropolitan University. The study was conducted according to the World Medical Association Declaration of Helsinki’s [ 37 ] principles of good and ethical practices in scientific research: informed consent, consequences and confidentiality. All the students who participated provided written informed consent at the beginning of the interviews. The students were informed about the aim of the study and the data collection method and were guaranteed confidentiality and the ability to withdraw from the study at any point in time.

All the researchers moderating the focus groups were nurse educators engaged in students’ clinical studies in nursing homes, and hence some of the participants knew the moderator prior to data collection. Being invited to participate in a focus group conducted by a nurse educator could put students in vulnerable positions given that the nurse educator may be perceived as an authority figure. According to Barbour [ 35 ], researchers should carefully consider the reasons participants may have for taking part in a study. In this study, it would question morality if a student would resort to participate for fear of being disadvantaged or poorly assessed by the nurse educator. Furthermore, if a student would customize his or her statements in the focus group, to convey an image as a ‘good’ student in front of the nurse educator, it would question morality as well as data authenticity. Therefore, the researchers always strived to be as transparent and open as possible with participants regarding potential implications.

In this study, openness related to in-depth information to invited participants concerning the authenticity of willingness as a participating principle, as well as of the genuineness that any statements made in the focus group would not affect the student in any way. Furthermore, the students were detailed informed that the focus group would occur as a conversation with peers, the moderators’ role facilitating discussions, and that any viewpoints would be welcomed. Debriefing before and after the focus group sessions, as recommended by Barbour [ 35 ], disclosed no incidents of students feeling obliged to participate or feeling restrained to express themselves freely.

The interview data were stored as secured computer files that were accessible only to the researchers. The records and transcripts will be permanently deleted after the research project has been completed and the results have been published.

Data analysis

All six focus group interviews were digitally recorded and transcribed verbatim by the researchers immediately after completion. The transcripts resulted in 52 A4 pages taped with 1.5 line spacing and New Roman font size. The duration from transcribing the interviews to completing the analysis ranged from four to six weeks.

To analyse the interviews, a phenomenological hermeneutical method inspired by Lindseth and Norberg [ 38 ] was used, which is ideal for understanding healthcare practices by exploring the narratives of lived experiences. This method involves three steps: naïve understanding, structural analysis and comprehensive understanding.

Initially, each researcher independently read the texts multiple times to gain a naïve understanding and highlighted passages describing nursing students’ perceptions of the preconditions that contributed to enabling their ethical competence. These passages were compared and discussed until a consensus was reached. The researchers then reread the texts to ensure that no relevant material was missed.

During the structural analysis, condensed meaning units were grouped into themes and reflected upon in light of the naïve understanding. The text was reassembled to integrate both naïve understanding and structural analysis. The literature was consulted to refine and deepen the understanding of the preconditions that contribute to enabling students’ ethical competence. A comprehensive understanding was developed, tested against the naïve understanding, discussed and revised multiple times, with further review given by the first author.

The data analysis concluded when that a comprehensive understanding of the meaning units was achieved, indicating saturation [ 39 ]. Coding meaning units involved reviewing each interview and noting every identified issue (or code). Saturation was reached when no new information emerged in any of the coded meanings [ 39 ].

Whittemore et al. [ 40 ] suggested four criteria to improve the rigour of a study with an EDQ design: credibility, authenticity, criticality and integrity.

To enhance study credibility, the researchers selected pertinent excerpts from participant statements to substantiate the findings. Researcher triangulation cross-verified the findings, enhancing credibility. Additionally, credibility was ensured through verbatim transcription of interviews and independent data analysis, which was followed by collaborative coding and theme development to reach a consensus.

Data authenticity was reinforced by encouraging the participants to freely express themselves during the interviews. The researchers supported and accurately represented participant voices in the findings.

The overall integrity of the study was evaluated through rigorous critical appraisal of the research decisions. A detailed description of the research process allows readers to comprehensively assess the study quality at every stage.

Criticality and integrity were further enhanced by addressing researcher bias, employing member checking and engaging in peer review. The researchers reflected on their positions relative to participants and maintained awareness of their preconceptions throughout. Reflexivity was pivotal in enhancing qualitative study rigour. Logistical challenges preclude member checking; however, the students were given ample opportunities during the focus group interviews to provide detailed input and clarify perspectives. Peer review involved all researchers critically evaluating the study for quality, validity and reliability. Although all team members reviewed the empirical data, only the first and last authors conducted structural analysis and developed a comprehensive understanding, with others providing expert assessments.

The interpretation process and findings are derived from the transcripts of six focus group interviews. The findings are presented in three distinct parts: naïve understanding, structural analysis and comprehensive understanding.

Naïve understanding

The nursing students, that is, the participants in the present study, encountered complex ethical situations during their clinical period in nursing homes, particularly when providing care to nursing home residents.

The students often encountered ethical challenges in clinical practice that conflicted with their theoretical knowledge of ethical care from university or from their personal values. They observed healthcare personnel engaging in behaviours they deemed unethical, such as ‘white lies’, causing feelings of powerlessness due to their inability to act. Despite witnessing challenging ethical caring actions, the students also noted positive examples of ethical sensitivity, actions and beneficiary caregiving. They navigated these complex situations by developing their own strategies and reflecting on their roles as future healthcare professionals.

The students recognised that their theoretical knowledge, practical skills and empathy for nursing home residents were crucial in identifying ethical problems. They internalised ethical principles deeply through their experiences, and this was often prompted by residents’ reactions. Although they emphasised the importance of guidance and reflective dialogue to enhance ethical competence, the lack of supervision and specific feedback on ethical problems was perceived as a hindrance to further developing ethical competence. The students valued discussions with peers, nurse educators and interdisciplinary meetings for support and ethical reflection, despite challenges in accessing consistent guidance from nurse preceptors.

Structural analysis

The structural analysis of the data revealed three themes: (i) ethical competence forges in practice, (ii) ethical competence evolves at the intersection of knowledge and skills and (iii) ethical competence unfolds through meaningful discussions. These themes are considered essential preconditions for the development of ethical competence among nursing students. An example of the structural analysis process is illustrated in Table  1 .

Ethical competence forges in practice – being able to identify ethical and unethical care

This theme suggests that ethical competence is developed and strengthened through practical experience, with students having hands-on engagement in ethical situations and being petitioned to act. This implies that students can assess various situations and distinguish between ethical and unethical caregiving and start grounding the course of their own ethical actions through their reflections.

The clinical period was evaluated as a positive experience offering numerous valuable learning opportunities. The students observed healthcare personnel providing ethical and dignified care to nursing home residents. However, they also witnessed some situations in which the care provided was less ethical and undignified. The situations described by the students as unethical caregiving were situations in which the residents resisted care or various procedures, such as changing ostomy bags, or refused personal hygiene tasks, such as grooming or brushing their teeth. Intuitively, most students were aware of the conflict between their own wish to help and the residents’ autonomy and right to say ‘no’. The students observed that, in most situations, healthcare personnel respected the residents’ wish to refuse assistance and, therefore, did not provide any help. One of the students said the following:

In our facility, some residents had not washed themselves for a long time and smelled. However, I appreciated seeing how the principle of autonomy was maintained. I felt that the healthcare personnel managed this very well, ensuring that the residents made their own decisions. Nevertheless, I had concerns about hygiene. If a resident did not want to wash and the healthcare personnel respected their wish, I think that it raised an ethical dilemma … what about the principle of nonmaleficence and beneficence … how are these maintained? (S3, FG1)

Other situations identified as unethical practices and triggering students’ ethical reflection were those situations in which healthcare personnel, because of high workload, time pressure or ingrained habits, ignored residents’ needs and wishes and focused on getting the job done. One of the students said the following:

I think that’s one of the worst things. It truly irritates me when I see nurses doing a job, that they are doing it just because it’s a job. They don’t think about the fact that it’s a person who has had a whole life before they got here [at the nursing home]. I’ve experienced it so many times that for some nurses, it’s just about the job, just about completing tasks and getting it over with. … (S3, FG2).

Ethical competence evolves at the intersection of knowledge and skills – Being able to apply theory in practice

This theme highlights the importance of both theoretical understanding (knowledge) and practical abilities (skills) in the development of students’ ethical competence. This finding suggests that ethical competence emerges as a result of the integration of knowledge and skills.

Several students felt that their ability to assess challenging situations as ethically laden resulted from their reflections on theoretical knowledge, practical skills and empathy for nursing home residents. Witnessing ethically challenging situations prompted them to reflect on ethical principles and find solutions, thereby acquiring and applying knowledge in practice. Students applied their knowledge, including their personal values and beliefs, as well as what they learned at university or during their clinical training, to assess the practical skills required for challenging situations. The skills the students often highlighted included the ability to initiate dialogue with residents to prevent ethical tensions, the capability to mediate and offer alternatives when residents did not comply with health measures, and the ability to articulate persuasive arguments to obtain residents’ consent for specific health measures they initially rejected but were deemed necessary.

Although the students were grateful for prior ethics education at the university and appreciated the knowledge gained from seminars, they believed that clinical practice provided real situations where they could reflect and discuss possible solutions. This is illustrated by one student’s statement:

When you’re in a nursing home, it’s much more real … when you discuss in the classroom, you won’t truly grasp the reality … yes, understanding the situation and what it entails … a case on paper is very black and white, but in reality, it involves emotions, observations and knowledge that help you assess the situation and find solutions. … (S4, FG4).

Nevertheless, the students perceived the nursing home as a valuable learning environment that offered many educational opportunities. Given that many nursing home residents had cognitive impairments or were persons with dementia, ethically challenging situations frequently arose. In addition to reflecting on how to apply their knowledge in practice, several students were interested in preventing the occurrence of ethical problems and/or finding solutions to these ethical situations. Therefore, the students stressed the importance of gaining skills using a model for ethical reflection, which helped them in ethical decision-making. This is illustrated by a student’s statement:

The CME model gave me a lot. I could organise things systematically and consider different courses of action. What can one choose to do and not do. In addition, then, I think in nursing homes, it’s special … you see so much, there are many residents who are diagnosed with dementia, and things where you stand in every day, such as assessing if they are competent to consent or not … Maybe you have to motivate a lot, spend a lot of time on diversion and such things … I think … it’s a place [nursing home] where you learn a lot about ethics. (S1, FG5)

Ethical competence unfolds through meaningful discussions – providing opportunities to exchange knowledge

This theme emphasises the role of dialogue and reflection in the development of ethical competence. This suggests that engaging in meaningful discussions with peers, nurse preceptors or nurse educators facilitates the growth and deepening of ethical competence.

