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Integrating Regulation into Nursing Curricula
Integrating Regulation into Nursing Curricula Linda R. Rounds, PhD, RN, FNP, FAANP Knowledge of applicable regulatory standards is crucial to the safe, effective practice of nursing at all levels. Boards of nursing recognize the importance of regulatory content in nursing education, and the concept of regulation is invariably included in regulatory requirements and accreditation standards; however, authority over integration within the educational curriculum is limited. This article presents a framework and instructional techniques for effectively teaching regulation in nursing curricula.
A
t a time when quality and safety are center stage in discussions of education and practice in the health-care professions, nursing students must understand the obligations and standards set for nursing through regulation. The goal of nursing regulation is to ensure the public that licensed nurses are providing safe, competent care. Nursing regulation includes the laws, rules, and standards that govern licensed nurses and their educational programs. Boards of nursing (BONs) recognize that the best way to protect the public is to ensure that nurses entering the workforce have the knowledge and skills necessary to practice safely. However, BONs have limited authority over a nursing curriculum and especially over the content of specific classes. Even accreditation standards do not dictate specific curriculum content. They indicate only general topics of importance. Nursing curricula do include content on legal and ethical issues of practice. Commonly, most of this information is presented in several classes related to professional role development. Or this content may be covered in a single course on legal, ethical, and health policy issues. Usually, the content is presented when students are nearing program completion because it is relevant to their approaching practice as new graduates. However, despite the efforts of faculty, some students graduate without comprehending the importance of regulatory standards. A research study of disciplinary reports from 44 BONs to NURSYS® (a comprehensive electronic information system of licensure and disciplinary information reported by BONs) found that 0.18% of the nursing population was disciplined over an 11-year period from 1996 to 2006. The disciplinary reports covered 114,570 violations of a nurse practice act by a total of 52,695 nurses. Thus, the disciplined nurses averaged two violations each. The study also notes that the number of violations increased by 72% over the 11-year period (Kenward, 2008).
4
Journal of Nursing Regulation
This article describes a rationale for integrating regulatory content throughout the nursing curriculum and offers varied methods for teaching the content.
Regulatory Content: Pre-Licensure Programs Accreditation standards, policies of BONs, and the level of a program (LPN or RN) help establish the regulatory or jurisprudence content in a nursing curriculum. The Essentials of Baccalaureate Education for Professional Nursing Practice (American Association of Colleges of Nursing [AACN], 2008) includes a curricular essential, Essential V, on Healthcare Policy, Finance, and Regulatory Environments. The expectations in this essential are that a graduate will be prepared with knowledge of regulatory environments; regulatory processes relevant to health care; “state and national statutes, rules, and regulations that authorize and define professional nursing practice” (AACN, 2008, p. 21); and “the roles and responsibilities of the regulatory agencies and their effect on patient-care quality, workplace safety, and the scope of nursing and other health professionals’ practice” (AACN, 2008, p. 21). The standards for curricula from the National League for Nursing Accrediting Commission for baccalaureate, associate degree, and practical nursing education state that each curriculum should “incorporate established professional standards, guidelines, and competencies” (National League for Nursing Accrediting Commission, 2008, pp. 76, 82, 94). No other specific reference to regulatory or jurisprudence content is made. The National Council of State Boards of Nursing Model Nursing Practice Act sets forth a suggested requirement for “content regarding legal and ethical issues, history and trends in nursing and health care, and professional responsibilities” (National Council of State Boards of Nursing, 2006, p. 55). The above accreditation standards vary in how prescriptive they are regarding content, and faculty members must interpret
the standards relative to the laws and regulations of their state. Safe practice dictates a minimal standard of knowledge for a graduate nurse, regardless of education. This minimal standard includes knowing the purpose of regulation, the state’s nurse practice act, and the BONs’ rules and regulations highlighting standards of practice, unprofessional conduct, criminal conduct, scope of practice, delegation, and license maintenance. Schools in some states may include peer review, alternative to discipline programs, the nurse licensure compact, and other regulatory programs unique to the state (see Table 1).
