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A Primer on the Politics of Partnership between Education and Regulation
A PRIMER
POLITICS OF BETWEEN EDUCATION REGULATION
ON THE
PARTNERSHIP AND
KAREN BURKE, MS, RN,⁎ SUSAN MOSCATO, EDD, RN,†
AND
JOANNE WARNER, DNS, RN‡
Too often there is a separation between education and regulation, as functions appear different, yet are truly complementary. Described is an exemplar of a successful education–regulation partnership that advanced the development of an innovation, the dedicated education unit. The work of building relationships, communication, mutual need and goal setting, and trust building are described in the context of innovation within a regulatory environment that can lead to empowerment and change. (Index words: Education; Regulation; Partnership) J Prof Nurs 25:349–351, 2009. © 2009 Published by Elsevier Inc.
T
HE POLITICS OF partnership can be framed in terms of relationships, timing, and strategic intent. At no time is it more important to understand and be fluid in the skills of partnership development than now. The challenges presented by the broken health care system, overtaxed and often inefficient educational system, and outdated strategies and practices require new thinking and collaboration through partnering to support innovation and achieve a desired future. Innovation is not for the timid, and it is not a quick fix. Innovation by definition involves change, risk, and action. It requires resistance of the status quo's inertia and surmounting the perceived and tangible barriers to change. In education, it is common to hear “we've never done it that way” or “our state board won't allow that here” when a new idea is suggested. In nursing, we often hear “I don't have the power to do that.” Understanding the potential barriers, incentives for innovation, and the inescapable politics can aid those leading the innovation. One aspect of nursing education that is both ripe for and resistant to innovation is clinical teaching. Effective clinical education requires a partnership between educators, practice, and regulators. A trusting relationship among these partners, a commitment to shared goals, open communication, and a willingness to take risks are ⁎Nursing education consultant (formerly on Oregon State Board of Nursing). †Associate Dean and Professor, University of Portland, Portland, OR. ‡Dean and Professor, University of Portland, Portland, OR. Address correspondence to Ms. Burke, 92924 Knappa Dock Road, Astoria, OR 97103. E-mail: [email protected] 8755-7223/09/$ - see front matter
essential for change in clinical nursing education. This primer was developed from lessons learned as one nursing program worked with practice partners and the regulatory board to bring life to a vision of a new model of clinical teaching: the dedicated education unit (DEU). Our recommendations emerge from the success of our project. They are presented to encourage other nurse leaders to effect change through productive partnerships with regulatory bodies.
Doing the Work of Building Relationships Building a relationship takes time and intentionality. Key components are open ongoing transparent communication, identifying common needs and shared goals, and developing trust.
Communication A structure that provides for open and frequent communication among partners is a key element. In our case, a coalition of nurse leaders and the board of nursing formed around the impending nursing shortage. This coalition became the vehicle for engagement and provided the communication structure for identifying mutual needs, joint problem solving, and information sharing. With the coalition, there was a spirit of transparency and commitment to not withhold problems, concerns, or ideas. The open nature of the communication (closely linked to the concept of trust) assures that even when missteps occur, the responses were characterized by resolution and not retribution. “Sacred cows” were named and thereby had their effect lessened by exposure to the light of day. The result of strong communication is collaborative, mutually beneficial relationships.
Journal of Professional Nursing, Vol 25, No 6 (November–December), 2009: pp 349–351 © 2009 Published by Elsevier Inc.
349 doi:10.1016/j.profnurs.2009.10.002
350
BURKE, MOSCATO AND WARNER
Mutual Needs and Shared Goals Innovation is influenced by social and organizational context. Although the functions vary, education and regulation are connected in a myriad of ways. Protecting public safety is the ultimate goal and purpose of regulators; educators and practice partners share this goal, preparing graduates to be safe and effective practitioners. Social and organizational pressures impacting the achievement of this goal provide the opportunity to work together in new ways to achieve a common purpose. In Oregon, the coalition's 5point strategic plan to combat the nursing shortage emerged as our mutual goals. These goals included doubling enrollment and using resources more efficiently (Oregon Center for Nursing, 2006).