Although most of the students were content with the nursing home as a learning environment and the supervision offered by nurse preceptors, some students revealed feelings of dissatisfaction about observing healthcare personnel conducting unethical practices, including ‘white lies’, breaching of residents’ privacy, respect, removing personal items from the resident, such as cigarettes or a lighter, without residents’ consent or neglecting to display the medication when the resident requested. A situation involving unethical conduct was illustrated by one of the students:

One resident was very sad and anxious about being there [nursing home]. She asked several times, ‘When will I get to go home?’ And then the nurse preceptor said, among other things, that ‘you are going home in three days’. However, that’s not true … The patient was on a two-week stay. The nurse preceptor said she did this to calm down the resident’s anxiety; she gave the resident hope … We discussed a little bit … and I think that it’s a bit of an ethical dilemma because the nurse said this to be kind, but she [the resident] had the right to know about her stay. (S1, FG6)

In such situations, the students felt the urge to discuss their emotions and their own assessments with someone. However, the nurse preceptors were often too busy, restricting their time for reflection and thorough supervision. As a result, the students turned to their peers or nurse educators for discussions. Often students felt safer discussing with peers and educators and found these discussions more helpful. If these discussions were supportive, they could lead the students to find confidence in their assessments and could help them find their voice, advocating for the residents and for ethical behaviour towards the residents.

However, the students also displayed positive experiences. Observations of commendable ethical actions and behaviour from staff and nurse preceptors demonstrating effective techniques for handling value-laden situations helped the students recognise and integrate beneficial ethical actions and behaviours into their own repertoires. At times, both students and healthcare personnel from the same ward were regularly provided with opportunities to reflect on their practices, particularly ethically challenging situations. These group discussions were facilitated by a priest. One student expressed enthusiasm for these discussions:

We had a visit from the priest in the ward to discuss ethical challenges. We stood in a circle, and the healthcare personnel shared the ethical challenges they faced in their daily work. We discussed various ethical dilemmas and explored the best ways to address them so that everyone involved would benefit. I found it quite rewarding to engage in these discussions. Although we did not reach a definitive conclusion, I felt that having such discussions improved my ethical knowledge and understanding. (S3, FG3)

Comprehensive understanding

The naïve understanding and structural analysis illustrate that nursing students embark on a journey towards ethical competence during their first period of clinical studies, with clinical experiences being essential waypoints along the path to their destination, that is, gaining ethical competence. Ethical sensitivity is foundational and the point of departure for the evolution of ethical competence in students. This sensitivity is driven by the compassion and understanding of residents’ needs and best interests, which students observe firsthand. Ethical knowledge evolves at the intersection of theoretical and practical insights within the nursing home setting and fuels and propels students’ ability to assess and reflect upon options in situations where there is ethical tension. Making meaningful discussions with their fellow passengers; peers, nurse preceptors and educators are crucial preconditions fostering students’ ethical reflections and decision-making in navigating the clinically rugged terrain. Ethical action and behaviour are the destinations of students’ journeys and hinge upon their learning of beneficial caring skills and on their opportunities to behave in accordance with their values in their caregiving. Overall, nursing students’ ethical competence evolves when they integrate ethical sensitivity, knowledge, reflection, decision-making, action and behaviour within clinical practice.

First-year nursing students with limited knowledge and skills enter their initial clinical studies and likely do not achieve the final level of ethical competence required in the nursing profession during this period. Nevertheless, our comprehensive understanding is that first-year nursing students begin a crucial journey towards ethical competence during their clinical placement in nursing homes. Their journey progresses through the integration of various components of ethical competence. Most prominently, the characteristics of ethical competence described in the integrative review of Lechasseur et al. [ 23 ] are identifiable in the scenic route the students’ take. Each of the components of ethical competence defined by Lechasseur et al. [ 23 ] evolve in the students, both distinctly and intertwined. Therefore, we find it valuable to discuss the students’ roadmap considering the components of ethical competence outlined by Lechasseur et al. [ 23 ]. We will discuss how ethical sensitivity, ethical knowledge, ethical reflection, ethical action and ethical behaviour play out in our finding, offering interpretations of how ethical competence evolves throughout their journey.

Ethical sensitivity is the point of departure

In all six focus groups, the students provided rich descriptions of the ethical problems that they encountered in their clinical studies and discussed how they individually identified ethical tension in these situations. Drawing on Weaver et al. [ 41 ], Lechasseur et al. [ 23 ] define ethical sensitivity in nursing as both a compassionate-driven and intelligence-driven capacity. The compassionate aspect is related to self-awareness and personal normative knowledge and is particularly described by the students in our study as to ‘imagine themselves in the role of the resident’ as a catalyst for them to identify tension.

The students were strongly affected by the residents’ vulnerability in value-laden situations when they sensed that the residents were not given choices and had to accept receiving care they did not consent to, involuntarily had to relate to strangers, felt that their intimate spheres were being invaded, felt that customised information was not given to them and so forth. For example, one student described her emotional discomfort witnessing a residents’ vulnerability being restricted access to his personal items (cigarettes and lighter). This caused the resident to be restless and his hands to shake.

The students’ emotions appear as a point of departure in their journey towards ethical competence enabling them to identify tension. In this sense, our findings are in line with those of Heggestad et al. [ 29 ], who found that undergraduate nursing students’ moral sensitivity is mostly linked to the affective dimension of empathy.

Studying senior nursing students, Shayestehfard [ 27 ] found that both affective and cognitive dimensions characterise ethical sensitivity in nursing students. In their study, nursing students’ ethical sensitivity is described as being affected emotionally and, hence, becoming aware, awakened, alarmed or shaken. The cognitive side to students’ sensitivity is described as processing signs and symptoms of vulnerability that enable the students to identify caring needs. The students in our study also described the cognitive components of their ethical sensitivity. Many of the descriptions in the focus group discussions represented their interpretations of the consequences of not intervening, professional caring duties in nursing and the beneficence or nonmaleficence of residents in critical situations as strong sources of their identification of ethical tension. Some of the students expressed that they were initially emotionally driven in their identification of ethical problems. However, as time progressed, their understanding and focus could change. One student related this change directly to the forging of ethical competence. As competence forges, the student said, one understands better what is ethically problematic and what is not, and you are not only driven by your feelings, but you are also driven by what you understand to be critical caring needs.

Ethical knowledge – pit stopping to fuel

Sometimes, the students identified ethical tension merely depending on their inherent and personal normative knowledge and values, but often, they also applied other knowledge, especially in the longer term. Lechasseur et al. [ 23 ] define ethical knowledge as multifaceted, including philosophical and theoretical knowledge as well as practical knowledge.

Ethical sensitivity is sometimes solely normative driven, but it is difficult to negate the relevance of factual knowledge in ethical reflection and decision-making [ 31 , 42 ]. Few would deny the importance of factual knowledge concerning the assessment of treatment and healthcare, consequences and obligations for specific patients or their next of kin that lead to decisions [ 42 ]. Thus, philosophical, and theoretical knowledge (‘ knowing that ’) is a necessary condition for assessing options and making decisions. The students described knowledge from medicine, nursing, psychology, and other disciplines as sources of ethical reflection, most frequently concerning the doctrine of informed consent, values and care needs at stake, ethical principles, ethical guidelines or directives and communication strategies and interaction. One student said that theoretical knowledge learned at university prior to clinical studies was ‘worth its weight in gold’. Nevertheless, philosophical, and theoretical knowledge is not merely something one learns and can apply instantly [ 7 , 43 , 44 ]. Decontextualized ethics education does not sufficiently help students transfer learning from the classroom to ethical nursing practice situations [ 45 ]. During the focus group interviews, the students highlighted the importance of the nursing home as a learning arena contributing to their acquisition of ethical knowledge in the form of practical skills. This means that the clinical studies offered them a real-world framework consisting of authentic situations, hence enabling students to acquire practical knowledge (‘ knowing how ’) through a meaningful understanding of the context at hand. Therefore, the students’ journey towards ethical competence hinges on understanding the particularity of each ethical problem, such as what and who it concerns in the specific context in which the problem arises and unfolds. These understandings fuel the forging of ethical competence among students.

Sometimes, the students described situations in which they experienced a noticeable lack of knowledge, which led them to question which skills were applicable and appropriate. According to Andersson et al. [ 9 ], to become ethically competent in clinical studies, three moments should be presented to students: the learning environment should create conditions for learning, nurse preceptors should design strategies for learning, and students should interact with others. The present study has revealed how the students described the nursing home as a learning environment in which encounters are both physical and personal; they learned to recognise and interpret residents’ verbal and nonverbal language and its meanings, and they were required to address ethical problems by applying practical skills and understanding. Concrete situations often triggered their inquiries. In their search for practical knowledge, the students had to interact with others, which fuelled and facilitated their journey towards achieving ethical competence.

Ethical reflection and ethical decision-making – navigating rugged terrain

Clinical studies provided the nursing students with the opportunities to engage in ethical reflection and decision-making processes in their placement wards. The students frequently reflected on the actions to take in various ethically tense situations and often provided sound justifications for their suggestions or raised relevant questions about what to consider. A recurring theme in their discussions was how much to push residents who resisted healthcare, speculating on the least invasive approaches. Ethical reflection represents the thinking process helping decision makers clarify beliefs and thoughts by considering various alternatives to ethical problems [ 23 ]. Ethical decision-making is closely intertwined with the reflective process, but differs in the sense that, when ‘deciding’, one also makes a choice from among the number of alternatives and thereby temporarily pauses the reflective process [ 23 ]. Nevertheless, being a student, especially encountering the clinical field for the first time, is a susceptible position, and it might be challenging for students to reflect on and make decisions. Particularly during the initial period of their placement, students mostly take part in caring actions that are already relatively settled and must learn how to implement prescribed caring chores.

