- Email: [email protected]
Reshaping clinical nursing education: an academic-service partnership
Reshaping Clinical Nursing Education: An Academic-Service Partnership CLAUDIA BARTZ, PHD, RN, FAAN,* AND SUSAN DEAN-BAAR, PHD, RN, FAAN†
This article describes the conceptualization and implementation of an academic-service partnership for a baccalaureate nursing program. The partnership began its fifth year in the fall of 2002; 107 students have entered the partnership since its inception. The partnership goals were to develop and implement clinical training experiences that teach students key skills for community-based practice settings, and to develop and evaluate an innovative and collaborative model for community-based clinical education. Students in the partnership have a unique opportunity for learning the art and science of nursing in a complex, integrated health care system with a strong emphasis on quality of environment, providers, and care delivery. A longitudinal program evaluation is underway, based on an American Association of Colleges of Nursing publication, the vision and goals of the School of Nursing, and the construct of organizational socialization. (Index words: Baccalaureate nursing education; Clinical nursing education; Community-based nursing; Program evaluation; Organizational socialization)) J Prof Nurs 19:216-222, 2003. © 2003 Elsevier Inc. All rights reserved.
T
HE WORK ENVIRONMENT of the early 21st century calls for new approaches in postsecondary education. Organizations will be structured to meet constantly changing demands for products that may be tangible or intangible, or a blend of the 2. As workers’ interests and capabilities change, or as their needs for change evolve, they will enter and leave the new-style organizations. Classic organization theory, with its principles of unity of command and single accountability (Rizzo, House, & Lirtzman, 1970), no longer explains how organizations function. Life-long careers
*Clinical Associate Professor, University of Wisconsin Milwaukee School of Nursing, Milwaukee, WI. †Associate Dean for Academic Affairs, University of Wisconsin Milwaukee School of Nursing, Milwaukee, WI. Supported in part by the Helene Fuld Health Trust, HSBC Bank, New York, NY. Address correspondence and reprint requests to Dr. Bartz: University of Wisconsin Milwaukee, Cunningham Hall, Post Office Box 413, Milwaukee, WI 53201-0413. E-mail: [email protected] © 2003 Elsevier Inc. All rights reserved. 8755-7223/03/1904-0000$30.00/0 doi:10.1016/S8755-7223(03)00090-5 216
and/or careers in homogenous organizations are a phenomena of the past (Lewis, 2000). This article presents the conceptualization of an academic-service partnership. The forces in today’s health care environment that shaped the conceptualization of an innovative approach to the clinical component of a nursing curriculum are discussed. The academic-service partnership is described in terms of its goals and objectives, the partner organizations, the student participants, and the implementation. Finally, the program evaluation constructs are described. An article to follow this one will present outcome data from the 3-year program evaluation that was designed to assess the impact, effectiveness, and overall worth of the program. Health Care: Toward Consumer-Provider Interdependence
Complex, integrated, health care systems are emerging to deal with the needs of a growing and aging population. The increasing sophistication of health care consumers is leading toward a consumer-provider interdependence model for care delivery. Rather than intermittent care for illness or injury, the movement is toward life-long care that includes health teaching, health promotion, disease prevention, and early detection of potential threats to health before medical intervention is necessary. Technology and, more broadly, research and development, are factors with which to contend in the implementation of a consumer-provider interdependence model. The continuing proliferation of technology for health care tends to threaten the interdependence model in that consumers may be overwhelmed by what is available and therefore feel powerless to participate in health care decisions. Similarly, the constant reports of findings and products from the research and development community are difficult for consumers to interpret, understand, and apply to their individual situations. Thus, many people may eschew an active role in their health maintenance or their care during illness or injury.
Journal of Professional Nursing, Vol 19, No 4 (July–August), 2003: pp 216-222
ACADEMIC-SERVICE PARTNERSHIP
Health care employers are challenged to sustain an environment in which competent, efficient, and whole-life encompassing care can be provided satisfactorily to their beneficiary population. Value-based health systems are replacing traditional sickness systems (Pesut, 2001; Porter-O’Grady, 1999, 2001). Further, in today’s competitive market, employers are challenged to create and foster learning organizations (Marquardt, 1999) and centers of excellence in selected aspects of care delivery. All levels of personnel in a health care system must therefore contribute to that excellence by virtue of their knowledge and abilities, and by their commitment to the values and goals of that organization. NURSING AND HEALTH CARE
The work of nursing is changing along with contemporary attitudes toward work, organizations, and health care delivery systems. Professional nurses have available to them an unprecedented range of work opportunities in contexts such as clinical practice, advanced clinical practice, management and administration, education, and research. Professional nurses also can make significant contributions to consumer-provider interdependence in contexts such as care and case management, health promotion, disease prevention, family teaching, and drug and alcohol use counseling. In addition, nurses often qualify for the increasing number of health care positions emerging that belong to no single discipline (McBride, 1999). As health care organizations continue to structure themselves for optimal care delivery and competitive market share, professional nurses are key contributors to those aims. A committed, professionally satisfied cohort of nurses throughout a complex, integrated health care delivery system may serve to advance the organization’s vision and goals. And, given sufficient complexity, breadth and depth of the delivery system, nurses within the organization could have sufficient variability, challenge, and professional growth to stay with the system for a substantial and worthwhile length of time. NURSING EDUCATION
Academia also is challenged by the changing attitudes toward work, organizations, and careers. On entry to the work context, nurses are faced with an immense amount of information to be synthesized into knowledge and skills that can be used in the work place. New information from research and development and from technology that includes information
217
systems (Staggers, Thompson, & Snyder-Halpern, 2001), constantly shapes health care delivery. The increased organizational complexity and the continued generation of new information means that nursing education has to foster the commitment to career-long learning (Lindeman, 2000; McBride, 1999; Skiba, 1997; Sorrels-Jones & Weaver, 1999). One can never stop learning to learn if an individual’s aim in any field is to be successful personally and professionally. Anderson (2000) noted that “a better-educated profession is necessary if nurses are to become full partners in health care, and intellectual equals with other health professionals” (p. 54). Nurses, in the earliest days of being named as such, learned by doing, sometimes with the guidance of a more experienced provider. A great deal of nursing care was rendered at home, often by family members who had varying amounts of knowledge, ability, and sense of responsibility. In the early days of formal education for nursing, hospital-educated diploma nurses served their communities’ needs by staying on to work where they were trained (Taylor & Care, 1999). With the advent of baccalaureate education, nurses were educated formally in the arts and sciences, in addition to their clinical education, which generally took place in medical centers with some added experiences in psychiatric facilities and in community health. Associate degree nursing education has blended some postsecondary education with substantial clinical experience, usually in traditional hospital settings. Although nursing education has come full circle in at least two ways, the circle has become decidedly more complex. First, faculty members are expected to be knowledgeable in the hands-on provision of health care while also having the ability to convey theoretical concepts that can be realized and applied by critically thinking students in a practice setting (Mundt, 1997). Students’ clinical experiences are enhanced through purposeful interactivity (e.g., preceptorships) with clinicians and managers. Faculty then assist the student to synthesize these experiences with the aim of students comprehending nursing in the context of the roles, ethics, and values of health care delivery systems. Second, students at the baccalaureate level are educated across the continua of health care, in particular, health throughout the lifespan and health care delivery across the wellness/disease and health/illness/injury phases experienced by people today. Students see that family care in homes or in community clinics is as much a part of health care as the most sophisticated technology-based care in hospitals. This horizontal learning approach looks across integrated systems and
218
BARTZ AND DEAN-BAAR
compares patient care outcomes and reveals relationships between the health care network and the community as a whole (Edwards & Alley, 2002; Mundt, 1997; Poell, VanderKrogt, & Warmerdam, 1998). A third way in which nursing education may be coming full circle is in the relationship between academia and service. McBride (1999) described a revitalized education-service link because these 2 major social systems are both in the process of re-inventing themselves. In a seminal article, Mundt (1997), while at this university, described a revolutionary academic service collaboration for the education of nurses. Mundt’s article seeded the idea of changing the way that clinical nursing education is structured within the service environment. Nonetheless, there are considerable conceptual and operational differences between her proposal and this partnership as it was conceived, developed, and implemented in our nursing program. Two large differences between Mundt’s work and our own are her recommendation that students be clientfocused rather than agency-focused and that the full clinical course curriculum would revolve around the principles of nursing case management. Our students continue to be agency-focused/assigned and we have not made nursing case management a critical element throughout the curriculum. The Pew Health Professions Commission (1995), in making recommendations for revitalizing the health professions, noted that the next generation of health care professionals would need to “be prepared to practice in more intensively managed and integrated systems” (p. vii). The Commission further encouraged the development of “partnerships and alliances that had not been a part of education in the past” (p. vii). In the partnership described in this article, for example, students are learning in an organization that seeks to employ them as graduate and registered nurses who are already reasonably knowledgeable about the history and values of the organization and about how that organization works.
