A collaborative clerkship with a focus on rural community health.

The Deans' Rural Primary Care Clerkship was developed through the collaborative efforts of South Carolina's two medical schools. The clerkship provides students an innovative learning experience in rural community medicine through the unique combination of learning opportunities with community-oriented primary care, continuous quality improvement, interdisciplinary health care teams, and cultural competency. Much of students' learning addresses current directives for population health training. The positive experience students are having in these rural, underserved South Carolina communities will help them better understand the rewards and challenges of rural, community-responsive health care.

Developing BSN leaders for the future: the Fuld Leadership Initiative for Nursing Education (LINE).

The Helene Fuld Leadership Initiative in Nursing Education (LINE) program was designed to enhance beginning leadership competencies of baccalaureate nursing students. Given the increasing need for strong and effective leadership throughout the health care system, and the demands new graduates encounter as they move into practice, the LINE program is built on the premise that leadership skills must be instilled at the undergraduate level. The program achieves its goal through an intensive 5-day institute focused on assessing and developing the leadership competencies of nurse educators and their clinical partners to enable them to be effective agents of curriculum change in their home institutions. The institute also assists participants to redesign their baccalaureate nursing (BSN) curricula to ensure that students learn to: (1) work effectively within and across complex, integrated organizational and institutional boundaries; (2) think and act from the perspective of a system; and (3) communicate, negotiate, lead, and facilitate change within health care organizations. D. Goleman's (1998) framework of emotional intelligence, which addresses both personal competence (managing oneself) and social competence (handling one's relationships with others) provides the framework for operationalizing leadership in the BSN curriculum. To date, 26 BSN programs and their clinical partners have participated in the LINE program, which has the potential to influence the beginning leadership development of more than 2,400 BSN students. Program outcomes reveal that education-practice collaboration, professional networking, individual leadership development of nurse educators and their clinical partners as change agents, and the integration of leadership experiences at all levels of the BSN curriculum are important in developing beginning leadership competencies in BSN students.

A proposed framework for differentiating the 21 Pew competencies by level of nursing education.

Now nearly a decade old, the original Pew Health Professions Commission Competencies have stood up well to the test of time. The competencies were designed to provide all health professionals, from physicians to physical therapists, with a general guide to the values, skills, and knowledge they would need to be successful in the health care system that was beginning to emerge in the late 1980s. They have been used across the range of health professions and in many practice settings to create a framework for curricular change, work redesign, and assessment of professional competence. The interpretation of the competencies offered here should prove to be a useful tool to nurses and health system leaders as they carry on the hard work of adapting the current model of nursing practice to the demands and realties of the contemporary and continually evolving health care environment. This work is important for two reasons. First, many of the skills and attributes of the professional nurse are not adequately used or valued by the health care system because the profession is both fragmented and poorly differentiated and articulated. Without markers that define and promote collaborative practice within nursing, the full potential of nurses at all levels of preparation will continue to be inadequately and inappropriately deployed. This model exacerbates the current nursing shortage because it fails to use nurses in appropriate, well-delineated, and challenging roles. Without this kind of differentiation, one that can be owned and supported by all nurses, there will continue to be suboptimal use of the nursing workforce in the United States. The framework of differentiated Pew competencies and the companion teaching-learning strategies proposed here offer one approach to rationalizing both nursing education and practice, with the potential for improving the quality of care, and reducing fragmentation, cost, and public confusion.

Recreating nursing practice for a new century. Recommendations and implications of the Pew Health Professions Commission's final report.

The erratic path of evolution of health care in the United States creates daunting threats as well as new opportunities for institutions, professionals, and the public. Perhaps no stakeholder has more to risk or gain than professional nursing. As the largest of all the health professions, nursing serves as the backbone for much of the care delivery system. Historically, nurses have been employed primarily in hospital settings. Toward the latter part of the 20th century, however, nurses assumed such expanded roles as independent practitioners, managers of care in large health plans, and providers of alternative and complementary health care services. These new roles point to how nursing may rapidly evolve as the health care system addresses continuing issues of cost, performance, access, and consumer satisfaction. While today's opportunities are great, threats remain to the traditional role of the nurse in the hospital setting, through regulatory constraints on nursing practice and the lack of clear purpose and direction within the broad professional nursing community. Following a decade of leadership and advocacy for health professions education, the Pew Health Professions Commission issued its fourth and final report in December 1998. In this report, the Commission assessed the challenges facing professionals in the 21st century and made general and profession-specific recommendations for action.

Differences in curriculum emphasis in US undergraduate and generalist residency education programmes.