Ranjbar et al. [ 46 ] developed a three-level model illustrating the route for moral development in nursing students. To achieve the final level of ethical competence, the students first pass through phases of development at the lower levels. As students enter their first year and are exposed to clinical practice, they begin acquiring practical and technical skills (first level). Here, their focus is essentially on acquiring and mastering these skills and being able to perform them with ease. It is at the second level that students advance in their ethical judgements. At level two, students can better reconstruct ethical problems and become more effective ethical agents. Until students reach level two, it is difficult for them to make sound ethical assessments without the support of others. In our study, the students’ abilities to take part in ethical reflections and ethical decision-making in practice varied. Some students were not very active in discussions concerning alternative actions and interventions to resolve ethical problems in their ward, but they expressed that they learned from observing and listening. Other students displayed a much more active role in the decision-making processes, discussing and sharing their views and opinions with staff, hence influencing the actions taken. Furthermore, the students often encountered ethical problems that arose unexpectedly or spontaneously and sometimes had to reflect there-and-then and decide what to do, often without supervision and without a prescribed recipe.

However, the process of learning how to understand and make decisions when encountering ethical problems in real-life nursing contexts continues to progress throughout the bachelor’s programme [ 21 ]. Managing ethical problems gave the students and participants confidence, triggering their potential to solve ethical problems now and in the future. However, the students expressed a need to take part in discussions and reflect on how to go forward in situations with ethical tension because they lacked the experience, knowledge and skills to navigate through ‘rugged terrain’. In many cases, the students said that, in their opinion, communication is crucial in solving ethical problems, and they need to reflect on and increase their skills using viable techniques and manners to initiate dialogue, mediation and persuading arguments.

According to Jakobsen et al. [ 21 ], using group discussions and discussing examples of ethical problems can help students engage in a more comprehensive reflection process. Discourse within the clinical setting has been outlined as a prerequisite concerning ethical competence [ 31 , 42 ]. Justifying a certain practice requires more than the competence of one individual; hence, the decision-making process should be based on a multitude of views and opinions, thus contributing to consolidating decisions throughout the healthcare team [ 42 ]. Crucial elements of knowledge and skills are transferred among clinicians through their mutual reflections on appropriate care actions. Hence, being part of ethical reflection is essential to nursing students’ learning [ 31 ]. According to a review of the empirical literature on nursing students’ ethical decision-making, discussions with contemporaries are perceived as the most influential source of developing ethical decision-making abilities [ 47 ]. In their study, Ramos et al. [ 31 ] found that ethical reflection serves as a mediator between the realisation of an ethical problem and the interventions that nursing students carry out. Discussing the problem at hand helps nursing students draw on both individual insights and others’ input, helping the students choose the best response to ethical issues. Sometimes, when lacking the opportunity to reflect, the students turned to peers and educators as sparring pairs, pondering the alternatives to problems. The students found peers to be central in this regard, with peers being in circumstances similar to themselves. Reflecting together with another person was essential to their understanding and ability to develop skills for assessing and knowing how to handle difficult situations. Using the CME model [ 20 ] was considered a fruitful method of sorting information as well as sorting objective facts from subjective emotions, hence resulting in greater clarity.

The students valued ethical reflection partly because they believed that some healthcare personnel’s interventions were based on poor assessments that did not sufficiently advocate for the residents; they also found that nurse preceptors or other employees were sometimes more concerned with getting the job done, avoiding extra work, and coping through the working day when assessing solutions to ethical problems. The students often mentioned ‘reflection’ both as a way of considering alternatives of action when facing ethical problems and as a way of processing their emotions while witnessing poor care and not having the courage to question nurse preceptors’ assessments. The results from a literature review on moral courage in undergraduate nursing students [ 48 ] highlight students’ strong identification with the role of patient advocacy. The same attitude was perceived by the participants in our study; they expressed that residents’ well-being was their primary objective. However, according to Bickhoff et al. [ 48 ], several factors inhibit nursing students from pursuing an advocacy role, sometimes also leading to students taking part in poor practice unintentionally or complying with unethical practices. The characteristics of nursing students’ experiences in their clinical studies, such as feeling or being subordinate on the ward, their identity as ‘just’ or ‘only’ a student, a desire to fit in, fear of reprisals and poor validation, have been reported in numerous studies [ 48 , 49 , 50 , 51 ]. These experiences diminish nursing students’ opportunities to take active roles in ethical reflections and decision-making and, thus, to take part in and influence the ward learning community. On the other hand, students who are given opportunities or who seize opportunities on their own to act as patients’ advocates report gaining the courage to voice their assessments and suggestions in the work environment [ 48 ]. The participants in our study expressed that they sometimes felt subordinate to the ward and were not given a voice, which hindered their ability to make sound assessments for the benefit of the residents. Nevertheless, some students, though not all, found the ability to seize opportunities to advocate for residents’ beneficial care.

Ethical action and ethical behaviour – the destination in sight

Ethical action involves implementing a course of action chosen after considering the possible alternatives, while ethical behaviour is characterised by an attitude of respect, responsiveness and support when carrying out the chosen action [ 23 ]. In a person with high ethical competence, ethical behaviour is embodied [ 23 ]. The students discussed actions they carried out to solve ethical problems, sometimes with nurse preceptors, peers or independently. Similar to the results of a systematic review [ 7 ], our study has revealed that students prioritised maintaining patients’ dignity, privacy and confidentiality, emphasised effective communication to resolve ethical issues and demonstrated a strong commitment to residents’ well-being. Consequently, the students showcased sound ethical behaviour.

Some students described the inability to act in accordance with ethical standards as a bodily experience of distress. One student mentioned that her feelings in tense situations settled in her body. According to Ranjbar et al. [ 46 ], the final level (level three) in the route for moral development in nursing students is where they internalise professional values and the ethos of nursing into their personal identity, making ethical actions and behaviour a reflection of their identity and personality. Few students reach this level during their nursing education [ 46 ]. Although it is difficult and impractical for us to claim that the students in our study had reached level three, their discussions rarely involved knowingly violating ethical values. When they did, they expressed discomfort. For example, one student described lying to a resident to get him indoors when he was not properly dressed because of cold weather, finding the experience distressing. Similar findings have also been presented in previous studies [ 52 , 53 ]. Nevertheless, even though nursing students tend to be idealistic and hold strong values [ 7 ], there is no guarantee that these values will consistently result in virtuous ethical actions and behaviours, either now or in the future.

A literature review investigating nurses’ ethical practices [ 54 ] revealed that contextual circumstances, such as limited time and resources and less authority in the ward hierarchy, can influence nurses’ ability to make decisions. These circumstances result in a conformist approach, adapting to existing practices and sometimes merely executing the decisions made by others. This, in turn, affects nurses’ internalisation of ethical behaviour and leads to less individually adapted care actions. Although this review [ 54 ] focused on professional nurses, there is evidence that nursing students’ ethical behaviour is similarly influenced by these circumstances. For example, Tanaka [ 55 ] reported that nursing students often adjust their ethical values to accommodate certain circumstances. Even when nursing students perceive the actions and behaviours of nurse preceptors as ‘wrong’, they may alter their stance on the issue and reorganise their ethical values to adopt coping behaviours that align with the situation. As a result, nursing students often struggle with prioritising their relationships, with nurses who exhibit inadequate care behaviours or with their commitment to patients. As nursing students progress through their programmes, they may become increasingly disillusioned, cynical and focused on completing their tasks, which ultimately ends with a loss of idealism [ 56 ].

The students participating in our study described instances in which they observed cynicism among certain employees and witnessed violations of residents’ dignity by nurse preceptors and other healthcare personnel. Examples included speaking over residents’ heads, ridiculing them and handling them roughly or even being disrespectful to residents’ family members. In these situations, the students often felt powerless and complicit, feeling ‘dragged along’ because of their subordinate role. Occasionally, they sought explanations from the nurse preceptors, but the responses varied in credibility. The students also observed commendable ethical actions from nurse preceptors, who demonstrated effective techniques for handling value-laden situations. Learning from these positive examples helped the students recognise ethical behaviours. They observed that the manner of coercion mattered and witnessed gentle, informative restraint techniques. Overall, the students were eager to adopt noncoercive approaches, seeking to balance assertiveness with positive persuasion.

Despite witnessing unethical actions and behaviours, these experiences did not necessarily hinder the students’ development of ethical competence. According to Engel et al. [ 57 ], experiencing unethical caregiving can actually strengthen students’ commitment to ethical practices. Most students act as informed bystanders and can navigate the space between observation and action. They may maintain a low profile while also developing the courage to advocate for patients. These adaptive strategies were evident among the students in our study. In distressing situations, the students occasionally assumed caregiving responsibilities to ensure proper care. For instance, when an employee force-fed a resident, a student intervened by gently and patiently helping the resident. We interpret this action as a coping strategy that bridges the gap between observation and action.

The students frequently mentioned that gaining confidence during their clinical studies might empower them to voice their concerns more effectively in the future. However, according to Bickhoff et al. [ 48 ], the lack of authority persists throughout the clinical curriculum, with students often assuming a subordinate role across different periods of clinical study. On a positive note, some students have reported that experiencing a lack of authority motivates them to avoid unethical practices in their future careers [ 48 ]. In our study, the students strongly expressed their desire to maintain their ability to advocate for residents’ best interests in the future. They observed that, for some healthcare personnel, the job had become routine, leading to a loss of perspective on ethical actions. The students were determined not to find themselves in a similar position in their careers.

Implications for nursing education and clinical practice

Findings from the current study suggest that building a solid ethical foundation in nursing involves more than just theoretical and practical knowledge. Several strategies are needed to sustain ethical practice and potentially mitigate moral distress among nursing students and nurses.