A Unique Academic-Service Partnership
Three major expectations arising from an academicservice partnership can influence where and how students in the health care fields learn their chosen profession. The first major expectation is that academic programs in health care must be designed to foster productive life-long learning. The second major expectation is that health care providers will have employment and career-building opportunities that are satis-
fying enough to keep those providers active and engaged members of their specialty. The third expectation is that the population’s health and/or recovery from disease, illness, or injury can and will be achieved through sophisticated, dynamic, health care delivery systems. This article describes the goals, objectives, implementation, and evaluation constructs of an academicservice partnership (Dean-Baar, 1998) that aims to address these expectations—life-long learning, career building, sophisticated and effective delivery systems—in the baccalaureate nursing student population. The model for the University of Wisconsin Milwaukee (UWM)/Aurora Health Care (AHC) Partnership in Clinical Nursing Education may prove to be a benchmark for education in the 21st century in that the academic setting is working diligently to be relevant to present and future health care service environments (Bellack, 1998; Larsen, 2000; Lindeman, 2000; Oneha, Sloat, Shoultz, & Tse, 1998; Skiba, 1997). PARTNERSHIP GOALS AND OBJECTIVES
The 2 goals of the UWM/AHC partnership were to develop and implement clinical training experiences that teach students key skills for community-based practice settings and to develop and evaluate an innovative and collaborative model for community-based clinical education. The community-based education for community-based practice settings means that students understand and synthesize their role in a health care delivery system that encompasses the lifespan and all health-related needs and events experienced by individuals in the context of their families and communities. PARTNER ORGANIZATIONS
The partners are the UWM School of Nursing (SON) and AHC. The UWM SON has 37 full-time faculty and approximately 1,100 prenursing and nursing undergraduate students enrolled as of spring 2003. Since UWM SON’s founding in 1965, nearly 5,800 students have graduated from the school, most of whom live and work in Wisconsin. The UWM SON offers a bachelor’s of science in nursing degree, and master’s of science and doctor of philosophy programs in nursing, all of which are fully accredited. The UWM SON has developed more than 65 contracts with community agencies that provide clinical experiences for students. The school offers an extensive continuing education program that is targeted to practicing
219
ACADEMIC-SERVICE PARTNERSHIP
nurses. The School is well known as a founder of the national community nursing center movement. AHC is the largest not-for-profit health care system in Wisconsin and the largest private employer, with more than 18,000 employees (more than 3,500 registered nurses) serving patients in more than 180 primary, secondary, and tertiary sties, including the Visiting Nurse Association. Aurora is focused on providing a continuum of health care that allows people to access treatment in the most logical, appropriate, and affordable settings. Aurora’s 180 facilities in eastern Wisconsin include 12 hospitals, more than 125 clinics, dozens of pharmacies, a comprehensive home health agency that provided more than 280,000 visits in 1997, and several long-term care facilities (Aurora Health Care, 1998). The UWM/AHC Partnership began with the following objectives: (1) to develop a model for collaborative community-based clinical education that provides experiences across the continuum of care (wellness-disease and health-illness/injury) and across the lifespan, from prenatal to dying/death; (2) to develop mechanisms to share resources to enhance the strategic plan of both partners in community-based care in an integrated health care system; and (3) to develop shared definitions of competencies and skills required by both the university and the health care settings so as to develop mechanisms to reduce redundancy.
STUDENT PARTICIPANTS
Students enter the program at the start of their clinical course work. The program is based on a learning model that views students as adults who are responsible for their own learning. The students begin the program with high student/faculty interaction in their first semester and end with low student/faculty interaction in their last semester. Conversely, the student’s relationship with AHC staff is minimal during the beginning experiences and increases until, in the final semester, an Aurora clinical staff nurse preceptor works one-on-one with the senior student. The student’s beginning experiences focus on communication and interviewing skills and move toward the last semester, with its focus on care planning, leadership, interdisciplinary teamwork, management, and policy development. Competencies developed in these areas help prepare the student immediately before graduation for entry to the AHC system as an advanced beginner practitioner and socialized staff member
(Haag-Heitman & Kramer, 1998; Nuccio et al., 1996). The students’ primary focus is to learn the art and science of nursing. The partnership is not a servicelearning experience (Norbeck, Connolly, & Koerner, 1998) wherein participants work for the employer as they pursue mastery of their academic objectives. Although the academic course content has not changed from the full class cohort from which these participants are drawn, the partnership students have a fundamentally consistent context for learning clinical nursing throughout their baccalaureate program. The consistent context addresses a need articulated in a study of professional socialization, “one of the difficulties of the student role is the need to adapt to a variety of nursing units. . .continually adjusting to a ‘new reality’ is stressful” (Reutter, Field, Campbell, & Day, 1997, p. 153). The students in the partnership have a number of benefits afforded to them. There are a diversity of community-based experiences and an in-depth experience with an integrated community-based health care system. The students have professional development opportunities to help them to understand the AHC system, and they have employment opportunities in community-based settings not usually offered to new graduates. Students are supported by a team of professionals committed to the program and also, at the student’s option, by a mentor from the Aurora nursing staff. The mentor is expected to serve as both a professional and career guide for the student, helping to build the student’s confidence, professional accountability, and professional leadership.
