The journey to nursing professionalism: a learner-centered approach.
ABSTRACT This article reports on a biannual baccalaureate nursing program designed to concentrate student learning on the tenets of professionalism in nursing. A seminar structure is used to promote student interaction, the exploration of professional issues, and critical thinking. Miller's Wheel of i Professionalism in Nursing provides a framework for discussion of professional concepts in nursing. Several teaching-learning strategies are used, including a short slide show, interactive lectures by area experts, and student-led group discussions of scenarios based on the elements of professionalism illustrated by Miller. Use of Miller's framework and these various educational strategies yielded greater faculty satisfaction and student participation than witnessed in previous years, resulting in a deeper foundation for professional behavior development throughout the curriculum.
Key Words Nursing Professionalism--Baccalaureate Education--Student-Centered Learning--Miller's Wheel of Professionalism in Nursing
HOW BEST TO INSTILL PROFESSIONALISM IN UNDERGRADUATE NURSING STUDENTS IS AN ELUSIVE QUESTION. While the goal of producing professional nurses remains the central organizing principle of nursing education, the challenge is to find learner-centered ways to explore and reinforce the concepts of professionalism. Our school of nursing chose a fore-hour seminar format, structured around Miller's Wheel of Professionalism in Nursing, to introduce and address basic tenets of professionalism. The professional behaviors that comprise the wheel (Adams & Miller, 2001) are recognized as essential by sociologists, nursing leaders, and the American Nurses Association (see Figure below).
The seminar begins with a presentation on historical and contemporary nursing leaders, followed by a discussion of the characteristics of nursing professionalism, a theoretical basis for nursing, and scope of practice. Groups then convene, with seniors as group leaders, recorders, and reporters, to discuss scenarios authored by faculty and facilitators based on Miller's wheel.
Student groups, consisting of seniors, juniors, and transition students, having matriculated from one week to as many as three semesters of the nursing curriculum, explore concepts depicted on the wheel. The scenarios feature fictitious students and new nurses in experiences familiar to seniors. This article outlines the scenarios as they are organized in accordance with Miller's wheel, with student responses.
Conceptual Framework Today's nursing educational environment is student driven, with "faculty guid[ing] the individual development of students as needed" (Billings & Halstead, 2005, p. xiii). A premium is placed on understanding learning preferences of individual students as well as developing a variety of teaching strategies and educational opportunities to support the learning styles extant in the student population (Schutt, 2009). When students at our school of nursing convene twice annually with faculty to further comprehension of ethics and professionalism, a learner-centered seminar format allows students to interact with each other, the faculty, and the information. The format promotes critical thinking as students explore issues or questions that require more than literal, concrete thinking.
As educators of adult learners, the nursing faculty consider the learner's need to know, readiness to learn, and the learner's experience when planning appropriate and effective learning activities (Knowles, Holton, & Swanson, 2005). The introductory content, an overview of the wheel of professionalism (Adams & Miller, 2001), is focused on the importance of professional behaviors expected of nursing students and professional nurses. This introduction serves to help participants understand the benefit of the material and increases their readiness to learn (Knowles, Holton, & Swanson).
The small-group discussions further integrate tenets of adult learning theory. Vygotsky's social cognition development theory centers on "the understanding of human cognition and learning as social and cultural rather than individual phenomena" (Kozulin, Gindis, Ageyev, & Miller, 2003, p. 1). Within social cognition development theory, the zone of proximal development explains how students develop increasingly complex thought processes when learning takes place in a nurturing environment (Schutt & Hodges, 2008). Students progress from the lower level, which includes independent problem solving, to the higher level with the guidance and oversight of educators and their more capable peers (Patsula, 1999). Group discussion involves the interaction of new and advanced nursing students while faculty facilitate the discussion concepts to promote higher level learning.
The Spokes of the Wheel
Adherence to Code for Nurses The issues addressed by these scenarios are behavior and professional dress.
THE BEHAVIOR SCENARIO A nurse who had exerted minimal effort in nursing school and had been observed by students to cheat on tests is now employed at a local hospital with several classmates. A pattern in client outcomes is discovered on the unit: clients have had sudden significant changes in vital signs during the shift following care provided by the student who took shortcuts in school. The unit manager asks all employees to verify the accuracy of charted information and requests further information that will help identify and/or prevent the pattern of significant clinical events. She asks classmates for specific information regarding the employee in question.
