Nursing Center - Journal Article

Abstract

Master's programs to prepare nurse educators have dramatically increased and are being transformed with the advent of the doctorate in nursing practice. In the absence of standards, questions arise regarding program design and curriculum models. To assess this issue, the authors discuss their review of Web sites for 198 nurse educator programs and describe curricular patterns and trends. The findings are then related to the AACN Essentials of Master's Education for Advanced Practice Nursing and NLN Nurse Educator Certification Criteria.

US nursing schools turned away almost 50,000 qualified applicants from baccalaureate and graduate nursing programs in 2008. Insufficient number of faculty is one of the most commonly cited reasons for not accepting all qualified applicants.1,2 Meanwhile, as the nursing faculty shortage worsened, the nursing education community was urged to provide increased opportunities in graduate programs to prepare faculty,3 resulting in growth in the number of master's programs that prepare nurse educators. Although this is a welcome change from previous reports that indicated a decline in nurses prepared for entry-level positions as faculty,3 questions exist regarding the curriculum standards that are governing the development of these rapidly proliferating programs.

The purpose of this descriptive study was to document growth trends in nurse educator programs and review the current curricular patterns in master's programs designed to prepare nurse educators. Annual report data from both the National League for Nursing (NLN)4 and American Association of Colleges of Nursing (AACN)5-18 were used to review program enrollment in nurse educator programs over the past 4 decades. A review of the Web sites for all institutions that reported having a nurse educator program, as reported to AACN for 2008,19 was the source of the curriculum information used in this study. From this information, it is possible to draw conclusions about national trends and standards for curricula that will inform the ongoing dialogue regarding the future of these master's education programs.

Nurse Educator Program Growth Patterns

A shift away from preparing nurses for roles as faculty members occurred in the 1990s when graduate nursing education increasingly focused on the preparation of nurse practitioners (NPs) rather than its long-held focus of preparation of nurse educators and administrators. The shift in enrollment in nurse educator programs is dramatically demonstrated by comparing the first and last year of NLN data collected from the schools it accredited between 1968 and 1995. In 1968, 66 nursing programs had a total enrollment in their master's programs of 4,018, with 1,344 of these students (33%) enrolled in nurse educator programs. Twenty-seven years later, in 1995, the 306 programs submitting information reported a total enrollment of 35,707 students, with only 576 (1.6%) enrolled in nurse educator programs.4 Although enrollment in master's nursing programs increased more than 600% during these 27 years, the decline in students selecting nurse educator programs is striking.

Because the NLN stopped collecting these data in 1995, AACN annual report data on enrollment and programs by major area of study were used for the period from 1996 through 2009.5-18 In 1996, AACN reported that 281 nursing schools had a total of 32,355 students enrolled in master's study; 93 schools (33%) had nurse educator programs that comprised a total of 1707 or 5.3% of the master's students. However, by 2009, 468 institutions reported a total enrollment of 77,146 master's students. Of those institutions, 296 (63%) had nurse educator programs, with a total enrollment of 13,883 or 18% of that total master's students. This represents a 218% increase in nursing education programs over a 13-year period and a 713% increase in total student enrollment in nurse educator programs (Figure 1).5-18

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Figure 1. Nurse educator program enrollment 1968-2009.

This growth has not been a steady event over the past 4 decades. The NLN data show a randomly variable pattern of growth and decline in nurse educator program enrollment from 1968 through 1978. In 1979, a very sharp 16-year decline in enrollment continued until 1995 when it began to slowly increase. However, the growth that has occurred in the first decade of the new millennium is an amazing phenomenon. For the past 9 years (2000 to 2009), enrollments grew between 15% and 80% per year. In 2000, 1285 nurse educator students were enrolled in a total of 84 programs. In 2009, there were 13,883 students enrolled in 296 programs. This trend shows no indication of slowing; from 2008 to 2009, 38 new programs were added to the AACN report of nurse educator programs (Figure 2).5-18

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Figure 2. Nurse educator program numbers 1994-2009.