UWM/AHC Partnership Implementation
The first cohort of students entered into the partnership in the fall semester of 1998. New students enter during the spring and fall semesters. The 12th cohort began in the partnership in the spring semester of 2003, bringing the total number of participating students to 107. Students are either traditional students, working on their first bachelor’s degree over approximately 4 years, or accelerated students who already hold a bachelor’s degree and are working toward their baccalaureate degree in nursing over approximately 16 months. At the start of each semester, all students starting their first clinical course are invited to apply for participation in the partnership program. All students receive brief written and oral descriptions of the partner-
220
BARTZ AND DEAN-BAAR
ship. During the first 3 years of the program, interested students were asked to write a 1-page summary of why they were interested in the program. All students who submitted the summary were interviewed by an Aurora staff member and a UWM SON faculty member. More recently, students were asked to complete a 1-page document that included a 1-paragraph statement of their interest in the program. Student selections were made from these submissions. Approximately 8 students are selected each spring semester (traditional students) and 16 students are selected each fall semester (traditional plus accelerated students). The first partnership students to complete their baccalaureate degree in nursing completed their academic program in December 2000; there were 6 traditional and 7 accelerated students. Program completion meant that the students had satisfactorily met all UWM SON requirements for graduation, including the requirements for the partnership-based clinical courses in the curriculum. For each clinical course, students were in AHC clinical settings consistent with the goals of the course, including rehabilitation, medical and surgical units, ambulatory care clinics, free-standing clinics, employee health clinics, and parish nursing sites. Academic student evaluations were based on academic performance, clinical performance, and written assignments. During the last clinical course, each student’s preceptor(s) regularly discussed the student’s progress with the clinical instructor and then met more formally with the instructor for midterm and final conferences. The determination of the student’s grade was the clinical instructor’s responsibility (SON faculty). Students were expected to keep portfolios of their work throughout the program. The portfolios included patient and classroom teaching materials developed by the student, care plans, descriptions of community-based experiences, case studies, clinical competency lists, papers written, and any other materials the students deemed appropriate.
UWM/AHC Partnership Program Evaluation Constructs
The purpose of the program evaluation was to assess the impact, effectiveness, and overall worth of the program. A review of the nursing and curriculum evaluation literature revealed no descriptions of comparable partnership programs, and, consequently, no templates for program evaluation. Three constructs guided this program evaluation: (1) The Essentials of Bacca-
laureate Education for Professional Nursing Practice (American Association of Colleges of Nursing, 1998); (2) the vision and goals of the UWM SON; and (3) a multilevel process model of organizational socialization (Saks & Ashforth, 1997). ESSENTIALS OF BACCALAUREATE EDUCATION
The American Association of Colleges of Nursing (1998) Essentials document provides a framework of concepts organized into liberal education, professional values, core competencies, core knowledge, and role development. Students’ inculcation of these concepts can be estimated by the students themselves and by their preceptors and clinical faculty. Once graduated and employed, the new nurse can continue to selfassess while the related clinical nurse specialist and manager also may be able to estimate growth and mastery in these essential aspects of professional nursing. This is one of the first systematic studies using the 1998 AACN Essentials document. Eddy, Elfirnk, Weis, and Schank (1994) used an earlier version (from 1986) to compare perceptions of students and faculty concerning 7 values: altruism, equality, esthetics, truth, freedom, human dignity, and justice. There were few differences between faculty and students. The only significant variance was ascribed to faculty years of teaching (P ⬍ .004). Thurston, Flood, Shupe, and Gerald (1989) also used an earlier set of AACN values (from 1986), together with the Rokeach Values Survey (Rokeach, 1973) in a study aiming to describe values held by nursing faculty. UWM SON VISION AND GOALS
The UWM SON vision emphasizes the school’s aim to be a premier urban health nursing program that (1) emphasizes the integration of research, teaching, practice, and service; (2) implements innovative models of scholarship; and (3) establishes collaborative systems of health care delivery, scholarship, and interdisciplinary education. Of the 7 UWM SON goals, 4 are particularly relevant to the partnership. First, create an environment that facilitates teaching, scholarship, and service activities. This would include community building and creating optimal organizational structures. Second, create and maintain flexible, timely, scholarly educational programs that correspond to the changing health care systems. Programs need to be tailored to present and future needs in health care. Third, ensure that graduates of all programs are prepared adequately to perform effectively in their respective roles. Students who value
221
ACADEMIC-SERVICE PARTNERSHIP
critical thinking, performance proficiency, and lifelong learning should be competent and effective professional nurses with individuals, families, and communities. Fourth, create and strengthen partnerships through education, research, and practice/service activities and initiatives. ORGANIZATIONAL SOCIALIZATION
The construct of organizational socialization is drawn from the psychology and management literature. Saks and Ashforth (1997) developed a multilevel process model of organizational socialization, based on Van Maanen and Schein’s (1979) typology of socialization tactics, and uncertainty reduction theory, social cognitive theory, and cognitive and sense-making theory. Organizational socialization is primarily a learning process (Chao, O’Leary-Kelly, Wolf, Klein, & Gardner, 1994; Ostroff & Kozlowski, 1992), building on the concept of organizational commitment (Mowday, Steers, & Porter, 1979; Porter & Steers, 1973; Porter, Steers, Mowday, & Boulian, 1974). Intent to remain (in the job) is embedded deeply within organizational commitment (Mowday et al.). With the Saks and Ashforth (1997) process model, there are contextual factors that influence socialization factors. Contextual factors arise from extra-organizational, organizational/group, and job/role levels. Socialization factors are categorized as organizational (socialization tactics, orientation programs, training programs, mentoring programs), group (socialization tactics, social support, social learning processes), and individual (productive strategies and behavior). Newcomers, shaped by many of these factors, gain information and, through cognitive sense making, experience uncertainty reduction and learning, leading to proximal and distal outcomes. Saks and Ashforth’s (1997) process model of organizational socialization identifies 8 proximal outcomes and 3 categories of distal outcomes: individual, group, and organization. The 8 proximal outcomes are: (1) role clarity, (2) person-job/organization fit, (3) skill acquisition, (4) social integration, (5) social identification, (6) motivation, (7) personal change, and (8) role
outcomes. The distal outcomes for the individual are (1) lower stress, (2) higher job satisfaction, (3) higher organizational commitment, (4) lower absenteeism and turnover, (5) higher organizational citizenship behaviors, (6) higher performance, and (7) role conformity/role innovation. The distal outcomes are essentially the same for the group and for the organization, with scope of application making the difference. The distal outcomes are (1) stronger subculture and culture, (2) stronger cohesion and higher morale, (3) more stable membership, (4) greater effectiveness, and (5) reputation. The longitudinal program evaluation entered its third year in the fall of 2002. Survey instruments were developed based on the program evaluation constructs. Data are being collected from students and graduate/ registered nurses who take employment with AHC, mentors, preceptors, clinical nurse specialists, and patient care managers. Summary
This article has described the conceptual framework and program implementation of a unique academicservice partnership. Three constructs underlying the program evaluation were described. The nature of nursing education must change to meet the expectations of the baccalaureate nursing student population for life-long learning, career building, and sophisticated and effective delivery systems. Nursing education also must change to address the increasing emphasis on community-based, consumer-provider, interdependent health care. New models of clinical nursing education such as this partnership address these needs for change. Acknowledgments The authors acknowledge all members of the University of Wisconsin Milwaukee School of Nursing/Aurora Health Care Partnership Working Group: Mary Cieslak-Duchek, Patricia Volkert, Susan Hughes, Siobahn McMahon, Lauren Lund, Sandy Pelczynksi, Marie Golanowski, Rita Herman, Jane Leske, Chris Olson, Marge Sebern, Karen Barger, Bobbie Spitz, and Susan Cashin.