One crucial strategy is to integrate ethics education throughout the entire curriculum, rather than treating it as a standalone module. This should include case studies, role-playing, and discussions relevant to real-world scenarios. Additionally, providing strong mentorship and supervision during clinical placements is vital. Experienced nurse educators and preceptors can model ethical behavior, offer guidance, and support students as they navigate complex situations. Encouraging regular reflective practice is also important. Discussions, debriefing sessions, and peer interactions can help students process their experiences and deepen their understanding of their ethical beliefs and responses. Since learning does not occur in a vacuum, creating a supportive learning environment with access to guidance can assist students and nurses in addressing moral distress and seeking guidance. Furthermore, offering diverse and challenging experiential learning opportunities allows students to confront ethical issues in a controlled setting, hence building their confidence and competence in managing ethical problems. Finally, fostering a culture of ethical leadership within educational and clinical environments can set a standard of ethical behavior that positively influences nursing students and nurses.

Strengths and limitations of the study

The present study’s findings are based on participating students’ accounts of their experiences with ethical issues during their first clinical period in nursing homes. One limitation of the study is that the students’ subjective perceptions and narratives may not always accurately reflect their actual ethical actions and behaviour in a real-world caring context.

Out of the 113 invited students, only 28 agreed to participate. It is worth considering whether those students who chose not to participate would have described their experiences differently. Although the sample size was limited to 28 participants across six focus groups, our transcription and analysis of the data indicated that saturation was achieved after the final focus group. Furthermore, our goal has not been to generalise but rather to present a possible interpretation of how ethical competence evolves in nursing students in the context of clinical studies in nursing homes.

Another potential limitation could stem from our interpretations, which might be shaped by our preconceptions, particularly because all the authors are nurse educators engaged in students’ clinical studies in nursing homes and know the curriculum well. To counter potential bias, we rigorously adhered to the data as they emerged from the transcripts.

Another challenge we encountered relates to the varied use of concepts concerning ethical practices by different authors [ 23 , 54 ]. While reviewing the literature on nursing students and their ethical competence, we observed that some studies aimed at exploring or describing ethical decision-making in students but primarily focused on aspects of ethical sensitivity. Therefore, in certain instances, we needed to heavily rely on specific findings from these studies, even if they did not align perfectly with their original aims. Throughout this process, we aimed to maintain accuracy and fairness in referencing other studies.

Some of the studies we have referenced in our discussion were older than five years and were conducted in contexts that may not resemble the environment of Norwegian or Nordic nursing education. Because of the limited research exploring ethical competence in nursing students, we reviewed these studies to provide supporting knowledge for our findings. The geographical differences between the places where the studies were conducted and our study could have led to discrepancies in our discussion of the development of students’ ethical competence during their initial clinical study period in Norwegian nursing homes. However, we did not find studies with aims similar to ours, so our discussion draws on the findings of Lechasseur et al. [ 23 ] and the general literature describing nursing students’ experiences with ethical issues in diverse and varying contexts. However, we believe that ethical competence in nursing students evolves during their theoretical and clinical education, regardless of their country of origin; therefore, our findings could be applicable to similar settings and practices among nursing students.

The aim of the present study was to explore the development of ethical competence in first-year nursing students during their first clinical placements in nursing homes. Our naïve understanding was that the ethical challenges students encounter in their clinical studies often conflict with their theoretical ethical knowledge and personal values. The students navigated complex ethical situations by reflecting on their experiences, expanding and adapting their knowledge base and internalising ethical principles in their actions. Through structural analysis, we identified three key themes that are considered essential preconditions for the development of ethical competence in nursing students. Our comprehensive understanding of the findings reveals that nursing students embark on a journey towards ethical competence, with clinical experiences serving as pivotal milestones.

Our findings illustrate that nursing students’ ethical competence evolves in complex ways when they first time are exposed to clinical settings. The first clinical period in nursing homes offers real-life insights into both ethical and less ethical care practices. Acting as informed observers or active participants in ethical problems involving nursing home residents offers students a unique perspective to critically evaluate care options that are distinct from those immersed in the ward culture. However, students’ ability to resist conventional practices and progress on their ethical journey may vary. Moments of reflection and supportive interactions are crucial for sustaining momentum on this journey. Therefore, peers, nurse preceptors, and nurse educators play vital roles in guiding students by providing robust support and navigation.

Our study suggests that structured professional development in nursing homes should prioritise the reflective supervision of students during their initial clinical placements. Educational institutions should continue to enhance and expand ethical reflection-based learning activities and opportunities for students and their peers during their clinical training.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Abbreviations

Student [number] participant in focus group interviews

Focus group [number]

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Acknowledgements

The authors express their gratitude to the students who participated in this study, thereby contributing to the data collection. Additionally, the authors sincerely thank Oslo Metropolitan University Library for granting approval and for their support in covering the publication fee of this article.

Open access funding provided by OsloMet - Oslo Metropolitan University. This research received no specific grant from any agency in the public, commercial or not-for-profit sectors. Open Access funding was provided by the University Library – Oslo Metropolitan University.

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Sylvia Hansen, Elisabeth Hessevaagbakke, Katrin Lindeflaten, Kaja Elvan & Daniela Lillekroken

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SH was involved in data collection and analysis, reflection, discussions regarding the manuscript’s intellectual content, and drafting the manuscript. DL contributed to the study conception, data collection, and analysis, and was involved in revising the manuscript critically for important intellectual content. EH, KL, KE were involved in data collection, analysis, and discussions regarding the manuscript’s intellectual content. All authors agreed to be accountable for all aspects of work and take public responsibility for appropriate parts of the content.

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The study was approved by the Norwegian Agency for Shared Services in Education and Research (Sikt/Ref. nr. 334855) and by the leader of the Department of Nursing and Health Promotion at Oslo Metropolitan University. This study does not seek to investigate participants’ health status, sexuality, ethnicity, or political affiliation (sensitive information); therefore, it is exempt from ethical approval by the Norwegian Regional Committees for Medical and Health Research Ethics as no health information or patient data are recorded. The study adhered to the principles outlined in the Declaration of Helsinki and followed Oslo Metropolitan University’s guidelines and regulations. Data confidentiality was strictly maintained, and the information was used solely for research purposes. Participant anonymity was safeguarded by not detailing participant characteristics in the paper. Researchers provided both verbal and written information about the study, and written voluntary informed consent was obtained from all participants prior to data collection.

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Hansen, S., Hessevaagbakke, E., Lindeflaten, K. et al. Nurturing ethical insight: exploring nursing students’ journey to ethical competence. BMC Nurs 23 , 568 (2024). https://doi.org/10.1186/s12912-024-02243-x

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Nursing Education Transformation

Gorski, Mary Sue PhD, RN; Gerardi, Tina MS, RN; Giddens, Jean PhD, RN, FAAN; Meyer, Donna MSN, RN; Peters-Lewis, Angelleen PhD, RN

Mary Sue Gorski is a consultant at the Center to Champion Nursing in America, Washington, DC. Tina Gerardi is deputy director of the national program office of Academic Progression in Nursing, located at the American Organization of Nurse Executives, Washington, DC. Jean Giddens is dean and professor in the Virginia Commonwealth University School of Nursing, Richmond. Donna Meyer is dean of health sciences and director of the Lewis and Clark Family Health Clinic, Lewis and Clark Community College, Godfrey, IL. Angelleen Peters-Lewis is chief nursing officer and senior vice president for patient care services at Women and Infants Hospital of Rhode Island, Providence. Contact author: Mary Sue Gorski, [email protected] . The authors have disclosed no potential conflicts of interest, financial or otherwise.

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This third article in a series examining the impact of the Institute of Medicine's 2010 report, The Future of Nursing: Leading Change, Advancing Health , describes the ongoing transformation of nursing education, including examples of initial progress, challenges, and successes.

At a time when the nation's health care landscape was being transformed and increasing evidence pointed to the need for more highly educated nurses, the Institute of Medicine (IOM) released a landmark report, The Future of Nursing: Leading Change, Advancing Health . Issued in 2010, the report states 1 :

“Major changes in the U.S. health care system and practice environment will require equally profound changes in the education of nurses. An improved education system is necessary to ensure that the current and future generations of nurses can deliver safe, quality, patient-centered care across all settings, especially in such areas as primary care and community and public health.”

An improved education system must also ensure that the nursing workforce reflects the diversity of the populations it serves.

The Future of Nursing report set an ambitious goal: 80% of practicing RNs should be prepared with a bachelor of science in nursing (BSN) or more advanced degree by 2020. It also cited evidence to support the call for more highly educated nurses, 1, 2 and subsequent studies have linked higher nurse education to improved patient outcomes. 3-7 The report also provided a blueprint for action to advance nursing education and reframe the conversation around this goal.

The transformation has begun, and the early work to establish a new education infrastructure is described in this article. We also review the activities taking place to advance this complex transformation, including examples of initial progress, challenges, and successes, and a call to action seeking nurses’ assistance in the process.

A NETWORK OF SUPPORT

The need for change is clear: the current education system is not equipped to handle the large influx of students needed to meet the increased demand for highly skilled nurses. It also does not adequately support seamless academic progression, in which a national network of community colleges and universities offers improved access to advanced education.

Students currently have multiple ways they can enter the nursing profession and advance their education. Many RNs begin their careers as graduates of community college associate's degree in nursing (ADN) programs and do not achieve a BSN, master of science in nursing (MSN), or more advanced degree—often because they face insurmountable barriers, such as affordability and access.

In addition to increasing the number of BSN-educated nurses, schools of nursing must also improve their capacity to prepare more graduate-level students who can assume roles in advanced practice, leadership, teaching, and research. Only 13% of nurses hold graduate degrees, and less than 1% hold a doctoral degree. 1 Nurses with doctorates are needed to teach future generations of RNs, provide care in advanced practice roles, serve in leadership positions, and conduct research that becomes the basis for improving nursing science and practice. Nurses with graduate and doctoral degrees are needed in direct patient care to meet the growing demand for chronic disease management and health promotion in today's complex health care system. The IOM committee that authored the Future of Nursing report recommends doubling the number of nurses with doctorates by 2020. 1 The current rate of academic progression—particularly from the ADN to the BSN—is simply not high enough to meet future needs.