Framework for Teaching Regulatory Content The literature contains little regarding useful methods of teaching regulatory content; however, the andragogical model of adult learning theory offers a framework for successfully teaching regulation. This model includes five elements: ⦁⦁ Need to know ⦁⦁ Learner’s self-concept ⦁⦁ Learner’s experiences ⦁⦁ Readiness to learn ⦁⦁ Orientation to learning (Knowles, Holton, & Swanson, 2005) Students need to know about regulation because it will, in one sense, control their future practice. Guido (2007) asserts that professional nursing is incorporating “increasing higher levels of expertise, specialization, autonomy, and accountability from both legal and ethical perspectives” (Guido, 2007, p. 60). She also identifies the state nurse practice act as the “single most important piece of legislation for nursing because it affects all facets of nursing practice” (Guido, 2007, p. 60). Increasing complexity of practice requires that nurses know about their obligations to protect the public. Educators should create a convincing argument for the value of learning the material as well as the consequences of not learning it. The learner’s self-concept equates to responsibility as adults for personal decisions and self-direction. Adult learners often resist having others telling them what they need to learn. To overcome resistance, educators must facilitate the transition to self-directed learning, motivating students using innovative methods, demonstrating examples of consequences, and offering compelling reasons for learning. Nursing students come to school with a variety of life experiences and a nursing program quickly adds to the quality and variety of those experiences. Often “the richest resources for learning reside in the adult learners themselves” (Knowles et al., 2005, p. 66). Educators can capitalize on this resource by asking students to share personal health-care experiences or events from clinical practice relevant to regulation. Adults demonstrate a readiness to learn when they realize they need to understand something that has a direct effect on their ability to function. Impending graduation and licensure Volume 1/Issue 3 October 2010
Table 1
Regulatory Content: Advanced Practice Programs Nurses enter advanced practice programs after completing a baccalaureate degree in nursing and usually have several years of practice experience. They should possess an understanding of the purpose and fundamental elements of the laws and regulations affecting professional practice. However, entry into advanced practice brings new and different regulations that vary greatly from state to state. Advanced practice registered nurses (APRNs) need knowledge regarding rules and regulations related to titles and roles of APRNs, requirements for education and certification to practice as APRNs, and scope of practice, including prescriptive authority. The Essentials of Master’s Education for Advanced Practice Nursing (American Association of Colleges of Nursing [AACN], 1996) addresses several areas related to regulation. Essential II, which is Policy, Organization, and Financing of Health Care, states that APRNs should have knowledge related to the differentiation of legislative and regulatory processes and the interaction of regulatory and quality controls in the health-care system. The introduction to Essential IV, Professional Role Development, indicates APRN students should have content in professional role development, including the requirements for and regulation of the specified role. In The Essentials of Doctoral Education for Advanced Nursing Practice (AACN, 2006), Essential V, Health Care Policy for Advocacy in Health Care, includes a stated outcome for leadership in health-care policy that shapes financing, regulation, and delivery of health care.
as a new nurse or advanced practice nurse are frequently the motivation to learn regulatory content. Orientation to learning indicates that adults learn because they can see relevance in what they are learning to real-life situations. Faculty members must create interesting and believable content that demonstrates the relationship between regulation and real-life practice. Table 2 summarizes the elements of the adult learning model, motivations for learning, and useful methods for teaching regulatory content while addressing the elements of the model. The methods used to teach regulatory content should focus on those most likely to create meaning and knowledge retention. In a study of knowledge retention (Raman et al., 2010), the authors compared two methods of teaching: dispersed content and massed content. Faculty members presented dispersed content over 4 weeks and massed content in a half day. Although shortterm retention was the same for both groups, only the dispersed method led to long-term knowledge retrieval. The study by Raman and colleagues (2010) suggests that integration of content over time and throughout several courses would result in greater knowledge retention. In Educating Nurses: A Call for Radical Transformation, Benner, Sutphen, Leonard, and Day (2010) emphasize the importance www.journalofnursingregulation.com
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Table 2
Elements of the Adult Learning Model and Methods for Teaching Regulatory Content Elements of Adult Learning Model
Motivation for Learning
Useful Teaching Methods
Need to know
Influence on future practice
⦁⦁
Case studies Online modules ⦁⦁ Real-life examples of regulatory impact ⦁⦁
Learner’s self-concept
Learner’s experiences Readiness to learn
Case studies Online scavenger hunt ⦁⦁ Role play
Need for life-long learning and updated information
⦁⦁
Personal experience as a resource for learning
⦁⦁
Impending licensure
⦁⦁
⦁⦁
⦁⦁
⦁⦁
Orientation to learning
Relevance to real-life situations
Journals Storytelling Journals Online scavenger hunt
Case studies Role play ⦁⦁ Mock hearing ⦁⦁ ⦁⦁
Based on Knowles, M., Holton, E., & Swanson, R. (2005). The adult learner (6th ed.). Burlington, MA: Elsevier.
of relevant learning integrated with clinical experience. One of the four essential shifts in nursing education they recommend is a shift to an emphasis on teaching for a sense of salience. This idea suggests that educators should help students learn what is important and unimportant using their own knowledge. This approach can help in teaching regulatory content as well as clinical care and offers an opportunity to integrate regulatory material with clinical experiences. A student can easily view regulation as being “all about me,” the nurse, and “protecting my license”; however, teaching methods and understanding should focus not only on the nurse’s vulnerability but also on patient safety—the purpose of regulation.