Trust The social network of all partners is characterized by reciprocal confidence in the other's ability, intentions, and character. This trust is both personal and professional. Trust frees the collaborators to focus energy on shared goals and not in search of nefarious agendas or distractions. Trust takes time to develop, and it must sometimes be facilitated when the stakes are perceived to be risky or when a perceived or real loss of status, role, or function for one or more of the stakeholders is likely (Ryan & Oestreich, 1991). At a working level, trust is earned by a focus on shared goals, demonstrated through knowledge, competence, honesty, and equality. Because trust is foundational, intentional steps are necessary to build it. Those steps include assessing assumptions about one another, seeking confirmation or refutation of the assumptions, and a reciprocal commitment to trust. In our case, trust was enhanced by our appreciation of the expertise of the other; credibility was enhanced by knowledge that each partner spoke for their represented entity.
Innovation Within Existing Rules and Resources Innovation starts with the assessment of existing resources through new lenses. As we began our conceptualization of the DEU model, an early conversation with our state board of nursing explored opportunities for innovation within existing law. We learned that our innovation could work within the current rules if we were able to justify and validate certain questions related to student safety, patient safety, and effective learning. Many, if not most, nurse practice acts specify instructor-to-student ratios for clinical practice. Generally, the community of nurse educators identifies the ratio based on traditional clinical education models. Innovation, by its nature, breaks away from the traditional model driving regulatory language for nursing education. Working within an atmosphere of trust and open communication allows the focus to be on shared goals and regulatory purpose, not on language. Traditional clinical instructor and nurse preceptor roles change in the DEU model. The staff nurse provides direct clinical supervision and instruction, whereas the
faculty member serves as a resource and clinical coordinator. Patient and student safety and effective learning are assured through the dual roles of the nurse preceptor and the clinical faculty, thus staying within the intent and purpose of regulatory language (Moscato, Miller, Logsdon, Weinberg, & Chorpenning, 2007). Existing regulatory language for nursing education in Oregon allows appointment of experienced, baccalaureate-prepared nurses as clinical instructors. Most nurses on DEUs meet these qualifications for appointment as a clinical instructor, allowing the DEU model to develop within existing resources and rule language. Experienced, master's-prepared nurse educators provided clinical coordination, orientation, mentoring, and guidance.
Empowerment and Change Partnership is sustained through planned and purposeful activities. Established partnerships with requisite trust and communication elements are nimble and able to take advantage of opportunities because the members feel empowered. In this culture, people believe it is their right and responsibility to change. This empowered attitude may seem peculiar in the stable education culture known for protecting the status quo and the regulatory culture that controls and governs by rule making. However, the empowerment contributes to an expectation and creates the space for the creativity required for innovation. Behind this empowerment is the assumption that support and resources exist or can be found; a spirit of sufficiency and abundance leaves little room for the scarcity model. The vision that is shared by all partners drives the innovation. When this vision is for the future, there is a unity that allows the group to be less rule based and traditional. Stating the future outcomes frees thinking from present processes. Out of innovations such as the DEU come recognition of the need to provide for innovation within the regulatory structure. In our case, education/regulation collaboration with the DEU model led to a redefinition of faculty roles and responsibilities, flexible application of faculty-to-student ratios, challenging of traditional clinical education models, and facilitation of partnerships between educators, health care providers, and regulators. Innovation by definition is something new, but not all things new are better. Thus, a key expectation is that when a partner brings forth a new idea, that the design is well thought out, has evidence that is principle based when possible, and fits the mutually agreed upon goals. Partners must be open to feedback, shared problem solving, commitment of resources, and evaluation of outcomes. In the politics of good partnership, there is the courage to take risks and not require a safe haven for all ideas and efforts. Courage is the confidence to try—whether the innovation is called a pilot project, experiment, or a research proposal. Courage produces the state of mind that sees possibilities not barriers (Hornstein, 1986). With today's emphasis on safety and quality, it is easy to dial back ideas to assure only success. The point of courage is not reckless risk taking but rather a brave spirit
EDUCATION AND REGULATION
to embrace new thinking. Even with these safeguards, failure will occur—defining failure as falling short of the agreed upon expectations—but it can be that in failure, learning takes place and innovations can arise. We recommend a spirit of courage so highly that we suggest building safe ways to admit failure honestly and the opportunity to redirect energy in a new direction. We endorse the ideas from the National League for Nursing Innovation in Nursing Education Task Force Group (2009) and the National Council of State Boards of Nursing (2009) that state boards consider adopting a rules provision for innovation. Rules written for the weakest programs should not be allowed to inhibit innovation necessary for the effective education of future generations. The courage required for innovation should pervade the culture rather than being held by a few brave outliers. However, an innovation often has a “champion” or an influential person willing to throw support to the cause and is usually a higher risk taker (Rogers, 1995). We found success in identifying and naming champions for our DEU clinical teaching model change. Nursing managers, innovator/early adopter RN, designated facilitators, and Oregon State Board of Nursing educational consultant representing service, academe, and regulation courageously wore the mantle of DEU champion and became the risk-taking influencers of change.