Curricular Review

As nurse educator programs continue to proliferate, what standards have guided the development of the curricula? Accrediting bodies require that nursing faculty be prepared in the area in which they teach, usually interpreted as a master's degree in the clinical area. At the same time, NLN and other organizations advocate preparation of faculty for the specialized role of faculty member in areas such as curriculum development, instructional design, and evaluation methods.3,20 The AACN Essentials of Master's Education for Advanced Practice Nursing,21 hereafter referred to as the Master's Essentials, provides curricular guidelines for clinical specialty focused programs. Although this document focuses on the clinical role, it also recognizes that educational theories and methods are tools used by expert clinicians. Nurse faculty members educated in such programs have been prepared in an area of clinical specialization with little, if any, instruction in how to teach or be a faculty member.

In 2005, the NLN developed the Nurse Educator Competencies 22,23 that can be used to guide the development of graduate nursing programs to prepare nurse educators. However, because the competencies are broad in scope, not prescriptive, and do not speak to curricular content, they may be of limited use to guide faculty in curriculum development. The NLN Nurse Educator Certification Criteria23 designates courses that could be used to create a nurse educator core: curriculum development, evaluation, instructional design, principles of adult learning, assessment and measurement, principles of teaching and learning, and instructional technology. Whereas the NLN criteria are specific for certification, neither the NLN nor the AACN offers curricular guidelines for programs that prepare nurse educators.

In the absence of clear standards, questions arise about both what is and should be in nursing education programs. What curriculum models should be applied; what courses should be included, how many practicum hours should be expected, and should that practicum include both clinical practice and teaching practice? Answers to these and other questions can help guide the ongoing dialogue regarding the future of programs to prepare nurse educators.

Methods

Annual report data from AACN were used to identify nursing education master's programs. The Web sites of the 250 programs that reported offering a master's degree 19 that prepared nurse educators were reviewed in the spring of 2009. Of these, 198 (79%) had curricular plans available on their Web site and were included in this study. Data from post master's certificate programs were not included in this study.

All curricular plans were reviewed in relation to the curriculum model that is described in the AACN Essentials document.21 In this model, 3 levels of curricular content are differentiated: Graduate Nursing Core, Advanced Practice Core, and Specialty Curricula. The graduate nursing core content is foundational and considered essential for all master's students regardless of specialty or functional content. Advanced practice nursing core is essential content for direct patient/client services, and specialty curricular content can be identified as clinical and didactic learning experiences that have been defined by specialty nursing organizations. In addition to the AACN Master's Essentials model,21 the curricula were reviewed for presence of the courses listed in the NLN Nurse Educator Certification Criteria22 and presence of courses in the areas of clinical specialty. Additionally, curriculum plans were reviewed to determine if the programs included a clinical and/or teaching practicum experience and how many contact hours were designated for these learning experiences.

Findings

The AACN report 19 lists nurse educator programs in every state in the United States and the District of Columbia and Puerto Rico. The geographic distribution of the 198 programs reviewed was in 50 states and the District of Columbia. The number of credits in each program ranged from 30 to 56. The average program contained 39 student credit hours, with 136 programs (69%) reporting 39 or less credits. Only 62 programs (31%) were 40 credits or more. Of those 62 programs, 7 (11%) were 50 credits or more, 15 (24%) were between 45 and 50 credits, and 40 (65%) were between 40 and 45 credits.

Courses considered to be part of the core curriculum included the following: theoretical foundations of nursing practice, research, ethics, professional role development, human diversity and social issues, health promotion and disease prevention, and policy, organization, and financing of healthcare. A course in theory was evident in 180 programs (91%), and a research course could be found in 191 programs (96%). An ethics course was evident in 98 programs (49%); however, on review of course descriptions, ethics content was found to be in many professional role courses. Professional role development courses were evident in 97 of the programs (49%). Curriculum content in human diversity and social issues was often integrated in professional role courses or other courses. A course in health promotion and disease prevention was evident in 43 of the programs (22%). Healthcare policy courses were included in 133 programs (67%), and content related to finance in healthcare was often integrated into policy, professional role, and issues courses.