Strategies for Teaching Regulatory Content Theories of learning and recommendations for improving nursing education form a foundation for successful methods of teaching regulatory content. Being aware that subject matter, situational differences, and individual differences affect adult learning (Knowles et al., 2005) helps guide effective teaching strategies. Integration of Content
The recommendations of Benner and colleagues (2010) suggest that content ought to be integrated throughout the nursing curriculum and linked to practice rather than standing alone in one course or several classes. Knowles and colleagues’ (2005) model of adult learning suggests that a variety of methods should be used, keeping in mind that students have different learning styles and learning situations, such as distance education, that may also suggest different methods. Integrating regulatory content throughout the curriculum means that basic content, such as the nurse practice act and material in rules and regulations, should be introduced early in 6
Journal of Nursing Regulation
the curriculum. This approach gives students a starting reference point. Selected sections, such as the definition of nursing and the standards of practice, are a good beginning. For example, standards of practice regarding confidentiality and a safe environment are appropriate for beginning courses because educators can link them to basic nursing care. As students progress, educators can integrate more complex ideas, such as documentation, delegation, and professional boundaries, and relate them to regulatory rules. All programs teach students how to document, but do they teach students that documentation is a regulatory expectation of competent practice? Relating this content to regulation may help students understand that such requirements are not merely an instructor’s request or an institution’s guideline, but that they have the force of law. Threading and building the concepts throughout the curriculum should give students a solid foundation in regulatory content. Methods
Methods of teaching regulatory content can be adapted from successful methods for other content in the nursing curriculum. Methods may include reading, lectures, and complex interactive experiences. Some students report that they can more easily remember content linked to stories or real-life experiences. Faculty members successfully use mock disciplinary hearings to illustrate the real-life meaning of the nurse practice act and the consequences of failing to adhere to regulatory standards (J. D. Baker, personal communication, February 19, 2010). Some states post outcomes of disciplinary hearings on the board’s website, and educators may draw from them to simulate cases. Complex or atypical cases provide more opportunity for discussion and learning because they present challenging situations and complicated choices on issues such as delegation and professional boundaries. Issues such as medication errors and falsification of
documentation tend to be more straightforward and easier to understand. Several strategies may be used with this method, including asking students to take roles as agency staff, board members, and the nurse respondent; giving students a list of possible stipulations and asking them to determine the discipline (D. Otto, personal communication, February 23, 2010); and having faculty members role play the parts and seek student commentary. In a similar technique, faculty members can ask students to watch a medically focused TV show that demonstrates complex legal or regulatory issues and then analyze the regulatory ramifications. Role playing and simulations offer the chance for rich discussion on the standards, the issues, and the element of public protection. With some additional work, these methods can be developed into podcasts or video presentations for students to view before a class or for online education. Case studies also help integrate practice with standards of regulation. They offer a chance to analyze related regulations and are especially helpful for learning about topics such as appropriate delegation and scope of practice. Although case studies may not be as close to reality as mock hearings, they do require less preparation and offer some of the same outcomes. Case studies and mock hearings both give educators the opportunity to start and stop the action for discussion. An online scavenger hunt can help familiarize students with the location of sections of a nurse practice act and a board’s rules and regulations. Faculty members can create questions about the law and rules that require students to search the nurse practice act or rules for the answers. This method is well suited to an online course or as an online assignment because students can find the information on a board’s website and report the information to classmates. This exercise can be extended by asking students to interpret the information they find and explain it in writing, using language their family members understand. Asking students to write individual journals is a method of learning that can be extended across the curriculum. Benner and colleagues (2010) cite the value of narrative pedagogy as a valuable teaching strategy that provides students with a safe environment for evaluating their experiences and those of patients. Cooper, Taft, and Thelen (2005) studied students’ reflections on their final clinical practice experience through weekly web journal postings. One of the themes that emerged was “feeling the weight of RN responsibility,” which had subthemes including “fear of making errors” and “struggles with perceived challenges of the RN role.” Keeping journals that identify and reflect on issues associated with regulation as part of clinical practice offers an opportunity for safe reflection, questioning, and learning. Students might be asked to describe possible sources of unsafe practice, situations in which the standards of practice apply, and encounters with a potential for violations of these standards. These entries need not be in a stand-alone journal; they could be integrated into a broader clinical practice journal.
Volume 1/Issue 3 October 2010
If schools of nursing have easy access to board members or staff, presentations of real experiences as well as insight into the challenges of public protection may be shared. This experience offers students the chance to see that a board is made up of real people who have concerns for patients and nursing. Web cameras and audio-video conferencing tools can make access to board members or staff easy, even if they are distant from a school. Many instructional techniques for pre-licensure students also work for advanced practice registered nurses (APRNs). For APRNs, an educator can vary the questions to suit the APRN scope of practice or pose scenarios that involve issues unique to APRNs, such as certification requirements and prescriptive authority.