References American Association of Colleges of Nursing. (1998). The essentials of baccalaureate education for professional nursing practice. Washington, DC: American Association of Colleges of Nursing. Aurora Health Care. (1998). Milwaukee, WI. Anderson, C. A. (2000). Editorial: Undereducated, ag-
ing, and . . . a cycle of decline? Nursing Outlook, 48, 191215. Bellack, J. P. (1998). Editorial: Community-based nursing practice: Necessary but not sufficient. Journal of Nursing Education, 37, 99-100. Chao, G. T., O’Leary-Kelly, A. M., Wolf, S., Klein, H. J.,
222
& Gardner, P. D. (1994). Organizational socialization: Its content and consequences. Journal of Applied Psychology, 79, 730-743. Dean-Baar, S. (1998). The UWM/Aurora partnership in clinical nursing education: A pilot program in communitybased nursing in an integrated health care system. Milwaukee, WI: University of Wisconsin-Milwaukee. Eddy, D. M., Elfirnk, V., Weis, D., & Schank, M. J. (1994). Importance of professional nursing values: A national study of baccalaureate programs. Journal of Nursing Education, 33, 257-262. Edwards, J. B., & Alley, N. M. (2002). Transition to community-based nursing curriculum: Process and outcomes. Journal of Professional Nursing, 18, 78-84. Haag-Heitman, B., & Kramer, A. (1998). Creating a clinical practice development model. American Journal of Nursing, 98, 39-43. Larsen, P. D. (2000). Community-based curricula: New issues to address. Journal of Nursing Education, 39, 144-148. Lewis, M. (2000, March 3). The artist in gray flannel pajamas. The New York Times Magazine, p. 45-48. Lindeman, C. A. (2000). The future of nursing education. Journal of Nursing Education, 39, 5-12. Marquardt, M. (1999). Action learning in action. Palo Alto, CA: Davies-Black Publishing. McBride, A. B. (1999). Breakthroughs in nursing education: Looking back, looking forward. Nursing Outlook, 47, 114-119. Mowday, R. T., Steers, R. M., & Porter, L. W. (1979). The measurement of organizational commitment. Journal of Vocational Behavior, 14, 224-247. Mundt, M. H. (1997). A model for clinical learning experiences in integrated health care networks. Journal of Nursing Education, 36, 309-316. Norbeck, J. S., Connolly, C., & Koerner, J. (Ed). (1998). Caring and community concepts and models for service learning in nursing. Washington, DC: American Association for Higher Education. Nuccio, S. A., Lingen, D., Burke, L. J., Kramer, A., Ladewig, N., Raaum, J., & Shearer, B. (1996). The clinical practice developmental model—the transition process. Journal of Nursing Administration, 37, 129-135. Oneha, M. F., Sloat, A., Shoultz, J., & Tse, A. (1998). Community partnerships: Re-directing the education of undergraduate nursing students. Journal of Nursing Education, 37, 129-135. Ostroff, C., & Kozlowski, S. W. (1992). Organizational socialization as a learning process: The role of information acquisition. Personnel Psychology, 45, 849-874. Pesut, D. J. (2001). Spiral dynamics: Leadership insights. Nursing Outlook, 49, 70. Pew Health Professions Commission (1995). Critical
BARTZ AND DEAN-BAAR
challenges: Revitalizing the health professions for the twenty-first century. San Francisco, CA: UCSF Center for the Health Professions. Poell, R. F., VanderKrogt, F. J., & Warmerdam, J. H. M. (1998). Project-based learning in professional organizations. Adult Education Quarterly, 49, 28-42. Porter, L. W., Steers, R. M., Mowday, R. T., & Boulian, P. V. (1974). Organizational commitment, job satisfaction, and turnover among psychiatric technicians. Journal of Applied Psychology, 59, 603-609. Porter, L. W., & Steers, R. M. (1973). Organizational, work, and personal factors in employee turnover and absenteeism. Psychological Bulletin, 880, 151-176. Porter-O’Grady, T. (1999). Quantum leadership—new roles for a new age. Journal of Nursing Administration, 29, 37-42. Porter-O’Grady, T. (2001). Profound change: 21st century nursing. Nursing Outlook, 49, 182-186. Reutter, L., Field, P. A., Campbell, I. E., & Day, R. (1997). Socialization into nursing: Nursing students as learners. Journal of Nursing Education, 36, 149-155. Rizzo, J. R., House, R. J., & Lirtzman, S. I. (1970). Role conflict and ambiguity in complex organizations. Administrative Science Quarterly, 15, 150-163. Rokeach, M (1973). The nature of human values. New York: Free Press. Saks, A. M., & Ashforth, B. E. (1997). Organizational socialization: Making sense of the past and present as a prologue for the future. Journal of Vocational Behavior, 51, 234279. Skiba, D. J. (1997). Transforming nursing education to celebrate learning. Nursing and Health Care Perspectives, 18, 124-129, 148. Sorrels-Jones, J., & Weaver, D. (1999). Knowledge workers and knowledge-intense organizations, part 3. Journal of Nursing Administration, 29, 14-21. Staggers, N., Thompson, C. B., & Snyder-Halpern, R. (2001). History and trends in clinical information systems in the United States. Journal of Nursing Scholarship, 33, 7581. Taylor, K. L., & Care, W. D. (1999). Nursing education as a cognitive apprenticeship—a framework for clinical education. Nurse Educator, 24, 31-36. Thurston, H. I., Flood, M. A, Shupe, I. S., & Gerald, K. B. (1989). Values held by nursing faculty and students in a university setting. Journal of Professional Nursing, 5, 199207. Van Maanen, J., & Schein, E.H. (1979). Toward a theory of organizational socialization. In B.M. Staw (Ed.), Research in organizational behavior (vol. 1, pp. 209-264). Greenwich, CT: JAI Press.