Conclusion The lessons from this political partnership suggest the requisite attitudes and processes to accomplish change. When educators, practice partners, and regulators work together toward common goals, opportunities are found,
351
risks are taken, and innovation is encouraged. Furthermore, innovation provides evidence to drive policy and regulation, helping define the future. Rather than antagonistic relationships or siloed responsibilities, education and regulation are shown in the Oregon experience as productive partners in the creation of new methods of clinical teaching. If regulators and educators share the same table to create change, acceleration of change is a likely outcome.
References Hornstein, H. A. (1986). Managerial courage: Revitalizing your company without sacrificing your job. New York: John Wiley & Sons. Moscato, S. R., Miller, J., Logsdon, K., Weinberg, S. & Chorpenning, L. (2007). Dedicated education unit: An innovative clinical partner education model. Nursing Outlook, 55, 31–37. National Council of State Boards of Nursing. (2009). Fostering innovation in nursing education. Leader to Leader, 3. NLN Innovation Task Group. (2009). How can state boards of nursing encourage curricular reform? Nursing Education Perspectives, 30, 59–61. Oregon Center for Nursing. (2006). Oregon Nursing Leadership Council strategic plan: Solutions to Oregon's nursing shortage. Retrieved from http://www.oregoncenterfornursing.org/documents/ONLC%20strategic%20plan%20final% 205-15-06.pdf. Rogers, E. (1995). Diffusion of innovations. (4th ed.). New York: The Free Press. Ryan, K. D. & Oestreich, D. K. (1991). Driving fear out of the workplace: How to overcome the invisible barriers to quality, productivity, and innovation. San Francisco: Jossey-Bass.
POLITICS OF BETWEEN EDUCATION REGULATION
ON THE
PARTNERSHIP AND
KAREN BURKE, MS, RN,⁎ SUSAN MOSCATO, EDD, RN,†
AND
JOANNE WARNER, DNS, RN‡
Too often there is a separation between education and regulation, as functions appear different, yet are truly complementary. Described is an exemplar of a successful education–regulation partnership that advanced the development of an innovation, the dedicated education unit. The work of building relationships, communication, mutual need and goal setting, and trust building are described in the context of innovation within a regulatory environment that can lead to empowerment and change. (Index words: Education; Regulation; Partnership) J Prof Nurs 25:349–351, 2009. © 2009 Published by Elsevier Inc.
T
HE POLITICS OF partnership can be framed in terms of relationships, timing, and strategic intent. At no time is it more important to understand and be fluid in the skills of partnership development than now. The challenges presented by the broken health care system, overtaxed and often inefficient educational system, and outdated strategies and practices require new thinking and collaboration through partnering to support innovation and achieve a desired future. Innovation is not for the timid, and it is not a quick fix. Innovation by definition involves change, risk, and action. It requires resistance of the status quo's inertia and surmounting the perceived and tangible barriers to change. In education, it is common to hear “we've never done it that way” or “our state board won't allow that here” when a new idea is suggested. In nursing, we often hear “I don't have the power to do that.” Understanding the potential barriers, incentives for innovation, and the inescapable politics can aid those leading the innovation. One aspect of nursing education that is both ripe for and resistant to innovation is clinical teaching. Effective clinical education requires a partnership between educators, practice, and regulators. A trusting relationship among these partners, a commitment to shared goals, open communication, and a willingness to take risks are ⁎Nursing education consultant (formerly on Oregon State Board of Nursing). †Associate Dean and Professor, University of Portland, Portland, OR. ‡Dean and Professor, University of Portland, Portland, OR. Address correspondence to Ms. Burke, 92924 Knappa Dock Road, Astoria, OR 97103. E-mail: [email protected] 8755-7223/09/$ - see front matter
essential for change in clinical nursing education. This primer was developed from lessons learned as one nursing program worked with practice partners and the regulatory board to bring life to a vision of a new model of clinical teaching: the dedicated education unit (DEU). Our recommendations emerge from the success of our project. They are presented to encourage other nurse leaders to effect change through productive partnerships with regulatory bodies.