Seamless academic progression. National nursing organizations have been focused on improving access to seamless academic progression programs for some time. In May 2010, the Tri-Council for Nursing—representing the American Association of Colleges of Nursing (AACN), the American Nurses Association, the American Organization of Nurse Executives (AONE), and the National League for Nursing (NLN)—issued a statement on the educational advancement of RNs that included many of the same recommendations outlined in the IOM report (see www.aacn.nche.edu/Education-resources/TricouncilEdStatement.pdf ). Leaders in nursing practice, education, and leadership have issued a powerful call to action by focusing on academic progression for all nurses, but it is not enough.

It is essential to build on current resources and structures to ensure that seamless academic progression exists. To this end, leaders of the AACN, the American Association of Community Colleges, the Association of Community College Trustees, the NLN, and the National Organization for Associate Degree Nursing have endorsed a shared goal of academic progression for nursing students and graduates (see www.aacn.nche.edu/aacn-publications/position/joint-statement-academic-progression ). This statement emphasizes the common aim of these organizations to foster a well-educated, diverse nursing workforce to advance the nation's health. Building on this imperative by leveraging the successful cooperation between community colleges and university nursing programs will help to transform nursing education and provide the maximum benefit to health care consumers.

Another critical aspect of the transformation of nursing education is the need to produce a nursing workforce that is reflective of the rich diversity of the communities in which nurses practice. Using figures compiled from AACN data, 8 the Integrated Postsecondary Education Data System, 9 and the U.S. Census Bureau, 10 the Future of Nursing: Campaign for Action compared the sex, race, and ethnicity of nursing graduates and found continuing disparities between graduates from both ADN and BSN programs and the populations they serve. As we transform our education system, we must build on the diversity of students in schools of nursing in community colleges and universities while accelerating progress toward specific diversity goals, such as providing patients with a nursing workforce that is similar to them in terms of race, ethnicity, sex, and socioeconomic status.

The need to accelerate academic progression and increase workforce diversity has also captured the attention of philanthropic organizations. For example, the Robert Wood Johnson Foundation (RWJF), the Gordon and Betty Moore Foundation, and the John A. Hartford Foundation have launched programs to boost faculty capacity and diversity and to increase capacity in geriatric care. These programs seek to ensure that enough qualified faculty is available to teach all levels of the nursing workforce.

Building on this growing consensus for change, the RWJF and AARP partnered to establish the Future of Nursing: Campaign for Action in late 2010 to implement the recommendations made in the Future of Nursing report. Although many of these recommendations have been made before at different times by different groups, the Future of Nursing report reframed the conversation. The Campaign for Action has provided the resources and support to move the work forward.

BUILDING AN INFRASTRUCTURE

The Center to Champion Nursing in America (CCNA), a national initiative of AARP and the RWJF, has been improving educational opportunities for nurses and nursing capacity since it launched in 2007. 11 It provides assistance to the Campaign for Action's 51 action coalitions, representing all 50 states and the District of Columbia. These coalitions implement the work of the campaign at the state level. 12

The CCNA's education work began with 30 state coalitions addressing education capacity. A multistate event was held by the CCNA in Oregon in 2009 to explore nursing education capacity for future workforce needs. Following the release of the Future of Nursing report, the CCNA hosted four regional Webinars in 2010 and 2011, followed by four regional face-to-face meetings to identify what was working in education transformation.

This CCNA education learning collaborative—the concept of which was based on the work of Gajda and Koliba 13 —formalized a state- and national-level network of nursing leaders and stakeholders, leveraging the 51 action coalitions and facilitating the sharing of resources and lessons learned. Learning collaborative members engaged community colleges, universities, health care providers, and the business community (to include nontraditional employers of nurses) to communicate the value of highly educated and trained nurses. 14

Four educational models. After this extensive grassroots outreach, the rich interaction framework of the learning collaborative was analyzed, and four educational models were identified as having the potential to help ensure that 80% of practicing RNs have a BSN or more advanced degree by 2020.

First is an ADN-to-BSN program in which the degree is conferred by a community college. It offers ADN nurses an opportunity to continue their education and receive a BSN in a community college setting. This model can be a less expensive and more accessible alternative to university BSN programs—for both students and financers.

The second model is the competency- or outcomes-based curriculum, in which university and community college partners develop a shared understanding, common goals, and a framework that provides students with a smooth transition from an ADN to a BSN program.

Third is an accelerated ADN-to-MSN program, which offers a shorter timeline to completion than traditional MSN programs. Its popularity has been driven by a shift in the nursing labor market, which now comprises more ADN graduates who are returning to school with the intention of obtaining an MSN. It is an accelerated model that values ADN practice, meets BSN criteria, provides seamless progression, and is university based.

The fourth model is a shared statewide or regional curriculum, which fosters collaboration between universities and community colleges, enabling students to transition automatically and seamlessly from an ADN program in a community college to a BSN program at a university. The schools share a curriculum, simulation facilities, and faculty. The implementation of this model requires adjustments to prerequisite and nursing curricula. 15

Forty-four of the 51 action coalitions are working on some aspect of academic progression using these four models, and schools in 30 states are enrolling students in programs that use at least one of the four.

The Academic Progression in Nursing (APIN) program is an initiative of the RWJF—in partnership with the Tri-Council for Nursing and administered by the AONE 16 —that collaborates with the CCNA, and with the state action coalitions and their partners, to help states move toward their goals. Currently, APIN is supporting nine action coalition projects that are refining and testing these four promising educational models as well as exploring additional innovative practices. 17, 18 (To learn about one APIN project, see An Academic-Practice Partnership .)

The CCNA also serves as the national program office for the RWJF's State Implementation Program (SIP), which supports 17 projects focusing on education initiatives. Thus, this powerful national network includes two major programs (SIP and APIN) with focused support for 26 specific projects. (For more information, see http://campaignforaction.org/apin and www.rwjf.org/en/grants/programs-and-initiatives/F/future-of-nursing--state-implementation-program0.html .)

In addition to the strong collaboration between community colleges and universities, the collaboration between entities in academic-practice partnerships is important in ensuring the sustainability of education transformation. Effective academic-practice partnerships, in which educational and clinical practice institutions cooperate to achieve mutual goals, create systems for nurses to achieve educational and career advancement, prepare nurses to practice and lead, and provide mechanisms for lifelong learning.

Employers should use data from a variety of sources to guide them in the development of a balanced mix of strategies and policies that promote academic progression in their workforce. It's especially important that academic-practice partners collaborate in the design and execution of programs to ensure the delivery of high-quality care to meet the health care needs of the communities they serve. APIN advises that in addition to evaluating educational outcomes, the analysis of employer practices, such as providing employees with financial and professional incentives to advance their education, should be part of this work. 19 The work of APIN and the AONE has strengthened the active role of practice partners in transforming nurse education. 16

Online and simulation education. The explosion of online and simulation education technology has increased nurses’ access to higher education through flexible delivery formats and increased capacity. Online education has increased access for students in rural areas and provided flexible scheduling for practicing nurses. 20 The National Council of State Boards of Nursing found strong evidence supporting the use of simulation as a substitute for up to 50% of traditional clinical time. 21 Since a lack of clinical practice opportunities is one of the major reasons nursing schools limit enrollment, clinical simulation could increase nursing education capacity significantly. Continuing to maximize online and simulation education strategies is an essential factor in providing nurses with better access to higher education.

An extensive network of stakeholders is sharing best practices and using a common language to describe these promising practices, with the goals of improving the nursing education system and ensuring that all nurses will be prepared to deliver safe, quality, patient-centered care across all settings. Sustaining the momentum, building on practice partnerships, and promoting the appropriate use of technology will be critical in ensuring that real and sustained change occurs.

The barriers and challenges to transforming the nursing education system are varied and complex, but there is currently a powerful drive to find and implement solutions. Both community college and university educators, as well as those working in practice settings, regulatory agencies, state boards of nursing, and professional nursing and education organizations, were convened by APIN in April 2014 in Washington, DC, to develop innovative sustainable solutions. Specific challenges documented in the literature that were discussed include defining national professional education standards, 22 rapidly increasing capacity while maintaining quality, 23 and reducing and avoiding confusion in the application of accreditation standards. Solutions were proposed for each challenge, and action steps were outlined.

A small group representing community college and university nursing programs, employers, regulators, and grantees were invited to analyze the data and suggest an ideal set of BSN program prerequisites and general education requirements for broader national consideration. A national standard of foundational courses for a BSN was proposed and disseminated, providing a framework for consistency across programs and smooth academic progression. There are wide variations in requirements, particularly for ADN and RN-to-BSN students. Programs can use national standards to ensure consistent professional foundations while streamlining both ADN-to-BSN and RN-to-BSN curricula. Additional bold and innovative solutions and strategies were proposed and will be implemented after further vetting.

SUCCESS STORIES

Achieving the needed transformation will be a marathon, not a sprint, so it is important to identify markers of success in order to sustain the momentum and keep fatigue and burnout at bay. How we prepare and motivate our professional colleagues in the first step of their education journey will affect each step they take thereafter. 24, 25

The first success stories are about people who advanced their education after feeling supported in their initial educational journeys.

Kayla is a home health nurse employed at a county health department who thoroughly enjoys her position and her patients. She believed that her associate's degree education provided her with a strong foundation, yet she also knew that continuing her education “would offer broader opportunities and expand my knowledge level.” She found that scheduling challenges were minimal when pursuing a BSN—she was able to take classes once a week at the hospital where she worked, and many classes were offered online.

Kayla ultimately plans to obtain a school nurse certificate and perhaps a master's degree. The strong partnership between Kayla's ADN-to-BSN and RN-to-BSN programs, coupled with the support of her employer, provides her with a smooth pathway to academic progression, setting the stage for lifelong learning.

Miguel, a retired veteran, developed an interest in nursing as a career after seeing fellow veterans struggle with mental health issues after discharge. Miguel was accepted into the ADN program at the community college he had previously attended. While pursuing his degree, a faculty member who recognized his potential and knew of his interests suggested he consider a future as an advanced practice nurse. This person helped him find a nearby university nursing school that offered an ADN-to-MSN program with a concentration in psychiatric–mental health nursing. Miguel was accepted into the program immediately.