This article describes the conceptualization and implementation of an academic-service partnership for a baccalaureate nursing program. The partnership began its fifth year in the fall of 2002; 107 students have entered the partnership since its inception. The partnership goals were to develop and implement clinical training experiences that teach students key skills for community-based practice settings, and to develop and evaluate an innovative and collaborative model for community-based clinical education. Students in the partnership have a unique opportunity for learning the art and science of nursing in a complex, integrated health care system with a strong emphasis on quality of environment, providers, and care delivery. A longitudinal program evaluation is underway, based on an American Association of Colleges of Nursing publication, the vision and goals of the School of Nursing, and the construct of organizational socialization. (Index words: Baccalaureate nursing education; Clinical nursing education; Community-based nursing; Program evaluation; Organizational socialization)) J Prof Nurs 19:216-222, 2003. © 2003 Elsevier Inc. All rights reserved.
T
HE WORK ENVIRONMENT of the early 21st century calls for new approaches in postsecondary education. Organizations will be structured to meet constantly changing demands for products that may be tangible or intangible, or a blend of the 2. As workers’ interests and capabilities change, or as their needs for change evolve, they will enter and leave the new-style organizations. Classic organization theory, with its principles of unity of command and single accountability (Rizzo, House, & Lirtzman, 1970), no longer explains how organizations function. Life-long careers
*Clinical Associate Professor, University of Wisconsin Milwaukee School of Nursing, Milwaukee, WI. †Associate Dean for Academic Affairs, University of Wisconsin Milwaukee School of Nursing, Milwaukee, WI. Supported in part by the Helene Fuld Health Trust, HSBC Bank, New York, NY. Address correspondence and reprint requests to Dr. Bartz: University of Wisconsin Milwaukee, Cunningham Hall, Post Office Box 413, Milwaukee, WI 53201-0413. E-mail: [email protected] © 2003 Elsevier Inc. All rights reserved. 8755-7223/03/1904-0000$30.00/0 doi:10.1016/S8755-7223(03)00090-5 216
and/or careers in homogenous organizations are a phenomena of the past (Lewis, 2000). This article presents the conceptualization of an academic-service partnership. The forces in today’s health care environment that shaped the conceptualization of an innovative approach to the clinical component of a nursing curriculum are discussed. The academic-service partnership is described in terms of its goals and objectives, the partner organizations, the student participants, and the implementation. Finally, the program evaluation constructs are described. An article to follow this one will present outcome data from the 3-year program evaluation that was designed to assess the impact, effectiveness, and overall worth of the program. Health Care: Toward Consumer-Provider Interdependence
Complex, integrated, health care systems are emerging to deal with the needs of a growing and aging population. The increasing sophistication of health care consumers is leading toward a consumer-provider interdependence model for care delivery. Rather than intermittent care for illness or injury, the movement is toward life-long care that includes health teaching, health promotion, disease prevention, and early detection of potential threats to health before medical intervention is necessary. Technology and, more broadly, research and development, are factors with which to contend in the implementation of a consumer-provider interdependence model. The continuing proliferation of technology for health care tends to threaten the interdependence model in that consumers may be overwhelmed by what is available and therefore feel powerless to participate in health care decisions. Similarly, the constant reports of findings and products from the research and development community are difficult for consumers to interpret, understand, and apply to their individual situations. Thus, many people may eschew an active role in their health maintenance or their care during illness or injury.
Journal of Professional Nursing, Vol 19, No 4 (July–August), 2003: pp 216-222
ACADEMIC-SERVICE PARTNERSHIP
Health care employers are challenged to sustain an environment in which competent, efficient, and whole-life encompassing care can be provided satisfactorily to their beneficiary population. Value-based health systems are replacing traditional sickness systems (Pesut, 2001; Porter-O’Grady, 1999, 2001). Further, in today’s competitive market, employers are challenged to create and foster learning organizations (Marquardt, 1999) and centers of excellence in selected aspects of care delivery. All levels of personnel in a health care system must therefore contribute to that excellence by virtue of their knowledge and abilities, and by their commitment to the values and goals of that organization. NURSING AND HEALTH CARE
The work of nursing is changing along with contemporary attitudes toward work, organizations, and health care delivery systems. Professional nurses have available to them an unprecedented range of work opportunities in contexts such as clinical practice, advanced clinical practice, management and administration, education, and research. Professional nurses also can make significant contributions to consumer-provider interdependence in contexts such as care and case management, health promotion, disease prevention, family teaching, and drug and alcohol use counseling. In addition, nurses often qualify for the increasing number of health care positions emerging that belong to no single discipline (McBride, 1999). As health care organizations continue to structure themselves for optimal care delivery and competitive market share, professional nurses are key contributors to those aims. A committed, professionally satisfied cohort of nurses throughout a complex, integrated health care delivery system may serve to advance the organization’s vision and goals. And, given sufficient complexity, breadth and depth of the delivery system, nurses within the organization could have sufficient variability, challenge, and professional growth to stay with the system for a substantial and worthwhile length of time. NURSING EDUCATION
Academia also is challenged by the changing attitudes toward work, organizations, and careers. On entry to the work context, nurses are faced with an immense amount of information to be synthesized into knowledge and skills that can be used in the work place. New information from research and development and from technology that includes information
217
systems (Staggers, Thompson, & Snyder-Halpern, 2001), constantly shapes health care delivery. The increased organizational complexity and the continued generation of new information means that nursing education has to foster the commitment to career-long learning (Lindeman, 2000; McBride, 1999; Skiba, 1997; Sorrels-Jones & Weaver, 1999). One can never stop learning to learn if an individual’s aim in any field is to be successful personally and professionally. Anderson (2000) noted that “a better-educated profession is necessary if nurses are to become full partners in health care, and intellectual equals with other health professionals” (p. 54). Nurses, in the earliest days of being named as such, learned by doing, sometimes with the guidance of a more experienced provider. A great deal of nursing care was rendered at home, often by family members who had varying amounts of knowledge, ability, and sense of responsibility. In the early days of formal education for nursing, hospital-educated diploma nurses served their communities’ needs by staying on to work where they were trained (Taylor & Care, 1999). With the advent of baccalaureate education, nurses were educated formally in the arts and sciences, in addition to their clinical education, which generally took place in medical centers with some added experiences in psychiatric facilities and in community health. Associate degree nursing education has blended some postsecondary education with substantial clinical experience, usually in traditional hospital settings. Although nursing education has come full circle in at least two ways, the circle has become decidedly more complex. First, faculty members are expected to be knowledgeable in the hands-on provision of health care while also having the ability to convey theoretical concepts that can be realized and applied by critically thinking students in a practice setting (Mundt, 1997). Students’ clinical experiences are enhanced through purposeful interactivity (e.g., preceptorships) with clinicians and managers. Faculty then assist the student to synthesize these experiences with the aim of students comprehending nursing in the context of the roles, ethics, and values of health care delivery systems. Second, students at the baccalaureate level are educated across the continua of health care, in particular, health throughout the lifespan and health care delivery across the wellness/disease and health/illness/injury phases experienced by people today. Students see that family care in homes or in community clinics is as much a part of health care as the most sophisticated technology-based care in hospitals. This horizontal learning approach looks across integrated systems and
218
BARTZ AND DEAN-BAAR
compares patient care outcomes and reveals relationships between the health care network and the community as a whole (Edwards & Alley, 2002; Mundt, 1997; Poell, VanderKrogt, & Warmerdam, 1998). A third way in which nursing education may be coming full circle is in the relationship between academia and service. McBride (1999) described a revitalized education-service link because these 2 major social systems are both in the process of re-inventing themselves. In a seminal article, Mundt (1997), while at this university, described a revolutionary academic service collaboration for the education of nurses. Mundt’s article seeded the idea of changing the way that clinical nursing education is structured within the service environment. Nonetheless, there are considerable conceptual and operational differences between her proposal and this partnership as it was conceived, developed, and implemented in our nursing program. Two large differences between Mundt’s work and our own are her recommendation that students be clientfocused rather than agency-focused and that the full clinical course curriculum would revolve around the principles of nursing case management. Our students continue to be agency-focused/assigned and we have not made nursing case management a critical element throughout the curriculum. The Pew Health Professions Commission (1995), in making recommendations for revitalizing the health professions, noted that the next generation of health care professionals would need to “be prepared to practice in more intensively managed and integrated systems” (p. vii). The Commission further encouraged the development of “partnerships and alliances that had not been a part of education in the past” (p. vii). In the partnership described in this article, for example, students are learning in an organization that seeks to employ them as graduate and registered nurses who are already reasonably knowledgeable about the history and values of the organization and about how that organization works.