Asked to identify issues, students responded that unprofessional behaviors developed in school were now adversely affecting the nurse's ability to properly care for patients. They established that the new nurse's repeated patterns of behavior diminished trust among the health care team and did not reflect professional knowledge, competence, integrity, trust, caring, or humility. Their advice for the new nurse was to assess life goals, understand nursing responsibilities, determine if nursing is the best career choice, and assume responsibility for changing behavior patterns. In addition, the group recommended that if students witnessed cheating, it was their responsibility to inform the student, then faculty, about the situation, understanding that this unprofessional behavior is not congruent with nursing values.
PROFESSIONAL DRESS A nursing student wears the school of nursing (SON) alternate uniform too tightly on her curvaceous figure to a volunteer event for the aged called the "Senior Prom." The agency director asks the student to leave so that clients will not feel discomfort. Later, this agency requests that the nursing school no longer support its activities.
Students identified the cascading effects of this incident and the people affected: the humiliated student, remaining student volunteers, faculty, the SON, the agency, and the elderly who lose the opportunity to meet future SON students. Students coined a phrase, "keep your Bs to yourself," referring to "belly, bottom, bulges," and private parts the students determine should remain private. They recommended that individuals look in their mirrors and if there is a question of inappropriate dress, then it is inappropriate. Also, they observed, classmates should tactfully communicate to their peers that their appearance is creating discomfort.
Community Service Orientation Unaware she is talking to a nurse volunteer, a woman diagnosed with AIDS and living in a homeless shelter confides to a volunteer that she is worried about her five children and does not know how to obtain health care for them. What does the nurse do?
Students identified that as a professional expectation, the nurse is a patient advocate obligated to do her best to meet patient needs. The group stated that this nurse should explore options and resources offered by the shelter and add any other resources; then teach basic health care, nutrition, and the need for adequate sleep and exercise.
Conversation led to SON community service, including work with autistic centers, geriatric day care centers, equestrian/physical therapy organizations, and numerous others. Some students conveyed that despite initial fears, they often came to appreciate agencies previously unfamiliar to them. The "Senior Prom," the focus of another scenario and a favorite volunteer experience, was discussed, with seniors strongly encouraging all juniors to participate. One senior stated, "While in nursing school, community service is a have to activity. When you graduate, it's a get to activity."
Continuing Education/Competence During the senior preceptorship, a staff nurse asks the student to initiate an IV on her patient. The student had successfully validated this skill in the lab but had two unsuccessful attempts since then. Hesitant to express her insecurity, the student starts the IV in the patient's left arm on the sixth attempt, using an IV catheter that had been used on two other attempts. After the IV start, the student reads in the patient's chart that the patient had undergone a left mastectomy last year. When the preceptor asks about the task, the student said it "went just fine."
Reading the scenario elicited gasps and shocked expressions from seniors. Beyond the expectations of the author, seniors rapidly identified all errors made by the nursing student and explained to juniors the safe and appropriate process of this nursing skill. Students noted that the student should not be "prideful" and should ask for assistance and must know and follow the scope of practice as set forth in the Nurse Practice Act. One junior student offered that the situation could have been avoided had the nursing student "followed guidelines" set forth in the Nurse Practice Act, specifically, having the education and training to perform a nursing task. The group emphasized the need to put the patient's needs first, always.
Research: Development, Use, Evaluation A newly graduated nurse explains to her mentor that she will administer a 3 ml injection into the ventrogluteal site, even though the mentor instructs her to "give it in the buttocks." The new nurse declines and explains that evidence supports a greater risk of nerve damage when injected into dorsogluteal muscle.
Students suggested sharing research with the mentor without appearing insubordinate or unappreciative of the mentor's guidance efforts. The group advised that the new nurse work with the nurse manager to promote safe practice. Students suggested an in-service or research poster on evidence-based practice and working with the clinical educator to change facility protocols. In addition, the group expressed the need for the graduate nurse to understand professional competence while accepting responsibility for nursing practice, maintaining professionalism, and encouraging collaboration to initiate change.