Miguel earned a bachelor's degree while in the program and graduated with an MSN, with the intention of becoming a mental health NP in only three years. Miguel believes that having the option to participate in this ADN-to-MSN program is the only reason he can now care for his fellow veterans in an advanced practice role.

Significant progress has also been made in the number of nurses with doctoral degrees and graduates of RN-to-BSN programs. According to AACN survey data, enrollment in doctor of nursing practice (DNP) programs increased by 21.6% from 2012 to 2013; during that same time, the rate of enrollment in research-focused doctoral (such as PhD or DNSc) programs increased by 1.7%. 8 Figures compiled by the Campaign for Action based on this data 8 show that the number of graduates from doctoral programs, including DNP and research doctoral programs, have more than doubled, from 1,227 in 2009 to 3,069 in 2013.

The AACN data include the number of graduates of 512 RN-to-BSN programs accredited by the Commission on Collegiate Nursing Education, which increased by 12.4% last year. 8 Accelerating this initial progress and sustaining positive change will be the next challenge.

CALL TO ACTION

The nursing profession is coalescing around action steps to meet the urgent need for a more highly educated nursing workforce. First and foremost, nurses should commit to being lifelong learners who seek to attain the highest possible level of education. Now is the time to advance nursing education and take advantage of a renewed emphasis on streamlined curricula, accessible delivery formats, financial support, and employer incentives. Second, joining a state action coalition and at least one professional nursing organization is one way to support the many developments occurring at this time. Finally, nursing colleagues should aim to provide support, mentorship, coaching, and encouragement to one another as they engage in this important work.

There is growing evidence that patients benefit from a more highly educated nursing workforce. 3, 5-7 More highly educated nurses can also help to address the shortage of primary care and public health providers, nurse scientists, and nurse faculty; care for an older population with more complex health care needs; and promote wellness.

It's going to take all of us working together to give nursing students—and nurses already in the workforce—more options and opportunities and easier pathways to continue their education. We will all benefit when the nation has the diverse nursing workforce it needs.

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Nurses’ roles in changing practice through implementing best practices: A systematic review

Wilma ten ham-baloyi.

1 Faculty of Health Sciences, Nelson Mandela University, Port Elizabeth, South Africa

Associated Data

Data sharing is not applicable to this article as no new data were created or analysed in this study.

Nurses play an important role in the implementation of best practices. However, the role of nurses in changing practice by implementing best practices requires further exploration. No systematic review was found that summarised the best available evidence on the roles of nurses in changing practice through the implementation of best practices. This study summarised the best available evidence on the roles of nurses in changing practice through the implementation of best practices. A systematic review was used to search for studies in the English language, where a best practice was implemented in a clinical context and which included findings regarding the roles of nurses when implementing best practices. Scopus, EBSCOhost (Academic Search Ultimate, APA PsycInfo, CINAHL with Full Text, ERIC, Health Source: Nursing/Academic Edition, MasterFILE Premier, MEDLINE Complete), PUBMED, and ScienceDirect databases were searched from January 2013 to June 2021. The search generated 1343 citations. After removing duplicates and applying eligibility criteria, 27 studies were included. Five definite roles were identified as follows: leadership, education and training, collaboration, communication and feedback and development and tailoring of the best practice. These roles are interrelated, but equally crucial in order to implement best practices. This study found five interrelated but equally crucial nurse roles in changing practice through the implementation of best practices.

Contribution

The study’s findings and gaps identified can be used for further nursing research, improving practice change and health outcomes through the implementation of best practices and the role nurses can play in this process.

Introduction

Globally, in the last decades, there have been rapid changes in healthcare and nursing practice, based on the best available evidence, to improve patient, nursing and organisational outcomes whilst, at the same time, using resources efficiently (Cullen & Donahue 2016 ; Salmond & Echevarria 2017 ). A sustained change in practice through the implementation of best practices is required to improve health and patient outcomes such as length and costs of hospital stay (Leviton & Melichar 2016 ).

Research findings based on rigorous methods that have been identified as best evidence and evidence-based products such as evidence-based innovations, interventions, strategies, practice improvements, guidelines, initiatives, programmes or recommendations (in this study referred to as ‘best practices’) assist in changing health and nursing practice (International Council of Nurses 2012 ). However, implementation of best practices remains problematic (Greenhalgh, Howick & Maskrey 2014 ). Innovative ways are required to firstly translate best evidence, which is the application of knowledge (Graham et al. 2018 ) and thereafter implement the best practice. This is especially relevant for a healthcare and nursing environment that is increasingly competitive and has to operate in a cost-effective way (Salmond & Echevarria 2017 ).

Furthermore, there are various stakeholders who influence implementation of best practices or change in practice and these stakeholders are also affected by change in practice (Agency for Healthcare Research and Quality [AHRQ] 2016 ). Thus, there is a strong drive for stakeholders to be actively engaged in and to make committed decisions about changing practice (Norris et al. 2017 ). To do so, the roles of the various stakeholders in changing practice – which includes patients and their families, the nurses and other healthcare practitioners and the managers at micro, meso and macro levels of the health system – need to be understood. Understanding the roles of these stakeholders in changing practice will assist in a more effective and efficient implementation and uptake of innovative best practices and, ultimately, will improve healthcare outcomes (Leviton & Melichar 2016 ).

Nurses, as one of the stakeholders, play an important role in the implementation of best practices. However, the role of nurses in changing practice by implementing best practices is not always well understood (Kristensen, Nymann & Konradsen 2016 ). No systematic review was found that summarised the best available evidence on the roles of nurses in changing practice through the implementation of best practices. This review therefore aimed to summarise the best available evidence on the roles of nurses in changing practice through the implementation of best practices.

A systematic review was conducted to collect data, identify high-quality relevant studies and to synthesise the findings in a rigorous and comprehensive way so that a comprehensive picture of current best available evidence could be provided. In this case, the best available evidence on the roles of nurses in changing practice through the implementation of best practices as a preliminary search did not yield any systematic reviews. The systematic review was conducted according to the Systematic Review guidelines of the Joanna Briggs Institute (JBI). The following review question was formulated: ‘What is/are the role(s) of nurses in changing practice when implementing best practices’?

Search methods

Sources of evidence.

The following databases were searched: Scopus, EBSCOhost (Academic Search Ultimate, APA PsycInfo, CINAHL with Full Text, ERIC, Health Source: Nursing/Academic Edition, MasterFILE Premier, MEDLINE Complete), Pubmed and ScienceDirect.

A broad combination of keywords was used to search the literature on the topic. A set of keywords per database was selected to yield the most relevant studies. The following keywords were used: role OR function AND nurse OR nurses OR nursing AND implement* AND best practice OR best practices.

Inclusion criteria and exclusion criteria

Studies of the following levels of evidence, according to JBI ( 2016 ), were included: Level I Experimental studies: (c) randomised controlled trials (RCT), (d) pseudo-RCTs; Level II Quasi-experimental studies: (c) quasi-experimental prospectively controlled study, (d) pre-test, post-test/retrospective control group; Level III Observational Analytical studies: (c) cohort study with control group, (d) case controlled study, (e) observational study without a control group; Level IV Observational Descriptive studies: (b) cross-sectional study, (c) case series, (d) case studies. Only those studies published in English from January 2013 to June 2021 were eligible for selection.

Studies were included where a best practice was implemented in a healthcare or clinical context (inside or outside a hospital setting where nursing care is rendered, e.g. old age setting), published in English, which included findings regarding the roles of nurses when implementing best practices. Systematic types of reviews and non-research studies were excluded as well as studies that were not implementing best practices (e.g. studies where no intervention was implemented or not described, studies regarding the views on the role of nurses implementing best practices in general or general perceived facilitators and barriers).

The entire search strategy, including the choice of keywords and electronic databases was conducted with the assistance of an experienced librarian from the Nelson Mandela University. Similar assistance was provided in obtaining studies, some via Inter-Library Loan services.

Search outcome

For this study, the following steps for selection were followed:

• The researcher read titles and abstracts (whereby irrelevant studies were excluded according to the pre-determined inclusion and/or exclusion criteria).
• Possible relevant literature was selected in order to obtain full-text. The researcher read the full text of potentially relevant studies and selections for inclusion were made according to pre-determined inclusion and/or exclusion criteria.
• When no full text could be obtained to determine inclusion and/or exclusion of an article, Inter-Library Loan services was used and authors were contacted.

EndNote X9 was used for data management, obtaining full-texts and for deduplication. The search and selection process is outlined in Figure 1 .

Search and selection process.

As a result of the literature search, 1343 initial hits were imported from electronic databases. After removing 456 duplicates, 887 titles and abstracts were read. A total of 823 were excluded as they did not meet inclusion criteria. From the remaining titles, total of 59 full-texts were obtained as five articles could not be located. Reading of the 59 articles led to exclusion of a further 29 articles, based on the study criteria.

Critical appraisal

A total of 30 studies fulfilled the review criteria and were included for critical appraisal. Appraisal was done using various tools, according to the different research designs or levels of evidence of the literature, including the various 64 JBI (Pearson, Jordan & Munn 2012 ) tools, including: checklist for analytical cross-sectional studies ( n = 2), checklist for cohort studies ( n = 1), checklist for qualitative research ( n = 7); checklist for quasi-experimental studies ( n = 2) (JBI 2021 ).

The following critical appraisal tools were found most suitable but were not available through JBI: The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: guidelines for reporting observational studies (Von Elm et al. 2007 ) ( n = 16), Mixed Methods Appraisal Tool (MMAT) (Hong et al. 2018 ) ( n = 1) and the Effective Practice and Organization of Care Risk of Bias (EPOC RoB) tool for retrospective observational studies such as audits, developed by Cochrane (eds. Higgins et al. 2019 ) ( n = 1).

To reduce bias in review selection and to ensure that the appraisal was performed in a rigorous way, whilst allowing for appropriate consensus, the appraisal was conducted by two reviewers independently using the same critical appraisal tools. The outcome of the critical appraisals was shared amongst the researcher and independent reviewer during a meeting and consensus was achieved in terms of inclusion or exclusion of literature. Out of the total of 30 articles that were included for critical appraisal, three observational studies using audits were excluded because of weak rigour (see Figure 1 ).