A Unique Academic-Service Partnership
Three major expectations arising from an academicservice partnership can influence where and how students in the health care fields learn their chosen profession. The first major expectation is that academic programs in health care must be designed to foster productive life-long learning. The second major expectation is that health care providers will have employment and career-building opportunities that are satis-
fying enough to keep those providers active and engaged members of their specialty. The third expectation is that the population’s health and/or recovery from disease, illness, or injury can and will be achieved through sophisticated, dynamic, health care delivery systems. This article describes the goals, objectives, implementation, and evaluation constructs of an academicservice partnership (Dean-Baar, 1998) that aims to address these expectations—life-long learning, career building, sophisticated and effective delivery systems—in the baccalaureate nursing student population. The model for the University of Wisconsin Milwaukee (UWM)/Aurora Health Care (AHC) Partnership in Clinical Nursing Education may prove to be a benchmark for education in the 21st century in that the academic setting is working diligently to be relevant to present and future health care service environments (Bellack, 1998; Larsen, 2000; Lindeman, 2000; Oneha, Sloat, Shoultz, & Tse, 1998; Skiba, 1997). PARTNERSHIP GOALS AND OBJECTIVES
The 2 goals of the UWM/AHC partnership were to develop and implement clinical training experiences that teach students key skills for community-based practice settings and to develop and evaluate an innovative and collaborative model for community-based clinical education. The community-based education for community-based practice settings means that students understand and synthesize their role in a health care delivery system that encompasses the lifespan and all health-related needs and events experienced by individuals in the context of their families and communities. PARTNER ORGANIZATIONS
The partners are the UWM School of Nursing (SON) and AHC. The UWM SON has 37 full-time faculty and approximately 1,100 prenursing and nursing undergraduate students enrolled as of spring 2003. Since UWM SON’s founding in 1965, nearly 5,800 students have graduated from the school, most of whom live and work in Wisconsin. The UWM SON offers a bachelor’s of science in nursing degree, and master’s of science and doctor of philosophy programs in nursing, all of which are fully accredited. The UWM SON has developed more than 65 contracts with community agencies that provide clinical experiences for students. The school offers an extensive continuing education program that is targeted to practicing
219
ACADEMIC-SERVICE PARTNERSHIP
nurses. The School is well known as a founder of the national community nursing center movement. AHC is the largest not-for-profit health care system in Wisconsin and the largest private employer, with more than 18,000 employees (more than 3,500 registered nurses) serving patients in more than 180 primary, secondary, and tertiary sties, including the Visiting Nurse Association. Aurora is focused on providing a continuum of health care that allows people to access treatment in the most logical, appropriate, and affordable settings. Aurora’s 180 facilities in eastern Wisconsin include 12 hospitals, more than 125 clinics, dozens of pharmacies, a comprehensive home health agency that provided more than 280,000 visits in 1997, and several long-term care facilities (Aurora Health Care, 1998). The UWM/AHC Partnership began with the following objectives: (1) to develop a model for collaborative community-based clinical education that provides experiences across the continuum of care (wellness-disease and health-illness/injury) and across the lifespan, from prenatal to dying/death; (2) to develop mechanisms to share resources to enhance the strategic plan of both partners in community-based care in an integrated health care system; and (3) to develop shared definitions of competencies and skills required by both the university and the health care settings so as to develop mechanisms to reduce redundancy.
STUDENT PARTICIPANTS
Students enter the program at the start of their clinical course work. The program is based on a learning model that views students as adults who are responsible for their own learning. The students begin the program with high student/faculty interaction in their first semester and end with low student/faculty interaction in their last semester. Conversely, the student’s relationship with AHC staff is minimal during the beginning experiences and increases until, in the final semester, an Aurora clinical staff nurse preceptor works one-on-one with the senior student. The student’s beginning experiences focus on communication and interviewing skills and move toward the last semester, with its focus on care planning, leadership, interdisciplinary teamwork, management, and policy development. Competencies developed in these areas help prepare the student immediately before graduation for entry to the AHC system as an advanced beginner practitioner and socialized staff member
(Haag-Heitman & Kramer, 1998; Nuccio et al., 1996). The students’ primary focus is to learn the art and science of nursing. The partnership is not a servicelearning experience (Norbeck, Connolly, & Koerner, 1998) wherein participants work for the employer as they pursue mastery of their academic objectives. Although the academic course content has not changed from the full class cohort from which these participants are drawn, the partnership students have a fundamentally consistent context for learning clinical nursing throughout their baccalaureate program. The consistent context addresses a need articulated in a study of professional socialization, “one of the difficulties of the student role is the need to adapt to a variety of nursing units. . .continually adjusting to a ‘new reality’ is stressful” (Reutter, Field, Campbell, & Day, 1997, p. 153). The students in the partnership have a number of benefits afforded to them. There are a diversity of community-based experiences and an in-depth experience with an integrated community-based health care system. The students have professional development opportunities to help them to understand the AHC system, and they have employment opportunities in community-based settings not usually offered to new graduates. Students are supported by a team of professionals committed to the program and also, at the student’s option, by a mentor from the Aurora nursing staff. The mentor is expected to serve as both a professional and career guide for the student, helping to build the student’s confidence, professional accountability, and professional leadership.