Advanced practice nursing core curricular components include courses often referred to as "the 3 P's": advanced health or physical assessment, advanced physiology and pathophysiology, and advanced pharmacology. Although the AACN Essentials document requires these courses only for programs that prepare graduates for direct client care, often these courses are required for all MSN students.21 Advanced health assessment or physical assessment courses were part of 81 of the programs (41%). Courses in advanced physiology and pathophysiology could be identified in 96 of the programs (48%), and advanced pharmacology was included in 54 programs (27%).

Specialty curricula for the purpose of this review were identified in 2 areas: education courses and clinical specialty courses. Courses in curriculum were evident in 191 programs (96%), whereas a teaching strategies course was in 193 of the programs (97%). Curricular content related to program evaluation, testing, and measurement was noted in 176 programs (89%). A few programs included more than 1 course with this content. An instructional technology course was evident in 51 of the programs (26%). Fifteen programs (8%) included courses taken through the College of Education either as required courses or electives such as a course in adult learning. A teaching practicum experience was evident in 182 programs (92%). These varied in number of credits and structure, with some throughout the program and others just at the end. Some of the programs offered practica in 2 parts, with the first experience focused on the advanced clinical specialty and the second focused on teaching. Practicum hours varied from 45 to 300 over the course of a semester.

Advanced specialty course work was evident in 92 programs (46%). There was no consistent pattern regarding how these courses were offered; some were only didactic, some only clinical, and some were both. The specialty courses were sometimes shared with other programs such as NP, clinical nurse leader, or clinical nurse specialist. A few programs referred to clinical hours as "clinical cognates" where students develop their own learning objectives and arrange independent study experiences with faculty members in their area of specialty practice. Some programs require a clinical teaching practicum where students work with master's-prepared faculty in their area of specialty teaching students. See Table 1 for a summary of these findings and percentage of programs containing each of the offerings.

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Table 1. Nurse Educator Program Curriculum Review

Limitations

The findings from this study were based on review of program Web sites and did not include personal communication with schools that might have revealed specific insights into curricular design or integration of content. Only schools with published curricula were included in the study. Data were gathered by 1 researcher who has more than 30 years of experience as a nurse educator. This process ensured consistency in review of program Web sites and content.

Discussion

Nurse educator master's programs need to be designed to prepare nurses to function as educators in the hospital setting, community colleges, and nontenure track positions in universities. They should offer a blend of courses that satisfy outcomes of the graduate core suggested by the AACN Essentials document,21 clinical specialty content and educational content that will prepare the graduates for the teaching role as well as prepare the graduates for eventual PhD study.

In the recently published Carnegie Foundation for the Advancement of Teaching publication Educating Nurses: A Call for Radical Transformation, Benner et al 24 presented an agenda for transforming nursing education. One item on this agenda was "Include teacher education courses in master's and doctoral programs."24^(p224) Although challenging all nursing master's programs to include teacher education content, the authors advise that an important caveat is that programs must also include clinical practice preparation for future teachers. The curriculum design challenge is to balance total credit hours against the essential elements. The curricula reviewed in this study revealed several approaches to this challenge.

When programs include all elements of the graduate core curriculum (approximately 21-29 credits) and also require the 3 courses of the advanced practice core (9-10 credits), the range of total credits falls between 31 and 39 without education courses or specialty content. Programs more than 40 credits in length required most of the core and advanced practice courses and included education-focused courses and clinical specialty-focused courses. If all of the graduate core and the advanced practice core are included, even at 45 credits there is little room for both education and clinical courses. When programs demonstrated flexibility in the areas of education and clinical courses, elements of the graduate core were affected. When elements of the graduate core were omitted, what was retained most often were the courses in research (97%), theory (91%), master's capstone project (78%), and healthcare policy (67%). These decisions were sound in terms of preserving the courses that teach students critical inquiry and the processes needed for the scholarship of teaching and learning. Benner et al 24 describe this as an essential skill of all nurse educators who must be supported in development of research programs that focus on pedagogies for nursing education. Content in areas such as legal, ethical, and issues was required by only 48% of the schools, but course descriptions reviewed indicated this content was often integrated in other courses.

The advanced practice core as a whole was required in 46 of the schools (23%). However, programs often selectively included these courses: 96 (46%) required pathophysiology, 81 (41%) required health assessment, and 54 (27%) required pharmacology. When schools required the advanced practice core, they tended to omit courses such as healthcare policy, roles, issues, and ethics.