Doing the Work of Building Relationships Building a relationship takes time and intentionality. Key components are open ongoing transparent communication, identifying common needs and shared goals, and developing trust.
Communication A structure that provides for open and frequent communication among partners is a key element. In our case, a coalition of nurse leaders and the board of nursing formed around the impending nursing shortage. This coalition became the vehicle for engagement and provided the communication structure for identifying mutual needs, joint problem solving, and information sharing. With the coalition, there was a spirit of transparency and commitment to not withhold problems, concerns, or ideas. The open nature of the communication (closely linked to the concept of trust) assures that even when missteps occur, the responses were characterized by resolution and not retribution. “Sacred cows” were named and thereby had their effect lessened by exposure to the light of day. The result of strong communication is collaborative, mutually beneficial relationships.
Journal of Professional Nursing, Vol 25, No 6 (November–December), 2009: pp 349–351 © 2009 Published by Elsevier Inc.
349 doi:10.1016/j.profnurs.2009.10.002
350
BURKE, MOSCATO AND WARNER
Mutual Needs and Shared Goals Innovation is influenced by social and organizational context. Although the functions vary, education and regulation are connected in a myriad of ways. Protecting public safety is the ultimate goal and purpose of regulators; educators and practice partners share this goal, preparing graduates to be safe and effective practitioners. Social and organizational pressures impacting the achievement of this goal provide the opportunity to work together in new ways to achieve a common purpose. In Oregon, the coalition's 5point strategic plan to combat the nursing shortage emerged as our mutual goals. These goals included doubling enrollment and using resources more efficiently (Oregon Center for Nursing, 2006).
Trust The social network of all partners is characterized by reciprocal confidence in the other's ability, intentions, and character. This trust is both personal and professional. Trust frees the collaborators to focus energy on shared goals and not in search of nefarious agendas or distractions. Trust takes time to develop, and it must sometimes be facilitated when the stakes are perceived to be risky or when a perceived or real loss of status, role, or function for one or more of the stakeholders is likely (Ryan & Oestreich, 1991). At a working level, trust is earned by a focus on shared goals, demonstrated through knowledge, competence, honesty, and equality. Because trust is foundational, intentional steps are necessary to build it. Those steps include assessing assumptions about one another, seeking confirmation or refutation of the assumptions, and a reciprocal commitment to trust. In our case, trust was enhanced by our appreciation of the expertise of the other; credibility was enhanced by knowledge that each partner spoke for their represented entity.
Innovation Within Existing Rules and Resources Innovation starts with the assessment of existing resources through new lenses. As we began our conceptualization of the DEU model, an early conversation with our state board of nursing explored opportunities for innovation within existing law. We learned that our innovation could work within the current rules if we were able to justify and validate certain questions related to student safety, patient safety, and effective learning. Many, if not most, nurse practice acts specify instructor-to-student ratios for clinical practice. Generally, the community of nurse educators identifies the ratio based on traditional clinical education models. Innovation, by its nature, breaks away from the traditional model driving regulatory language for nursing education. Working within an atmosphere of trust and open communication allows the focus to be on shared goals and regulatory purpose, not on language. Traditional clinical instructor and nurse preceptor roles change in the DEU model. The staff nurse provides direct clinical supervision and instruction, whereas the
faculty member serves as a resource and clinical coordinator. Patient and student safety and effective learning are assured through the dual roles of the nurse preceptor and the clinical faculty, thus staying within the intent and purpose of regulatory language (Moscato, Miller, Logsdon, Weinberg, & Chorpenning, 2007). Existing regulatory language for nursing education in Oregon allows appointment of experienced, baccalaureate-prepared nurses as clinical instructors. Most nurses on DEUs meet these qualifications for appointment as a clinical instructor, allowing the DEU model to develop within existing resources and rule language. Experienced, master's-prepared nurse educators provided clinical coordination, orientation, mentoring, and guidance.