UWM/AHC Partnership Implementation
The first cohort of students entered into the partnership in the fall semester of 1998. New students enter during the spring and fall semesters. The 12th cohort began in the partnership in the spring semester of 2003, bringing the total number of participating students to 107. Students are either traditional students, working on their first bachelor’s degree over approximately 4 years, or accelerated students who already hold a bachelor’s degree and are working toward their baccalaureate degree in nursing over approximately 16 months. At the start of each semester, all students starting their first clinical course are invited to apply for participation in the partnership program. All students receive brief written and oral descriptions of the partner-
220
BARTZ AND DEAN-BAAR
ship. During the first 3 years of the program, interested students were asked to write a 1-page summary of why they were interested in the program. All students who submitted the summary were interviewed by an Aurora staff member and a UWM SON faculty member. More recently, students were asked to complete a 1-page document that included a 1-paragraph statement of their interest in the program. Student selections were made from these submissions. Approximately 8 students are selected each spring semester (traditional students) and 16 students are selected each fall semester (traditional plus accelerated students). The first partnership students to complete their baccalaureate degree in nursing completed their academic program in December 2000; there were 6 traditional and 7 accelerated students. Program completion meant that the students had satisfactorily met all UWM SON requirements for graduation, including the requirements for the partnership-based clinical courses in the curriculum. For each clinical course, students were in AHC clinical settings consistent with the goals of the course, including rehabilitation, medical and surgical units, ambulatory care clinics, free-standing clinics, employee health clinics, and parish nursing sites. Academic student evaluations were based on academic performance, clinical performance, and written assignments. During the last clinical course, each student’s preceptor(s) regularly discussed the student’s progress with the clinical instructor and then met more formally with the instructor for midterm and final conferences. The determination of the student’s grade was the clinical instructor’s responsibility (SON faculty). Students were expected to keep portfolios of their work throughout the program. The portfolios included patient and classroom teaching materials developed by the student, care plans, descriptions of community-based experiences, case studies, clinical competency lists, papers written, and any other materials the students deemed appropriate.
UWM/AHC Partnership Program Evaluation Constructs
The purpose of the program evaluation was to assess the impact, effectiveness, and overall worth of the program. A review of the nursing and curriculum evaluation literature revealed no descriptions of comparable partnership programs, and, consequently, no templates for program evaluation. Three constructs guided this program evaluation: (1) The Essentials of Bacca-
laureate Education for Professional Nursing Practice (American Association of Colleges of Nursing, 1998); (2) the vision and goals of the UWM SON; and (3) a multilevel process model of organizational socialization (Saks & Ashforth, 1997). ESSENTIALS OF BACCALAUREATE EDUCATION
The American Association of Colleges of Nursing (1998) Essentials document provides a framework of concepts organized into liberal education, professional values, core competencies, core knowledge, and role development. Students’ inculcation of these concepts can be estimated by the students themselves and by their preceptors and clinical faculty. Once graduated and employed, the new nurse can continue to selfassess while the related clinical nurse specialist and manager also may be able to estimate growth and mastery in these essential aspects of professional nursing. This is one of the first systematic studies using the 1998 AACN Essentials document. Eddy, Elfirnk, Weis, and Schank (1994) used an earlier version (from 1986) to compare perceptions of students and faculty concerning 7 values: altruism, equality, esthetics, truth, freedom, human dignity, and justice. There were few differences between faculty and students. The only significant variance was ascribed to faculty years of teaching (P ⬍ .004). Thurston, Flood, Shupe, and Gerald (1989) also used an earlier set of AACN values (from 1986), together with the Rokeach Values Survey (Rokeach, 1973) in a study aiming to describe values held by nursing faculty. UWM SON VISION AND GOALS
The UWM SON vision emphasizes the school’s aim to be a premier urban health nursing program that (1) emphasizes the integration of research, teaching, practice, and service; (2) implements innovative models of scholarship; and (3) establishes collaborative systems of health care delivery, scholarship, and interdisciplinary education. Of the 7 UWM SON goals, 4 are particularly relevant to the partnership. First, create an environment that facilitates teaching, scholarship, and service activities. This would include community building and creating optimal organizational structures. Second, create and maintain flexible, timely, scholarly educational programs that correspond to the changing health care systems. Programs need to be tailored to present and future needs in health care. Third, ensure that graduates of all programs are prepared adequately to perform effectively in their respective roles. Students who value
221
ACADEMIC-SERVICE PARTNERSHIP
critical thinking, performance proficiency, and lifelong learning should be competent and effective professional nurses with individuals, families, and communities. Fourth, create and strengthen partnerships through education, research, and practice/service activities and initiatives. ORGANIZATIONAL SOCIALIZATION
The construct of organizational socialization is drawn from the psychology and management literature. Saks and Ashforth (1997) developed a multilevel process model of organizational socialization, based on Van Maanen and Schein’s (1979) typology of socialization tactics, and uncertainty reduction theory, social cognitive theory, and cognitive and sense-making theory. Organizational socialization is primarily a learning process (Chao, O’Leary-Kelly, Wolf, Klein, & Gardner, 1994; Ostroff & Kozlowski, 1992), building on the concept of organizational commitment (Mowday, Steers, & Porter, 1979; Porter & Steers, 1973; Porter, Steers, Mowday, & Boulian, 1974). Intent to remain (in the job) is embedded deeply within organizational commitment (Mowday et al.). With the Saks and Ashforth (1997) process model, there are contextual factors that influence socialization factors. Contextual factors arise from extra-organizational, organizational/group, and job/role levels. Socialization factors are categorized as organizational (socialization tactics, orientation programs, training programs, mentoring programs), group (socialization tactics, social support, social learning processes), and individual (productive strategies and behavior). Newcomers, shaped by many of these factors, gain information and, through cognitive sense making, experience uncertainty reduction and learning, leading to proximal and distal outcomes. Saks and Ashforth’s (1997) process model of organizational socialization identifies 8 proximal outcomes and 3 categories of distal outcomes: individual, group, and organization. The 8 proximal outcomes are: (1) role clarity, (2) person-job/organization fit, (3) skill acquisition, (4) social integration, (5) social identification, (6) motivation, (7) personal change, and (8) role
outcomes. The distal outcomes for the individual are (1) lower stress, (2) higher job satisfaction, (3) higher organizational commitment, (4) lower absenteeism and turnover, (5) higher organizational citizenship behaviors, (6) higher performance, and (7) role conformity/role innovation. The distal outcomes are essentially the same for the group and for the organization, with scope of application making the difference. The distal outcomes are (1) stronger subculture and culture, (2) stronger cohesion and higher morale, (3) more stable membership, (4) greater effectiveness, and (5) reputation. The longitudinal program evaluation entered its third year in the fall of 2002. Survey instruments were developed based on the program evaluation constructs. Data are being collected from students and graduate/ registered nurses who take employment with AHC, mentors, preceptors, clinical nurse specialists, and patient care managers. Summary
This article has described the conceptual framework and program implementation of a unique academicservice partnership. Three constructs underlying the program evaluation were described. The nature of nursing education must change to meet the expectations of the baccalaureate nursing student population for life-long learning, career building, and sophisticated and effective delivery systems. Nursing education also must change to address the increasing emphasis on community-based, consumer-provider, interdependent health care. New models of clinical nursing education such as this partnership address these needs for change. Acknowledgments The authors acknowledge all members of the University of Wisconsin Milwaukee School of Nursing/Aurora Health Care Partnership Working Group: Mary Cieslak-Duchek, Patricia Volkert, Susan Hughes, Siobahn McMahon, Lauren Lund, Sandy Pelczynksi, Marie Golanowski, Rita Herman, Jane Leske, Chris Olson, Marge Sebern, Karen Barger, Bobbie Spitz, and Susan Cashin.