Preparing Educators Generally, faculty members are not likely to be experts in regulation, and to teach regulation, they must gain an understanding beyond their basic education as a nurse. A variety of learning methods may be available to faculty, including online courses, face-to-face seminars, and periodic workshops offered by the state’s BON. The experiences of faculty members may be similar to those of the chief nursing officers (CNOs) described by Hudson in a project related to enhancing awareness of regulation. Hudson stated, “Unfortunately, knowledge about nursing regulation is all too often gained in a piecemeal fashion” (Hudson, 2008, p. 312). She asserts that much of the regulatory knowledge of CNOs came from independent reading of the nurse practice act, rules and regulations, standards, and policies or from discussions with colleagues. Faculty members may not be very different. To overcome this potential deficiency for CNOs, the Oregon State Board of Nursing developed an orientation program for nurse executives (Hudson, 2008). Pre- and posttest results showed an improvement in knowledge about various elements of regulation. The Texas Board of Nursing (2010a) has a similar orientation for deans and directors of educational programs that includes an online learning module followed by a face-to-face session. Evaluations of learning have been positive, and the content has been viewed as relevant. A common request of participants is to create a webinar as a means of education. The Texas Board of Nursing (2010b) requires applicants for licensure to pass a jurisprudence examination on content related to the nurse practice act and board rules and regulations. The board has also created an online prep-course available for a fee to anyone who wants to learn more about the nurse practice act and other regulations not only for the examination, but for future practice. This prep-course is a potential resource for educators who want to learn more about regulatory content in preparation for teaching it. The North Carolina Board of Nursing (2010), as part of its information on continued competence, includes self-assessment www.journalofnursingregulation.com
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worksheets in four areas: professional responsibility, knowledgebased practice, legal and ethical practice, and collaborative practice. These worksheets could be used by faculty to identify areas of strength and areas for improvement in their regulatory foundation for practice.
Summary Understanding a nurse’s obligations to adhere to the regulations of his or her BON is vital to maintaining patient safety and good practice. Schools of nursing have a responsibility to teach students regulatory content pertinent to their future roles as licensed nurses. Fink (2003) identifies shortcomings of traditional lecturing as a method for imparting new knowledge. These shortcomings include limited retention of information, ineffective transfer of knowledge to new situations, limited ability to develop problem-solving skills, and limited achievement of effective outcomes such as motivation for life-long learning. The ability of faculty members to develop and use novel and creative methods for teaching regulatory content can help overcome these shortcomings while gaining student interest and involvement.
References American Association of Colleges of Nursing. (2008). The essentials of baccalaureate education for professional nursing practice. Retrieved from http://www.aacn.nche.edu/Education/bacessn.htm American Association of Colleges of Nursing. (2006). The essentials of doctoral education for advanced nursing practice. Retrieved from http:// www.aacn.nche.edu/DNP/pdf/Essentials.pdf American Association of Colleges of Nursing. (1996). The essentials of master’s education for advanced nursing practice. Retrieved from http:// www.aacn.nche.edu/Education/pdf/MasEssentials96.pdf Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Educating nurses: A call for radical transformation. San Francisco, CA: Jossey-Bass. Cooper, C., Taft, L., & Thelen, M. (2005). Preparing for practice: Students’ reflections on their final clinical experience. Journal of Professional Nursing, 21, 293–302. Fink, L. D. (2003). Creating significant learning experiences: An integrated approach to designing college courses. San Francisco, CA: Jossey-Bass. Guido, G. W. (2007). Legal and ethical issues. In P. Yoder-Wise (Ed.), Leading and managing in nursing (pp. 59–90). St. Louis, MO: Mosby-Elsevier. Hudson, M. (2008). Enhancing awareness of nursing regulation through a board of nursing orientation program for chief nursing officers. Nursing Administration Quarterly, 32, 312–316. Kenward, K. (2008). Discipline of nurses: A review of disciplinary data 1996–2006. JONA’s Healthcare Law, Ethics, and Regulation, 10(3), 81–84. Knowles, M., Holton, E., & Swanson, R. (2005). The adult learner (6th ed.). Burlington, MA: Elsevier. National Council of State Boards of Nursing. (2006). Model nursing practice act and model administrative rules. Retrieved from https://www. ncsbn.org/Model_Nursing_Practice_Act_December09_final.pdf National League for Nursing Accrediting Commission. (2008). NLNAC 2008 standards and criteria. Retrieved from http://www.nlnac. org/manuals/NLNACManual2008.pdf
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Journal of Nursing Regulation
North Carolina Board of Nursing. (2010). Continued competence: Self assessment dimension worksheets 1–4. Retrieved from http://www.ncbon. com/content.aspx?id=664 Raman, M., McLaughlin, K., Violato, C., Rostom, A., Allard, J.P., & Coderre, S. (2010). Teaching in small portions dispersed over time enhances long-term knowledge retention. Medical Teacher, 32, 250–255. Texas Board of Nursing. (2010a). Report on Board of Nursing new dean, director, and coordinator orientation workshop. Retrieved from http:// www.bon.state.tx.us/about/January10/3-2-2.pdf Texas Board of Nursing. (2010b). Texas nursing jurisprudence prep-course. Retrieved from http://www.bon.state.tx.us/olv/je-course.html
Linda R. Rounds, PhD, RN, FNP, FAANP, is the Betty Lee Evans Distinguished Nursing Professor in the School of Nursing, The University of Texas Medical Branch in Galveston and president of the Texas Board of Nursing. The author wishes to thank Dr. Joy Don Baker and Dr. Dorothy Otto for sharing their ideas and experiences in teaching nursing regulation.