Empowerment and Change Partnership is sustained through planned and purposeful activities. Established partnerships with requisite trust and communication elements are nimble and able to take advantage of opportunities because the members feel empowered. In this culture, people believe it is their right and responsibility to change. This empowered attitude may seem peculiar in the stable education culture known for protecting the status quo and the regulatory culture that controls and governs by rule making. However, the empowerment contributes to an expectation and creates the space for the creativity required for innovation. Behind this empowerment is the assumption that support and resources exist or can be found; a spirit of sufficiency and abundance leaves little room for the scarcity model. The vision that is shared by all partners drives the innovation. When this vision is for the future, there is a unity that allows the group to be less rule based and traditional. Stating the future outcomes frees thinking from present processes. Out of innovations such as the DEU come recognition of the need to provide for innovation within the regulatory structure. In our case, education/regulation collaboration with the DEU model led to a redefinition of faculty roles and responsibilities, flexible application of faculty-to-student ratios, challenging of traditional clinical education models, and facilitation of partnerships between educators, health care providers, and regulators. Innovation by definition is something new, but not all things new are better. Thus, a key expectation is that when a partner brings forth a new idea, that the design is well thought out, has evidence that is principle based when possible, and fits the mutually agreed upon goals. Partners must be open to feedback, shared problem solving, commitment of resources, and evaluation of outcomes. In the politics of good partnership, there is the courage to take risks and not require a safe haven for all ideas and efforts. Courage is the confidence to try—whether the innovation is called a pilot project, experiment, or a research proposal. Courage produces the state of mind that sees possibilities not barriers (Hornstein, 1986). With today's emphasis on safety and quality, it is easy to dial back ideas to assure only success. The point of courage is not reckless risk taking but rather a brave spirit
EDUCATION AND REGULATION
to embrace new thinking. Even with these safeguards, failure will occur—defining failure as falling short of the agreed upon expectations—but it can be that in failure, learning takes place and innovations can arise. We recommend a spirit of courage so highly that we suggest building safe ways to admit failure honestly and the opportunity to redirect energy in a new direction. We endorse the ideas from the National League for Nursing Innovation in Nursing Education Task Force Group (2009) and the National Council of State Boards of Nursing (2009) that state boards consider adopting a rules provision for innovation. Rules written for the weakest programs should not be allowed to inhibit innovation necessary for the effective education of future generations. The courage required for innovation should pervade the culture rather than being held by a few brave outliers. However, an innovation often has a “champion” or an influential person willing to throw support to the cause and is usually a higher risk taker (Rogers, 1995). We found success in identifying and naming champions for our DEU clinical teaching model change. Nursing managers, innovator/early adopter RN, designated facilitators, and Oregon State Board of Nursing educational consultant representing service, academe, and regulation courageously wore the mantle of DEU champion and became the risk-taking influencers of change.
Conclusion The lessons from this political partnership suggest the requisite attitudes and processes to accomplish change. When educators, practice partners, and regulators work together toward common goals, opportunities are found,
351
risks are taken, and innovation is encouraged. Furthermore, innovation provides evidence to drive policy and regulation, helping define the future. Rather than antagonistic relationships or siloed responsibilities, education and regulation are shown in the Oregon experience as productive partners in the creation of new methods of clinical teaching. If regulators and educators share the same table to create change, acceleration of change is a likely outcome.
References Hornstein, H. A. (1986). Managerial courage: Revitalizing your company without sacrificing your job. New York: John Wiley & Sons. Moscato, S. R., Miller, J., Logsdon, K., Weinberg, S. & Chorpenning, L. (2007). Dedicated education unit: An innovative clinical partner education model. Nursing Outlook, 55, 31–37. National Council of State Boards of Nursing. (2009). Fostering innovation in nursing education. Leader to Leader, 3. NLN Innovation Task Group. (2009). How can state boards of nursing encourage curricular reform? Nursing Education Perspectives, 30, 59–61. Oregon Center for Nursing. (2006). Oregon Nursing Leadership Council strategic plan: Solutions to Oregon's nursing shortage. Retrieved from http://www.oregoncenterfornursing.org/documents/ONLC%20strategic%20plan%20final% 205-15-06.pdf. Rogers, E. (1995). Diffusion of innovations. (4th ed.). New York: The Free Press. Ryan, K. D. & Oestreich, D. K. (1991). Driving fear out of the workplace: How to overcome the invisible barriers to quality, productivity, and innovation. San Francisco: Jossey-Bass.