Data extraction

Data extraction from the sample was done by recording relevant elements of studies regarding the topic in a tabular format. Headings in the table included: study reference, design, level of evidence, sample and setting, best practice and change strategy and findings relevant to the topic.

Data synthesis

For this review because of the heterogeneous nature of the study designs included thematic analysis, which was done to synthesise the extracted findings of each study, followed by a classification of findings and a summary of findings under thematic headings (as formulated in Academy of Nutrition and Dietetics [ 2012 ]).

Ethical considerations

This study obtained ethical approval from the University’s Faculty Postgraduate Studies Committee (ethics number: H19-HEA-NUR-008). The author adhered to the principles of honesty and transparency in reporting the data. In line with recommendations of Vergnes et al. ( 2010 ), participant consent was not obtained because this study had no participants.

Quality of evidence

The majority of studies ( n = 17) were observational analytical studies: Level III(e) evidence and Level IV evidence ( n = 7, of which n = 4 IV(b) and n = 3 IV(d)). Two other studies ( n = 2) included Level II(d) evidence. One ( n = 1) mixed method study included both Level III(e) and Level IV(b) evidence (JBI 2016 ).

Healthcare or clinical context

Studies were from a variety of healthcare or clinical contexts, with the majority ( n = 20) from a hospital setting. Of these, n = 14 were conducted in specialised hospital-based settings, including: medical and surgical wards ( n = 2) (Siegel 2020 ; Travers et al. 2018 ), paediatric settings ( n = 2) (Rosenberg et al. 2016 ; Yu et al. 2017 ), postnatal ward ( n = 1) (Anderson & Kynoch 2017 ), neonatal intensive care unit ( n = 1) (Ceballos et al. 2013 ), surgical ward ( n = 1) (Hu et al. 2019 ), haemodialysis centre ( n = 1) (Jia et al. 2016 ), haematology–oncology ( n = 1) (Naseer et al. 2017 ), orthopaedic ward ( n = 1) (Ong et al. 2017 ), medical ward ( n = 1) (Ullrich, McCutcheon & Parker 2015 ), intensive care unit ( n = 1) (Chiwaula et al. 2021 ), in-patient rehabilitation ( n = 1) (Mullins 2021 ) and a neurology department (Sheng et al. 2020 ).

A total of five ( n = 5) studies were from outside hospital settings, including long-term care ( n = 2) (Kilpatrick et al. 2020 , Mitchell 2017 ), homecare centres ( n = 1) (Bayly et al. 2018 ), acute ambulatory settings ( n = 1) (Chong et al. 2013 ) and a general practitioner (GP) practice ( n = 1) (Williams et al. 2020 ).

Two ( n = 2) studies were conducted inside and outside hospital settings. One of these studies was conducted in both a residential age-care facility and hospital setting (Ullrich, McCutcheon & Parker 2014 ) and the other study was conducted in a hospital setting (inpatient, acute care medical or surgical, intensive care units) and in a long-term care setting (progressive care/stepdown, community home, long-term care, rehabilitation, palliative/hospice care and spinal cord injury) (Becker et al. 2020 ).

Studies were conducted in a variety of countries, including Australia ( n = 6), United States of America ( n = 6), Canada ( n = 4), China ( n = 4), Singapore ( n = 3), United Kingdom ( n = 2), Malawi ( n = 1) and Thailand ( n = 1).

Best practices and implementation strategies for change

In total, seven ( n = 7) best practices and 11 ( n = 11) implementation strategies for change were identified from the included studies. The best practices included: best practice, intervention, strategy, guideline, initiative, programme and recommendation. The implementation strategies included: educational sessions or workshops, (development of) educational material, champion or knowledge broker, discussions, evaluation and feedback, development of an evidence-based practice (EBP) product, employing team or specialists, meetings, observations, equipment, assessments or examinations. Table 1 outlines the best practice and implementation strategies for change, per included study.

Best practices and implementation strategies for change ( n = 27).

EBP, evidence-based practice.

As outlined in Table 1 , included studies indicated a variety of implemented best practices, with best practice or intervention being mostly identified as best practice. Various implementation strategies for change were used, but most studies used more than one strategy, up to six strategies and had an element of education and leadership.

Roles of nurses

Eleven ( n = 11) of the included studies were nurse-led quality improvement projects, in which a team was formed in the clinical setting with nurses who took the lead and facilitated change through the implementation of the best practice in this setting (Anderson & Kynoch 2017 ; Bayly et al. 2018 ; Ceballos et al. 2013 ; Chong et al. 2013 ; Hu et al. 2019 ; Jia et al. 2016 ; Monkong et al. 2020 ; Naseer et al. 2017 ; Ong et al. 2017 ; Travers et al. 2018 ; Yu et al. 2017 ).

Five definite roles were identified: leadership, education and training, collaboration, communication and feedback and development and tailoring of the best practice. These roles are further described in the following subsections.

Leadership played a role in almost all studies ( n = 21). This could be individuals, for example, a clinical champion (Allen et al. 2018 ; Becker et al. 2020 ), a (clinical) team leader (Anderson & Kynoch 2017 ; Chong et al. 2013 ), a project leader (Hu et al. 2019 ; Mullins 2021 ; Yu et al. 2017 ) or nurse leader (Ceballos et al. 2013 ), a nurse clinician (Nazeer et al. 2017; Ong et al. 2017 ), a knowledge broker (Bayly et al. 2018 ), a practice facilitator (Shade et al. 2020 ), Facilitator CogChamps (Travers et al. 2018 ), a programme or project coordinator (Fleiszer et al. 2015 , 2016 ; Monkong et al. 2020 ) or an audit team leader (Jia et al. 2016 ). In some studies, the leader was the researcher (Mitchell 2017 ) or part of the research team (Kilpatrick et al. 2020 ; Rosenberg et al. 2016 ; Williams et al. 2019 ).

Roles of leaders included:

• recruitment of participants (Becker et al. 2020 )
• facilitating the implementation of the best practice (Anderson & Kynoch 2017 )
• creating educational material (e.g. a computer-based educational module, completion of a comprehensive literature review to inform the educational intervention) (Ceballos et al. 2013 ; Yu et al. 2017 ).
• communication (e.g. sending staff electronic communication with information about the best practice and why practice changes were necessary [Ceballos et al. 2013 ]; explain roles and responsibilities to every team member in fortnightly meetings [Chong et al. 2013 ]; introduce the project to the members and project timelines [Becker et al. 2020 ; Naseer et al. 2017 ])
• data analysis, interpretation of data and report writing (Ceballos et al. 2013 ; Chong et al. 2013 ; Yu et al. 2017 )
• managing the project, process control and promotion and keeping timelines (Monkong et al. 2020 ; Mullins 2021 ; Yu et al. 2017 )
• role modelling in terms of enthusiasm (Chong et al. 2013 ; Yu et al. 2017 ; Williams et al. 2019 ), commitment (Chong et al. 2013 ; Williams et al. 2019 ), approachability, sound clinical knowledge and legitimacy (Williams et al. 2019 ), ability to communicate clearly, being tenacious (keep on going when some nurses showed disinterest) and being able to think creatively about patients and patient care (Travers et al. 2018 )

Education and training

Education and training were found to play a big role in nurses implementing best practices in the majority of the studies ( n = 21). Education and training were sometimes provided by the nurse leader (Shade et al. 2020 ; Travers et al. 2018 ; Yu et al. 2017 ).

Education focused mainly on nursing/healthcare staff in terms of educational sessions (Mitchell 2017 ; Monkong et al. 2020 ; Naseer et al. 2017 ), such as ward-based in-service training (Anderson & Kynoch 2017 ; Chong et al. 2013 ; Hu et al. 2019 ), (1-day) training/workshop (Chiwaula et al. 2021 ; Fleiszer et al. 2015 ; Shade et al. 2020 ; Travers et al. 2018 ), two half-day training sessions including formal presentations, video demonstration of the delivery of the best practice, participative learning and practice sessions (Williams et al. 2020 ), an educational programme (Yu et al. 2017 ), a lecture (Siegel 2020 ), a multimedia educational framework (Rosenberg et al. 2016 ; Sheng et al. 2020 ), online educational videos (Siegel 2020 ), online modules or courses (Bayly et al. 2018 ; Ceballos et al. 2013 ; Williams et al. 2019 ), along with educational tools such as notebooks containing hard copies of online training (Ceballos et al. 2013 ).

Other educational tools and strategies included: user guide (Kilpatrick et al. 2020 ), demonstration of sample scripts (Ong et al. 2017 ), scripts to educate patients (Siegel 2020 ) and documents and ‘informants’ with knowledge (Fleiszer et al. 2015 ). Training of the stakeholders (e.g. volunteer practice change advocates) in the implementation of best practices (Fleiszer et al. 2015 ) and daily practice under supervision (Chong et al. 2013 ) was also done.

As part of the implementation, nurses also used patient education through the development and use of educational tools such as hand-outs (Anderson & Kynoch 2017 ), a patient education leaflet (Hu et al. 2019 ), an educational booklet (Bayly et al. 2018 ) and pamphlets, posters or slides using an iPad (Jia et al. 2016 ).

The impact of education and training as part of the implementation of best practices for nurses was that it imparted knowledge, increased nurses’ empathetic and adaptable problem-solving skills, raised awareness and compliance with best practices amongst nurses and made nurses more confident in their roles (Allen et al. 2018 ; Naseer et al. 2017 ; Shade et al. 2020 ; Travers et al. 2018 ; Williams et al. 2019 ; Yu et al. 2017 ).