A
t a time when quality and safety are center stage in discussions of education and practice in the health-care professions, nursing students must understand the obligations and standards set for nursing through regulation. The goal of nursing regulation is to ensure the public that licensed nurses are providing safe, competent care. Nursing regulation includes the laws, rules, and standards that govern licensed nurses and their educational programs. Boards of nursing (BONs) recognize that the best way to protect the public is to ensure that nurses entering the workforce have the knowledge and skills necessary to practice safely. However, BONs have limited authority over a nursing curriculum and especially over the content of specific classes. Even accreditation standards do not dictate specific curriculum content. They indicate only general topics of importance. Nursing curricula do include content on legal and ethical issues of practice. Commonly, most of this information is presented in several classes related to professional role development. Or this content may be covered in a single course on legal, ethical, and health policy issues. Usually, the content is presented when students are nearing program completion because it is relevant to their approaching practice as new graduates. However, despite the efforts of faculty, some students graduate without comprehending the importance of regulatory standards. A research study of disciplinary reports from 44 BONs to NURSYS® (a comprehensive electronic information system of licensure and disciplinary information reported by BONs) found that 0.18% of the nursing population was disciplined over an 11-year period from 1996 to 2006. The disciplinary reports covered 114,570 violations of a nurse practice act by a total of 52,695 nurses. Thus, the disciplined nurses averaged two violations each. The study also notes that the number of violations increased by 72% over the 11-year period (Kenward, 2008).
4
Journal of Nursing Regulation
This article describes a rationale for integrating regulatory content throughout the nursing curriculum and offers varied methods for teaching the content.
Regulatory Content: Pre-Licensure Programs Accreditation standards, policies of BONs, and the level of a program (LPN or RN) help establish the regulatory or jurisprudence content in a nursing curriculum. The Essentials of Baccalaureate Education for Professional Nursing Practice (American Association of Colleges of Nursing [AACN], 2008) includes a curricular essential, Essential V, on Healthcare Policy, Finance, and Regulatory Environments. The expectations in this essential are that a graduate will be prepared with knowledge of regulatory environments; regulatory processes relevant to health care; “state and national statutes, rules, and regulations that authorize and define professional nursing practice” (AACN, 2008, p. 21); and “the roles and responsibilities of the regulatory agencies and their effect on patient-care quality, workplace safety, and the scope of nursing and other health professionals’ practice” (AACN, 2008, p. 21). The standards for curricula from the National League for Nursing Accrediting Commission for baccalaureate, associate degree, and practical nursing education state that each curriculum should “incorporate established professional standards, guidelines, and competencies” (National League for Nursing Accrediting Commission, 2008, pp. 76, 82, 94). No other specific reference to regulatory or jurisprudence content is made. The National Council of State Boards of Nursing Model Nursing Practice Act sets forth a suggested requirement for “content regarding legal and ethical issues, history and trends in nursing and health care, and professional responsibilities” (National Council of State Boards of Nursing, 2006, p. 55). The above accreditation standards vary in how prescriptive they are regarding content, and faculty members must interpret
the standards relative to the laws and regulations of their state. Safe practice dictates a minimal standard of knowledge for a graduate nurse, regardless of education. This minimal standard includes knowing the purpose of regulation, the state’s nurse practice act, and the BONs’ rules and regulations highlighting standards of practice, unprofessional conduct, criminal conduct, scope of practice, delegation, and license maintenance. Schools in some states may include peer review, alternative to discipline programs, the nurse licensure compact, and other regulatory programs unique to the state (see Table 1).