OBJECTIVES: Little attention has been paid to the differential emphasis undergraduate and graduate medical education programmes place on the broad competencies that will be needed for practice in an increasingly managed health care environment. The purpose of this study was to determine differences in emphasis that undergraduate and primary care graduate medical education programmes are currently placing on 33 broad practice competencies, compared with the emphasis they ideally would like to give them, and the barriers they perceive to curriculum change. DESIGN: Subjects were surveyed by mailed questionnaire. A reminder postcard and follow-up mailing were sent to non-respondents. SETTING: US allopathic medical schools. SUBJECTS: Academic deans identified by the Association of American Medical Colleges (AAMC) and generalist (family medicine, internal medicine, paediatrics and obstetrics-gynaecology) residency programme directors identified by the American Council on Graduate Medical Education (ACGME). RESULTS: Findings revealed that residency programmes placed greater emphasis on the study's broad curriculum topics than did undergraduate medical education programmes. Statistically significant differences were found in current emphasis for 12 topics and ideal emphasis for six topics. Both groups identified an already crowded curriculum and inadequate funding as the top two barriers to curriculum change. CONCLUSIONS: The differences in curriculum emphases and perceived barriers to curriculum change most probably reflect the different realities of undergraduate and graduate medical education programmes, i.e. academics vs. a focus on immediate practice realities.

Curriculum trends in nurse practitioner programs: current and ideal.

The purpose of this study was to ascertain the extent to which nurse practitioner (NP) education programs are addressing curriculum topics related to practice competencies needed for the next century as recommended by the Pew Health Professions Commission and other professional organizations, including the American Association of Colleges of Nursing and the National Organization of Nurse Practitioner Faculties. The study was part of a comprehensive survey of 11 health professions education programs. NP program directors indicated greatest dissatisfaction with curriculum coverage of "use of electronic information systems" and "business management of practice." The three most important curriculum topics identified by respondents were "primary care," "health promotion/disease prevention," and "effective patient-provider relationships/communication," identical to the three topics rated most important by all groups combined. The most significant barriers to change identified by the respondents included "an already crowded curriculum" and "limited availability of clinical learning sites." Findings show that NP program directors perceive that they are doing an effective job addressing most of the 33 curriculum topics, but they also recognize a need to continue to improve their curricula in response to the ever-changing health care environment. Barriers to achieving the desired curricular improvements, however, may be significant. Recommendations for overcoming these barriers to change are offered.

Responses of baccalaureate and graduate programs to the emergence of choice in nursing accreditation.

Specialized accreditation in nursing is a widely recognized and respected hallmark of program quality. The advent of a second specialized accrediting agency for baccalaureate and higher degree programs in nursing prompted a survey of these programs to determine their choice of nursing accreditation agency, factors influencing their choice, their perceptions of the value added by nursing accreditation, and the difficulties encountered with the accreditation process. These study variables and the relationships between choice of accrediting agency and types of degree-granting nursing education programs offered by the institution, agency membership in the National League of Nursing (NLN) or the American Association of Colleges of Nursing (AACN), expected date of next accreditation visit, geographic region, public versus private status, and type of institution (Carnegie classification) were analyzed. Findings revealed that nearly a quarter (24%) of respondents intend to continue with the NLN Accrediting Commission (NLNAC), whereas 30% indicated they have already switched to the Commission on Collegiate Nursing Education (CCNE) or intend to do so prior to their next accreditation cycle. However, nearly a quarter (24%) of respondents said they plan to be accredited by both agencies for the immediate future, and 21% indicated they are still undecided. Study findings suggest an end to single-source accreditation, and the beginning of a new market-oriented approach.

Students add value to learning organizations: the Medical University of South Carolina experience.

Students bring fresh ideas, knowledge, and perspective to health care organizations. As students learn how to apply the principles and methods of continuous improvement, they help improve both the quality of health care and the organization's way of improving quality.

Curriculum trends in nurse-midwifery education. Views of program directors.

The purpose of this study was to determine the extent to which nurse-midwifery education programs are addressing the practice competencies that have been recommended by the Pew Health Professions Commission and others as essential for effective practice in the 21st century. This study was part of a larger survey of eleven health professions education programs. The 56 nurse-midwifery program directors whose names and addresses were provided by the American College of Nurse-Midwives were surveyed by mailed questionnaire, with a response rate of 59% (n = 33). The study sought to identify current and ideal emphasis placed on 33 broad topics, most important curriculum topics, and barriers to curriculum change as perceived by respondents. Findings revealed that nurse-midwifery program directors would like to see greater emphasis placed on every topic except one (tertiary/quaternary care). Desired increases ranged from .04 to 1.36. The overall mean rating for all topics was 3.51 for current emphasis (5-point scale) and 4.18 for ideal emphasis, both of which were higher than any other survey group. The greatest desired increases (> 1.00) were for "primary care," "managed care," "use of electronic information systems," and "business management of practice." Respondents identified "primary care," "health promotion/disease prevention," and "accountability for cost-effectiveness and patient outcomes" as the most important topics. The top three barriers to curriculum change were identified as "already crowded curriculum," "inadequate funding," and "limited availability of clinical learning sites," the last being statistically significant compared with other survey groups. Findings indicate that nurse-midwifery program directors perceived that they are adequately addressing most of the curriculum topics, while continuing to focus on the need for curriculum change as the health care environment changes.