References American Association of Colleges of Nursing. (1998). The essentials of baccalaureate education for professional nursing practice. Washington, DC: American Association of Colleges of Nursing. Aurora Health Care. (1998). Milwaukee, WI. Anderson, C. A. (2000). Editorial: Undereducated, ag-
ing, and . . . a cycle of decline? Nursing Outlook, 48, 191215. Bellack, J. P. (1998). Editorial: Community-based nursing practice: Necessary but not sufficient. Journal of Nursing Education, 37, 99-100. Chao, G. T., O’Leary-Kelly, A. M., Wolf, S., Klein, H. J.,
222
& Gardner, P. D. (1994). Organizational socialization: Its content and consequences. Journal of Applied Psychology, 79, 730-743. Dean-Baar, S. (1998). The UWM/Aurora partnership in clinical nursing education: A pilot program in communitybased nursing in an integrated health care system. Milwaukee, WI: University of Wisconsin-Milwaukee. Eddy, D. M., Elfirnk, V., Weis, D., & Schank, M. J. (1994). Importance of professional nursing values: A national study of baccalaureate programs. Journal of Nursing Education, 33, 257-262. Edwards, J. B., & Alley, N. M. (2002). Transition to community-based nursing curriculum: Process and outcomes. Journal of Professional Nursing, 18, 78-84. Haag-Heitman, B., & Kramer, A. (1998). Creating a clinical practice development model. American Journal of Nursing, 98, 39-43. Larsen, P. D. (2000). Community-based curricula: New issues to address. Journal of Nursing Education, 39, 144-148. Lewis, M. (2000, March 3). The artist in gray flannel pajamas. The New York Times Magazine, p. 45-48. Lindeman, C. A. (2000). The future of nursing education. Journal of Nursing Education, 39, 5-12. Marquardt, M. (1999). Action learning in action. Palo Alto, CA: Davies-Black Publishing. McBride, A. B. (1999). Breakthroughs in nursing education: Looking back, looking forward. Nursing Outlook, 47, 114-119. Mowday, R. T., Steers, R. M., & Porter, L. W. (1979). The measurement of organizational commitment. Journal of Vocational Behavior, 14, 224-247. Mundt, M. H. (1997). A model for clinical learning experiences in integrated health care networks. Journal of Nursing Education, 36, 309-316. Norbeck, J. S., Connolly, C., & Koerner, J. (Ed). (1998). Caring and community concepts and models for service learning in nursing. Washington, DC: American Association for Higher Education. Nuccio, S. A., Lingen, D., Burke, L. J., Kramer, A., Ladewig, N., Raaum, J., & Shearer, B. (1996). The clinical practice developmental model—the transition process. Journal of Nursing Administration, 37, 129-135. Oneha, M. F., Sloat, A., Shoultz, J., & Tse, A. (1998). Community partnerships: Re-directing the education of undergraduate nursing students. Journal of Nursing Education, 37, 129-135. Ostroff, C., & Kozlowski, S. W. (1992). Organizational socialization as a learning process: The role of information acquisition. Personnel Psychology, 45, 849-874. Pesut, D. J. (2001). Spiral dynamics: Leadership insights. Nursing Outlook, 49, 70. Pew Health Professions Commission (1995). Critical
BARTZ AND DEAN-BAAR
challenges: Revitalizing the health professions for the twenty-first century. San Francisco, CA: UCSF Center for the Health Professions. Poell, R. F., VanderKrogt, F. J., & Warmerdam, J. H. M. (1998). Project-based learning in professional organizations. Adult Education Quarterly, 49, 28-42. Porter, L. W., Steers, R. M., Mowday, R. T., & Boulian, P. V. (1974). Organizational commitment, job satisfaction, and turnover among psychiatric technicians. Journal of Applied Psychology, 59, 603-609. Porter, L. W., & Steers, R. M. (1973). Organizational, work, and personal factors in employee turnover and absenteeism. Psychological Bulletin, 880, 151-176. Porter-O’Grady, T. (1999). Quantum leadership—new roles for a new age. Journal of Nursing Administration, 29, 37-42. Porter-O’Grady, T. (2001). Profound change: 21st century nursing. Nursing Outlook, 49, 182-186. Reutter, L., Field, P. A., Campbell, I. E., & Day, R. (1997). Socialization into nursing: Nursing students as learners. Journal of Nursing Education, 36, 149-155. Rizzo, J. R., House, R. J., & Lirtzman, S. I. (1970). Role conflict and ambiguity in complex organizations. Administrative Science Quarterly, 15, 150-163. Rokeach, M (1973). The nature of human values. New York: Free Press. Saks, A. M., & Ashforth, B. E. (1997). Organizational socialization: Making sense of the past and present as a prologue for the future. Journal of Vocational Behavior, 51, 234279. Skiba, D. J. (1997). Transforming nursing education to celebrate learning. Nursing and Health Care Perspectives, 18, 124-129, 148. Sorrels-Jones, J., & Weaver, D. (1999). Knowledge workers and knowledge-intense organizations, part 3. Journal of Nursing Administration, 29, 14-21. Staggers, N., Thompson, C. B., & Snyder-Halpern, R. (2001). History and trends in clinical information systems in the United States. Journal of Nursing Scholarship, 33, 7581. Taylor, K. L., & Care, W. D. (1999). Nursing education as a cognitive apprenticeship—a framework for clinical education. Nurse Educator, 24, 31-36. Thurston, H. I., Flood, M. A, Shupe, I. S., & Gerald, K. B. (1989). Values held by nursing faculty and students in a university setting. Journal of Professional Nursing, 5, 199207. Van Maanen, J., & Schein, E.H. (1979). Toward a theory of organizational socialization. In B.M. Staw (Ed.), Research in organizational behavior (vol. 1, pp. 209-264). Greenwich, CT: JAI Press.