Framework for Teaching Regulatory Content The literature contains little regarding useful methods of teaching regulatory content; however, the andragogical model of adult learning theory offers a framework for successfully teaching regulation. This model includes five elements: ⦁⦁ Need to know ⦁⦁ Learner’s self-concept ⦁⦁ Learner’s experiences ⦁⦁ Readiness to learn ⦁⦁ Orientation to learning (Knowles, Holton, & Swanson, 2005) Students need to know about regulation because it will, in one sense, control their future practice. Guido (2007) asserts that professional nursing is incorporating “increasing higher levels of expertise, specialization, autonomy, and accountability from both legal and ethical perspectives” (Guido, 2007, p. 60). She also identifies the state nurse practice act as the “single most important piece of legislation for nursing because it affects all facets of nursing practice” (Guido, 2007, p. 60). Increasing complexity of practice requires that nurses know about their obligations to protect the public. Educators should create a convincing argument for the value of learning the material as well as the consequences of not learning it. The learner’s self-concept equates to responsibility as adults for personal decisions and self-direction. Adult learners often resist having others telling them what they need to learn. To overcome resistance, educators must facilitate the transition to self-directed learning, motivating students using innovative methods, demonstrating examples of consequences, and offering compelling reasons for learning. Nursing students come to school with a variety of life experiences and a nursing program quickly adds to the quality and variety of those experiences. Often “the richest resources for learning reside in the adult learners themselves” (Knowles et al., 2005, p. 66). Educators can capitalize on this resource by asking students to share personal health-care experiences or events from clinical practice relevant to regulation. Adults demonstrate a readiness to learn when they realize they need to understand something that has a direct effect on their ability to function. Impending graduation and licensure Volume 1/Issue 3 October 2010
Table 1
Regulatory Content: Advanced Practice Programs Nurses enter advanced practice programs after completing a baccalaureate degree in nursing and usually have several years of practice experience. They should possess an understanding of the purpose and fundamental elements of the laws and regulations affecting professional practice. However, entry into advanced practice brings new and different regulations that vary greatly from state to state. Advanced practice registered nurses (APRNs) need knowledge regarding rules and regulations related to titles and roles of APRNs, requirements for education and certification to practice as APRNs, and scope of practice, including prescriptive authority. The Essentials of Master’s Education for Advanced Practice Nursing (American Association of Colleges of Nursing [AACN], 1996) addresses several areas related to regulation. Essential II, which is Policy, Organization, and Financing of Health Care, states that APRNs should have knowledge related to the differentiation of legislative and regulatory processes and the interaction of regulatory and quality controls in the health-care system. The introduction to Essential IV, Professional Role Development, indicates APRN students should have content in professional role development, including the requirements for and regulation of the specified role. In The Essentials of Doctoral Education for Advanced Nursing Practice (AACN, 2006), Essential V, Health Care Policy for Advocacy in Health Care, includes a stated outcome for leadership in health-care policy that shapes financing, regulation, and delivery of health care.
as a new nurse or advanced practice nurse are frequently the motivation to learn regulatory content. Orientation to learning indicates that adults learn because they can see relevance in what they are learning to real-life situations. Faculty members must create interesting and believable content that demonstrates the relationship between regulation and real-life practice. Table 2 summarizes the elements of the adult learning model, motivations for learning, and useful methods for teaching regulatory content while addressing the elements of the model. The methods used to teach regulatory content should focus on those most likely to create meaning and knowledge retention. In a study of knowledge retention (Raman et al., 2010), the authors compared two methods of teaching: dispersed content and massed content. Faculty members presented dispersed content over 4 weeks and massed content in a half day. Although shortterm retention was the same for both groups, only the dispersed method led to long-term knowledge retrieval. The study by Raman and colleagues (2010) suggests that integration of content over time and throughout several courses would result in greater knowledge retention. In Educating Nurses: A Call for Radical Transformation, Benner, Sutphen, Leonard, and Day (2010) emphasize the importance www.journalofnursingregulation.com
5
Table 2
Elements of the Adult Learning Model and Methods for Teaching Regulatory Content Elements of Adult Learning Model
Motivation for Learning
Useful Teaching Methods
Need to know
Influence on future practice
⦁⦁
Case studies Online modules ⦁⦁ Real-life examples of regulatory impact ⦁⦁
Learner’s self-concept
Learner’s experiences Readiness to learn
Case studies Online scavenger hunt ⦁⦁ Role play
Need for life-long learning and updated information
⦁⦁
Personal experience as a resource for learning
⦁⦁
Impending licensure
⦁⦁
⦁⦁
⦁⦁
⦁⦁
Orientation to learning
Relevance to real-life situations
Journals Storytelling Journals Online scavenger hunt
Case studies Role play ⦁⦁ Mock hearing ⦁⦁ ⦁⦁
Based on Knowles, M., Holton, E., & Swanson, R. (2005). The adult learner (6th ed.). Burlington, MA: Elsevier.
of relevant learning integrated with clinical experience. One of the four essential shifts in nursing education they recommend is a shift to an emphasis on teaching for a sense of salience. This idea suggests that educators should help students learn what is important and unimportant using their own knowledge. This approach can help in teaching regulatory content as well as clinical care and offers an opportunity to integrate regulatory material with clinical experiences. A student can easily view regulation as being “all about me,” the nurse, and “protecting my license”; however, teaching methods and understanding should focus not only on the nurse’s vulnerability but also on patient safety—the purpose of regulation.