When the clinical specialty content was included, sometimes distinct courses in health assessment or pharmacology were not evident, rather that content was integrated into the clinical specialty courses. Often, nurse educator students share the same advanced practice core courses with students from advanced practice specialty programs. Sharing courses provides a rich environment for students to interact; however, the focus and direction of the teaching-learning practices may be different for each student group. Faculty members who use this shared approach need to be vigilant that all student learning needs are met, and the course is foundational and not specific to track such that no group is made to feel marginalized by course focus.

Educational content was uniformly included in most curricula (96%): teaching strategies (97%), evaluation (89%), and an educational practicum (92%) as compared with courses in instructional technology (26%) and adult learning (19%). Although evidence of a separate instructional technology course was surprisingly low at 26%, it is likely that much of this content may be included in most teaching strategy courses since these are 21st century strategies for teaching. Often the role course was specified as nurse educator role, or it was built into the practicum. Frequently, the scholarship of teaching and learning was mentioned either as a separate course or part of one of the education core courses. An educational practicum was a crucial part of almost every (92%) program. These practica were either offered numerous times throughout the program or in a concentrated internship course at the end of the program. Benner et al 24 recommend that good teachers need to reflect on practice, investigate the goals and outcomes of teaching, and evaluate the choice of teaching strategies and the effectiveness of classroom and clinical teaching. These are the core elements of a teaching practicum.

Only 92 programs (46%) required some form of advanced clinical specialty courses. This falls short of the suggestion by Benner et al 24 that all nurse educator preparation programs offer clinical preparation as well as educational preparation. Many programs shared clinical courses with other tracks. This was evident with 12 programs (13%) that share clinical nurse specialist courses and 11 (12%) that share NP courses. Again, this approach requires faculty vigilance in attention to student needs across specialty tracks. The remaining 69 programs (75%) that have clinical specialty courses appear to have developed them specifically for their nurse educator tracks. These courses vary between 2 and 6 credit hours for theory and may or may not have a clinical component. One creative solution to the clinical practice element seen numerous times was to create a course that focused on learning how to be an effective clinical teacher in a specific area of specialty. This approach supports the recommendation by Benner et al24 that faculty must learn how to coach on practical clinical reasoning for their students to develop sound clinical judgment skills.

Curricular decisions include weighing marketability of the program in terms of length and cost against the desired learning outcomes. In a perfect world, a 54-credit master's program with everything valued for nurse educator students would be the standard. However, how many students would select that program when there is a 36-credit program at a nearby institution? The looming crisis of faculty shortage makes marketability imperative for nurse educator programs to attract the brightest and best nurses to join the ranks of nursing faculty. And these programs must provide the foundation for graduates to move on to the PhD in nursing as they progress in their careers.

As master's education undergoes a transformation with the advent of the advanced practice nurses' transition to the doctor of nursing practice, a rare opportunity for reflection and thoughtful reconstruction exists in nursing education. With 63% of the institutions who report to AACN now offering master's in nursing education, it is time for open discussion about what curricular standards need to be applied to these programs. In the years that followed the 1996 publication of the AACN Master's Essentials document,21 strides were made in the standardization of clinical master's programs and providing a framework on which to build specialty nursing education.20 This AACN Master's Essentials document21 is now undergoing a thoughtful revision process. The most recent draft is available on the AACN Web site at http://www.aacn.nche.edu. As the essential components of master's education are reconfigured, it will be important to consider the preparation of nurse educators.

Gone is the notion that teachers learn to teach "on the job" after completing a PhD in a nursing content area 3 or that in-depth knowledge somehow naturally prepares an individual to transmit that knowledge to others.20 The work of Benner et al24 clearly spells out what is needed to transform nursing education, especially in terms of the need to include education coursework and clinical specialty preparation in the graduate education of nursing faculty. Now is the time for the nursing education community to work together to develop curricular standards that can be applied to nurse educator programs. Graduate faculty needs such structure to ensure that their curricular decisions are evidence based and in keeping with national trends. Hopefully, the data in this review will help to inform decisions regarding nurse educator curriculum standards.