Setting the record straight on the Carnegie nursing study
Commentary
By P. Benner, M. Sutphen, V. Leonard and L. Day, Published March 19, 2010

As often happens with media coverage, the media overstated the intent and content of the Carnegie National Study of Nursing Education, creating more heat than light. We hope to clarify and shed light on the intent and major findings of the recently released report published under the title “Educating Nurses: A Call for Radical Transformation.”

Seven years ago, the Carnegie Foundation for the Advancement of Teaching launched a series of studies of professional education designed to examine the professions from the view of civic professionalism rather than technical professionalism. The five professions studied were clergy, engineering, law, medicine and nursing.

 A framework for the studies was that all professional education required at least three professional apprenticeships (the term “apprenticeships” was used as a metaphor for learning a practice, rather than as a model of work organization):

• The cognitive apprenticeship, which refers to the science, theory and humanities education required to think like a nurse, physician, lawyer, engineer, clergy or a teacher.
• The practice apprenticeship, where the professional learns to effectively practice the discipline, for example, skilled know-how, practical or clinical reasoning, situated cognition and the use of knowledge in complex under-determined situations as well as well the structured use of technology.
• The ethical comportment and formation apprenticeship, where the professional learns to perceive and practice the notions of good, and the best practices in actual practice situations.

The studies were designed to discover and articulate the signature pedagogies of the different professions and to describe and examine the content, pedagogical evaluation of these professions through intensive case studies, and in the case of nursing and clergy, through national surveys of educators and students.

The Carnegie nursing study conducted three national surveys, two of educators, co-sponsored by National League for Nursing and the American Association of Colleges of Nursing, and one co-sponsored by the National Student Nurses Association. These national surveys were designed to extend, confirm or disconfirm findings from nine intensive site visits.

We sought in each report to study best educational practices at the top institutions for nursing education. The study was not designed to answer questions about the comparative outcomes of different types of nursing education programs. Two associate-degree programs, one diploma program, one registered nurse-to-baccalaureate completion program and four baccalaureate programs (one liberal arts colleges and three university health sciences campuses). All programs had been rated highly in their academic standings.

The study found that all nursing programs have a major practice-education gap. In all nursing programs, natural and social sciences and humanities need to be updated and upgraded. We found a radical separation of classroom and clinical practice teaching and a radical separation of knowledge acquisition and knowledge use, sometimes with little or no emphasis on knowledge use in the classroom, and poor connections in  clinical and classroom learning.

We also found that all nursing programs are effective in shaping a nursing identity, ethical comportment, formation of a practitioner with internal notions of good practice and the ability to perceive ethical conflicts and issues in practice situations.

Now, as professional educational programs are compared, nursing stands out in this area. Clinical education is usually better than classroom education, and classroom and clinical education are most integrated when there is planned, ongoing teamwork with classroom and clinical faculty or when the classroom teacher also teaches in the clinical area.

Fundamental shifts in nursing ed

The Carnegie study recommends four major shifts in the way nursing education is thought about and taught:

Move from focusing on decontextualized knowledge to teaching for a sense of salience, situated cognition and action in particular situations. Many teachers organize their classes around lists of abstract taxonomies or other abstract theory and knowledge, which give their students little or no indication about how to use that knowledge in clinical practice. Students find it difficult to imagine how to use the classification systems or scientific evidence in their actual practice.

There is a built in crisis to over-focusing pedagogically on breaking situations down to their most simple elements and mastering those elements. This is a good strategy for the beginning student, but soon, in order to have an effective integrated practice, students must learn to recognize the nature of whole situations. This can be done in simulation labs but finally must be mastered in ambiguous clinical settings.

Shift from a sharp separation of clinical and classroom teaching to integration of classroom and clinical teaching. There is a sharp divide between classroom and clinical teaching. Students notice the differences between classroom presentation and their clinical experiences, which makes integrating knowledge and skills nearly impossible.

Move from emphasizing critical thinking to focusing on clinical reasoning and multiple ways of thinking that include critical thinking. More emphasis on practical reasoning and multiple ways of thinking is needed in all nursing education programs. Students need to draw on knowledge from disparate, sometimes even conflicting domains, in clinical situations. This requires the skill of seeing a situation from different angles and from different perspectives.

Shift from focusing on socialization and role-taking to a focus on formation. A distinguishing feature of nurse education, as well as professional education in general, is the emphasis on forming in students the knowledge; relational skills; and habits of hand, heart and mind that cohere in professional identity and practice, commitments and integrity.

All nursing programs need upgrades

In the Carnegie study, we conclude that nursing education in all types of nursing programs need to be upgraded and that the goal of every nursing student should be progression in education  to a graduate level. We recommend that within 10 years of graduation that all nursing students complete the master’s degree.

We do not suggest, nor think it wise to disband nursing education in the community colleges. We are concerned that due to underfunding of nursing education in community colleges and over-subscription of potential nursing students that more attention be paid to the long waiting times and delay in program completion beyond the minimum three years to complete prerequisites and the nursing program.

In our surveys and site visits, we found that nursing students were often spending four to seven years completing their nursing programs. Most of this delayed completion is due to wait times and credit creep.

Students who must support families while continuing their education choose to go to school part-time. Where possible, these students should be better funded to go to school, but, in principle, we recognize going to school part-time is the only option for many students.

Our two recommendations regarding community college nursing education are to:

Develop local articulation programs to ensure a smooth, timely transition from the associate-degree nursing (ADN) programs to bachelor’s of sciences nursing degrees. We recommend a redesign and reconfiguration of the roles of diploma and community colleges in nursing education. What was meant to constitute a swift entry to practice has resulted in a logjam, and students are not moving on to the BSN in appreciable numbers. We urge local and regional consortia, on the order of the Oregon Consortium for Nursing Education, to create a seamless transition from the ADN program to the BSN—and beyond.

Develop more ADN-to-master’s of science nursing (MSN) degree programs. Researcher Liana Orsolini-Hain has found that few ADN students felt motivated to return to school for a baccalaureate degree because the degree would not significantly influence their job capacities, functions or salaries. We believe that ADN-to-MSN programs would appeal to practicing ADNs and give them a realistic incentive to return to school for better job opportunities and salaries. Another benefit of this action would be growth of the applicant pool for doctoral study and enlargement of the faculty pipeline.

The writers—Patricia Benner, Molly Sutphen, Victoria Leonard and Lisa Day—are authors of the Carnegie Foundation for the Advancement of Teachings study “Educating Nurses: A Call for Radical Transformation.”