Strategies for Teaching Regulatory Content Theories of learning and recommendations for improving nursing education form a foundation for successful methods of teaching regulatory content. Being aware that subject matter, situational differences, and individual differences affect adult learning (Knowles et al., 2005) helps guide effective teaching strategies. Integration of Content
The recommendations of Benner and colleagues (2010) suggest that content ought to be integrated throughout the nursing curriculum and linked to practice rather than standing alone in one course or several classes. Knowles and colleagues’ (2005) model of adult learning suggests that a variety of methods should be used, keeping in mind that students have different learning styles and learning situations, such as distance education, that may also suggest different methods. Integrating regulatory content throughout the curriculum means that basic content, such as the nurse practice act and material in rules and regulations, should be introduced early in 6
Journal of Nursing Regulation
the curriculum. This approach gives students a starting reference point. Selected sections, such as the definition of nursing and the standards of practice, are a good beginning. For example, standards of practice regarding confidentiality and a safe environment are appropriate for beginning courses because educators can link them to basic nursing care. As students progress, educators can integrate more complex ideas, such as documentation, delegation, and professional boundaries, and relate them to regulatory rules. All programs teach students how to document, but do they teach students that documentation is a regulatory expectation of competent practice? Relating this content to regulation may help students understand that such requirements are not merely an instructor’s request or an institution’s guideline, but that they have the force of law. Threading and building the concepts throughout the curriculum should give students a solid foundation in regulatory content. Methods
Methods of teaching regulatory content can be adapted from successful methods for other content in the nursing curriculum. Methods may include reading, lectures, and complex interactive experiences. Some students report that they can more easily remember content linked to stories or real-life experiences. Faculty members successfully use mock disciplinary hearings to illustrate the real-life meaning of the nurse practice act and the consequences of failing to adhere to regulatory standards (J. D. Baker, personal communication, February 19, 2010). Some states post outcomes of disciplinary hearings on the board’s website, and educators may draw from them to simulate cases. Complex or atypical cases provide more opportunity for discussion and learning because they present challenging situations and complicated choices on issues such as delegation and professional boundaries. Issues such as medication errors and falsification of
documentation tend to be more straightforward and easier to understand. Several strategies may be used with this method, including asking students to take roles as agency staff, board members, and the nurse respondent; giving students a list of possible stipulations and asking them to determine the discipline (D. Otto, personal communication, February 23, 2010); and having faculty members role play the parts and seek student commentary. In a similar technique, faculty members can ask students to watch a medically focused TV show that demonstrates complex legal or regulatory issues and then analyze the regulatory ramifications. Role playing and simulations offer the chance for rich discussion on the standards, the issues, and the element of public protection. With some additional work, these methods can be developed into podcasts or video presentations for students to view before a class or for online education. Case studies also help integrate practice with standards of regulation. They offer a chance to analyze related regulations and are especially helpful for learning about topics such as appropriate delegation and scope of practice. Although case studies may not be as close to reality as mock hearings, they do require less preparation and offer some of the same outcomes. Case studies and mock hearings both give educators the opportunity to start and stop the action for discussion. An online scavenger hunt can help familiarize students with the location of sections of a nurse practice act and a board’s rules and regulations. Faculty members can create questions about the law and rules that require students to search the nurse practice act or rules for the answers. This method is well suited to an online course or as an online assignment because students can find the information on a board’s website and report the information to classmates. This exercise can be extended by asking students to interpret the information they find and explain it in writing, using language their family members understand. Asking students to write individual journals is a method of learning that can be extended across the curriculum. Benner and colleagues (2010) cite the value of narrative pedagogy as a valuable teaching strategy that provides students with a safe environment for evaluating their experiences and those of patients. Cooper, Taft, and Thelen (2005) studied students’ reflections on their final clinical practice experience through weekly web journal postings. One of the themes that emerged was “feeling the weight of RN responsibility,” which had subthemes including “fear of making errors” and “struggles with perceived challenges of the RN role.” Keeping journals that identify and reflect on issues associated with regulation as part of clinical practice offers an opportunity for safe reflection, questioning, and learning. Students might be asked to describe possible sources of unsafe practice, situations in which the standards of practice apply, and encounters with a potential for violations of these standards. These entries need not be in a stand-alone journal; they could be integrated into a broader clinical practice journal.
Volume 1/Issue 3 October 2010
If schools of nursing have easy access to board members or staff, presentations of real experiences as well as insight into the challenges of public protection may be shared. This experience offers students the chance to see that a board is made up of real people who have concerns for patients and nursing. Web cameras and audio-video conferencing tools can make access to board members or staff easy, even if they are distant from a school. Many instructional techniques for pre-licensure students also work for advanced practice registered nurses (APRNs). For APRNs, an educator can vary the questions to suit the APRN scope of practice or pose scenarios that involve issues unique to APRNs, such as certification requirements and prescriptive authority.