Collaboration

Changing practice was often performed through a collaborative effort, as found in most studies ( n = 20). For example, the nurse often led and formed a team with other nurses (Chiwaula et al. 2021 ; Chong et al. 2013 ; Fleiszer et al. 2016 ; Jia et al. 2016 ; Mitchell 2017 ; Naseer et al. 2017 ; Ong et al. 2017 ; Ullrich et al. 2015 ; Yu et al. 2017 ). Alternatively, a nurse led and collaborated with multiple health professionals besides nurses (specialists and managers) in a team in order to implement the best practice (Allan et al. 2018). Such teams including mainly medical staff/directors (Ceballos et al. 2013 ; Hu et al. 2019 ; Kilpatrick et al. 2020 ; Monkong et al. 2020 ; Rosenberg et al. 2016 ; Shade et al. 2020 ), as well as other professions such as a lactation consultant (Anderson & Kynoch 2017 ), a researcher (Bayly et al. 2018 ), a clinical pharmacist (Rosenberg et al. 2016 ), a respiratory specialist (Ceballos et al. 2013 ) and a dietician (Mullins 2021 ). One study also collaborated with a patient’s family as part of the interventions (Mullins 2021 ).

The various team members or stakeholders served as support (Anderson & Kynoch 2017 ; Chong et al. 2013 ; Kilpatrick et al. 2020 ; Naseer et al. 2017 ; Travers et al. 2018 ). Collaboration overcame challenges (Chong et al. 2013 ), enhanced care policies based on best evidence (Rosenberg et al. 2016 ), enhanced accountability (Fleiszer et al. 2016 ), raised collective awareness and expectations for practice, leading to a change in culture, empowerment, mutual respect and communication (Ceballos et al. 2013 ).

Communication and feedback

Besides education, communication and feedback by nurses played an important role in the implementation of the best practice and often facilitated the implementation and uptake of the best practice, as found by more than half ( n = 16) of the studies. Pre-implementation of the best practice, communication was done through meetings or brain storming sessions with ward stakeholders to discuss current practices (Monkong et al. 2020 ) or outlining the project audit (data collection) and timelines (Anderson & Kynoch 2017 ; Hu et al. 2019 ).

During the implementation, discussions or (feedback) meetings were held to present baseline audits and to gather feedback about the project (Anderson & Kynoch 2017 ; Becker et al. 2020 ; Chong et al. 2013 ; Fleiszer et al. 2015 ; Hu et al. 2019 ; Mullins 2021 ; Naseer et al. 2017 ; Shade et al. 2020 ), to discuss barriers to the implementation of the best practice (Jia et al. 2016 ; Mullins 2021 ; Naseer et al. 2017 ; Ong et al. 2017 ; Shade et al. 2020 ; Ullrich et al. 2014 , 2015 ; Yu et al. 2017 ) and how to overcome the barriers (Mullins 2021 ; Shade et al. 2020 ; Ullrich et al. 2014 , 2015 ; Yu et al. 2017 ), to develop and further improve strategies for implementation (Ceballos et al. 2013 ; Naseer et al. 2017 ; Ong et al. 2017 ) and to discuss progress (Rosenberg et al. 2016 ).

Post-implementation communication was used to brief stakeholders regarding the evaluation of the intervention (Chong et al. 2013 ; Fleiszer et al. 2015 ; Ong et al. 2017 ; Ullrich et al. 2015 ), to discuss how to overcome future barriers (Ong et al. 2017 ; Shade et al. 2020 ) or to celebrate success (Shade et al. 2020 ). Communication was also done online regarding the intervention (Becker et al. 2020 ; Ceballos et al. 2013 ), using emails (Naseer et al. 2017 ; Rosenberg et al. 2016 ) and text messages (Naseer et al. 2017 ).

Ongoing communication and feedback assisted in facilitating the implementation of best practices as it led to the creation of a supportive rapport, which increased engagement (Anderson & Kynoch 2017 ), compliance (Hu et al. 2019 ) and both technical and personal support for the project (Anderson & Kynoch 2017 ; Hu et al. 2019 ). It further helped to keep the knowledge translation strategies on track (Bayly et al. 2018 ; Shade et al. 2020 ), enhance the collaborative processes, enhance the ability to learn from peers’ professional experiences and share and use new information learned (Bayly et al. 2018 ). Finally, ongoing communication helped to identify barriers (Ceballos et al. 2013 ; Hu et al. 2019 ) and enhanced sustainability of the change (Becker et al. 2020 ).

Development and tailoring of the best practice

Nurses play a role in the development and tailoring of the best practice, including the development of intervention materials as part of the implementation, as found in more than half ( n = 16) of the included studies. The roles of nurses mainly involved developing an action plan (knowledge translation) or strategies, which was often done through informal discussions with nursing/midwifery staff and identifying barriers and facilitators of planned practice change (Anderson & Kynoch 2017 ; Bayly et al. 2018 ; Becker et al. 2020 ; Chong et al. 2013 ; Hu et al. 2019 ; Jia et al. 2016 ; Monkong et al. 2020 ; Naseer et al. 2018; Ong et al. 2017 ). Development of the best practice activities were also done (Sheng et al. 2020 ; Ullrich et al. 2015 ).

Other roles included developing educational material based on best evidence as part of the best practice, such as educational content, posters and hand-outs (Anderson & Kynoch 2017 ; Travers et al. 2018 ), videos and slides and a nursing newsletter (Becker et al. 2020 ), a computer-based educational module (Ceballos et al. 2013 ) and notebooks containing hardcopies of the online training information or information/resource booklet (Bayly et al. 2018 ; Ceballos et al. 2013 ).

Checklists to assist nurses to care for patients (Travers et al. 2018 ), a structured tool based on communication skills, workflows and reminder cards (Yu et al. 2017 ) and audit tools to evaluate the best practices were developed by nurses to be implemented as part of the best practice (Becker et al. 2020 ; Chong et al. 2013 ). In one study regarding improving the quality of care for hospitalised patients with cognitive impairment (Travers et al. 2018 ), nurses developed resources (e.g. card games, camouflage aprons/fiddle blankets) for patients to use whilst in hospital as part of the implemented best practice.

This review highlighted five definite roles nurses play in the implementation of best practices: leadership, collaboration, education and training, communication and feedback and development and tailoring of the best practice. The importance of the leadership role nurses play in this regard was also discussed elsewhere (Bianchi et al. 2018 ; Vogel et al. 2021 ). In this review, multiple sub-roles in the nurses’ leadership role in the implementation of best evidence were identified, including recruitment, developing the educational intervention and data analysis. However, it seems from this study that behaviour such as role-modelling, plays a big role in the success of practice change, as found elsewhere (Whitby 2018 ). Furthermore, for nurses to be equipped for this leadership role, they need to have the necessary educational and managerial support and resources required for implementation of best practices (Bianchi et al. 2018 ).

Education and training were found to be one of the major roles, with multiple benefits, that the nurse can play in changing practice. These findings confirmed those of Davis and D’Lima ( 2020 ), who found that teaching and training initiatives can build capacity in dissemination and implementation of best practices. However, the authors also found a need to increase the number of training opportunities to enhance the number of researchers and practitioners who implement best practices.

Changing practice was often carried out through a collaborative effort with other (specialist) nurses and stakeholders, as part of an interdisciplinary team. The concept of the (interdisciplinary) team approach is widely accepted as the ‘gold standard’ of care delivery globally, influencing patient, nursing and organisational outcomes and policy development which, taken together, are aspired for achievement of high-quality care (Ansell, Sørensen & Torfing 2017 ; Soukup et al. 2018 ). Collaboration in changing practice should be fostered through engagement and involvement (Holmes et al. 2019 ), preferably early in implementation as, from the studies included, collaboration showed multiple benefits. Furthermore, evidence-based practice also includes the patient and families as part of clinical decision-making. However, the nurses’ collaboration with the patient during the implementation of best practices was not highlighted in most included studies. Therefore, the collaborative roles of nurses with patients and families when implementing best practices should be further explored.

The nurse also had a role in ongoing communication and feedback when implementing best practices. Doing so could improve care for an increased number of patients and enhance cost-effectiveness (Brown et al. 2019 ). Leaders also have a role in enhancing the facilitation of communication. It is important that they are trained in using various platforms for communication in order to facilitate the implementation of the best practice.

Nurses also had a role in development and tailoring of the best practice. As the included studies were conducted in different clinical contexts, with different resources, using a variety of implementation strategies, a needs assessment and intervention mapping – which refers to planning the implementation of best practices based on using theory and evidence – could assist in systematically tailoring a best practice for both nurses and patients and their families (Van Belle et al. 2018 ).

These identified five roles are interrelated but equally crucial in order to implement best practices. For example, the leadership role will not be fully executed without education and training or collaboration. Communication was found to enhance teamwork (Bayly et al. 2018 ).

This review found several best practices and implementation strategies. However, studies were found from predominantly middle- and high-income countries. More nurse-led intervention studies describing the role of nurses in the implementation of best practices could therefore be conducted in lower- and middle-income countries where resources are often limited and where the role of nurses is inclined to be more innovative and cost-effective in order to implement these best practices (WHO 2020 ). Finally, there is a need for nurse-led quality improvement studies to be conducted to produce Level I (e.g. randomised controlled trials) as no such studies were identified.

Conclusions

The role of nurses in changing practice by implementing best practices is not always well understood. This study found five interrelated, but equally crucial nurse roles in changing practice through the implementation of best practices, namely leadership, education and training, collaboration, communication and feedback and development and tailoring of the best practice. Further exploration on the roles of nurses in changing practices, using randomised controlled trials, including low- and middle-income settings, is required. The study’s findings and identified gaps can be used for further nursing research and education to improve the implementation of best practices and enhance the role nurses can play in this process, thus enhancing patient, nursing and organisational outcomes.

Acknowledgements

The author would like to thank Vicki Igglesden for editing the article.

Competing interests

The author declares that she has no financial or personal relationships that may have inappropriately influenced her in writing this article.

Author’s contributions

W.T.H.B. is the sole author of this review article.

Funding information

This work is based on the research supported in part by the National Research Foundation of South Africa in partnership with FUNDISA for the PLUME grant (unique reference: FUNDISA/NRF 2019/009). Any opinion, finding and conclusion or recommendation expressed in this material is that of the author. The NRF and FUNDISA do not accept any liability in this regard.

Data availability

The views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of any affiliated agency of the authors.

How to cite this article: Ten Ham-Baloyi, W., 2022, ‘Nurses’ roles in changing practice through implementing best practices: A systematic review’, Health SA Gesondheid 27(0), a1776. https://doi.org/10.4102/hsag.v27i0.1776

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