Preparing Educators Generally, faculty members are not likely to be experts in regulation, and to teach regulation, they must gain an understanding beyond their basic education as a nurse. A variety of learning methods may be available to faculty, including online courses, face-to-face seminars, and periodic workshops offered by the state’s BON. The experiences of faculty members may be similar to those of the chief nursing officers (CNOs) described by Hudson in a project related to enhancing awareness of regulation. Hudson stated, “Unfortunately, knowledge about nursing regulation is all too often gained in a piecemeal fashion” (Hudson, 2008, p. 312). She asserts that much of the regulatory knowledge of CNOs came from independent reading of the nurse practice act, rules and regulations, standards, and policies or from discussions with colleagues. Faculty members may not be very different. To overcome this potential deficiency for CNOs, the Oregon State Board of Nursing developed an orientation program for nurse executives (Hudson, 2008). Pre- and posttest results showed an improvement in knowledge about various elements of regulation. The Texas Board of Nursing (2010a) has a similar orientation for deans and directors of educational programs that includes an online learning module followed by a face-to-face session. Evaluations of learning have been positive, and the content has been viewed as relevant. A common request of participants is to create a webinar as a means of education. The Texas Board of Nursing (2010b) requires applicants for licensure to pass a jurisprudence examination on content related to the nurse practice act and board rules and regulations. The board has also created an online prep-course available for a fee to anyone who wants to learn more about the nurse practice act and other regulations not only for the examination, but for future practice. This prep-course is a potential resource for educators who want to learn more about regulatory content in preparation for teaching it. The North Carolina Board of Nursing (2010), as part of its information on continued competence, includes self-assessment www.journalofnursingregulation.com
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worksheets in four areas: professional responsibility, knowledgebased practice, legal and ethical practice, and collaborative practice. These worksheets could be used by faculty to identify areas of strength and areas for improvement in their regulatory foundation for practice.
Summary Understanding a nurse’s obligations to adhere to the regulations of his or her BON is vital to maintaining patient safety and good practice. Schools of nursing have a responsibility to teach students regulatory content pertinent to their future roles as licensed nurses. Fink (2003) identifies shortcomings of traditional lecturing as a method for imparting new knowledge. These shortcomings include limited retention of information, ineffective transfer of knowledge to new situations, limited ability to develop problem-solving skills, and limited achievement of effective outcomes such as motivation for life-long learning. The ability of faculty members to develop and use novel and creative methods for teaching regulatory content can help overcome these shortcomings while gaining student interest and involvement.
References American Association of Colleges of Nursing. (2008). The essentials of baccalaureate education for professional nursing practice. Retrieved from http://www.aacn.nche.edu/Education/bacessn.htm American Association of Colleges of Nursing. (2006). The essentials of doctoral education for advanced nursing practice. Retrieved from http:// www.aacn.nche.edu/DNP/pdf/Essentials.pdf American Association of Colleges of Nursing. (1996). The essentials of master’s education for advanced nursing practice. Retrieved from http:// www.aacn.nche.edu/Education/pdf/MasEssentials96.pdf Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Educating nurses: A call for radical transformation. San Francisco, CA: Jossey-Bass. Cooper, C., Taft, L., & Thelen, M. (2005). Preparing for practice: Students’ reflections on their final clinical experience. Journal of Professional Nursing, 21, 293–302. Fink, L. D. (2003). Creating significant learning experiences: An integrated approach to designing college courses. San Francisco, CA: Jossey-Bass. Guido, G. W. (2007). Legal and ethical issues. In P. Yoder-Wise (Ed.), Leading and managing in nursing (pp. 59–90). St. Louis, MO: Mosby-Elsevier. Hudson, M. (2008). Enhancing awareness of nursing regulation through a board of nursing orientation program for chief nursing officers. Nursing Administration Quarterly, 32, 312–316. Kenward, K. (2008). Discipline of nurses: A review of disciplinary data 1996–2006. JONA’s Healthcare Law, Ethics, and Regulation, 10(3), 81–84. Knowles, M., Holton, E., & Swanson, R. (2005). The adult learner (6th ed.). Burlington, MA: Elsevier. National Council of State Boards of Nursing. (2006). Model nursing practice act and model administrative rules. Retrieved from https://www. ncsbn.org/Model_Nursing_Practice_Act_December09_final.pdf National League for Nursing Accrediting Commission. (2008). NLNAC 2008 standards and criteria. Retrieved from http://www.nlnac. org/manuals/NLNACManual2008.pdf
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North Carolina Board of Nursing. (2010). Continued competence: Self assessment dimension worksheets 1–4. Retrieved from http://www.ncbon. com/content.aspx?id=664 Raman, M., McLaughlin, K., Violato, C., Rostom, A., Allard, J.P., & Coderre, S. (2010). Teaching in small portions dispersed over time enhances long-term knowledge retention. Medical Teacher, 32, 250–255. Texas Board of Nursing. (2010a). Report on Board of Nursing new dean, director, and coordinator orientation workshop. Retrieved from http:// www.bon.state.tx.us/about/January10/3-2-2.pdf Texas Board of Nursing. (2010b). Texas nursing jurisprudence prep-course. Retrieved from http://www.bon.state.tx.us/olv/je-course.html
Linda R. Rounds, PhD, RN, FNP, FAANP, is the Betty Lee Evans Distinguished Nursing Professor in the School of Nursing, The University of Texas Medical Branch in Galveston and president of the Texas Board of Nursing. The author wishes to thank Dr. Joy Don Baker and Dr. Dorothy Otto for sharing their ideas and experiences in teaching nursing regulation.