Self-Regulation, Autonomy A new graduate is instructed by the charge nurse to administer a medication intravenously that is classified as a chemotherapeutic agent. The new nurse wants to make a good impression in her job and does not want to be considered a troublemaker by her unit manager. What is the nurse's scope of practice?
The group determined that administering chemotherapy was not within the nursing scope of practice for this new graduate because she had not been educated specifically in the administration of chemotherapy, nor had she been validated on that particular nursing skill. The new graduate must be knowledgeable about the Nurse Practice Act specific to each state. Nurses must comply with agency policies and procedures, which cannot expand the scope of practice beyond that delineated in the Nurse Practice Act.
Professional Organization Participation This scenario, based on an actual incident, was embellished by the author. A state transfers $2.5 million from the Board of Nursing (BONy budget to augment its general fund. The Medical Board takes control of the BON, raising nurse license fees and requiring mandatory overtime for hospital nurses. What should the state nurses' association do? What can the individual nurse do?
The seniors first differentiated the roles of the BON and the state nurses' association. Students spoke of the potential damage to the nursing profession if it were to be regulated by others. They promoted the education of nurses and communities about this event and spoke of the need to encourage nurses to become involved with their state association. The goal would be to influence the legislature to rescind recent laws while increasing the visibility of nursing and giving voice to nurses.
Publication/Communication For this segment of Miller's wheel, students discuss scenarios about nurse faculty communication and working as a team to achieve student skill validations. They also discuss staff nurses arguing on a nursing unit in front of a family member. The student groups identified essential elements of teamwork, including respectful communication, planning, flexibility, accountability, and a positive mental attitude. They emphasized that nurses must consider patients' needs or the mission more important than self.
One scenario involves a poorly written letter to the editor describing a family present during patient resuscitation. The letter contains profanity and names of those involved and is not published. The presenting senior reads the scenario to the assembly and exclaims, "HIPAA, HIPAA, HIPAA!" The group agreed that profanity is never appropriate or professional and recommended that the nurse write an apology to the editor, work to mitigate HIPAA issues, research the presence of families at resuscitation efforts, and understand that the nurse is always a nurse and must maintain professional demeanor and speech.
Conclusion This School of Nursing typically begins the academic year with the Professionalism Seminar. Miller's Wheel of Professionalism in Nursing provides a framework for an effective learning opportunity that is based on fertile student discussions about professional nursing issues. All spokes of the wheel are discussed.
The absence of disruptive side conversations is notable, along with vibrant and appropriate visual and audible responses from the students, confirming the effectiveness of this learner-centered approach to instilling professionalism in nursing students. Moreover, pairing juniors and seniors in seminar groups allows entree into the socialization of nurses during the first week of their student careers, demonstrating the professional growth of senior nursing students and promoting higher level learning. The Professionalism Seminar provides the foundation for professional behavior development throughout our students' future nursing careers.
Adams, D., & Miller, B. K. (2001). Professionalism in nursing behaviors of nurse practitioners. Journal of Professional Nursing, 17, 203-210.
Billings, D. M., & Halstead, J.A. (2005). Teaching in nursing: A guide for faculty (2nd ed.). St. Louis, MO: Elsevier Saunders.
Knowles, M. S., Holton III, E. F., & Swanson, R.A. (2005). The adult learner: The definitive classic in adult education and human resource development (6th ed.). Burlington, MA: Elsevier.
Kozulin, A., Gindis, B., Ageyev, V. S., & Miller, S. M. (Eds.) (2003). Vygotsky's educational theory in cultural context. Cambridge, UK. Cambridge University Press.
Patsula, P. J. (1999). Applying learning theories to online instructional design. Retrieved from www.patsula.com/usefo/webbasedlearning/ tutoriall/learning_theories full version.html
Schutt, M.A. (2009). Examination of academic self-regulation variance in nursing students (Doctoral dissertation). Retrieved from http://etd.auburn.edu/etd/handle/10415/1610
Schutt, M.A., & Hodges, T. L. (2008). Peer mentoring: A service-learning project. Contemporary Issues in Education Research, 2(1), 28-34.
All authors were faculty at Auburn Montgomery School of Nursing, Montgomery; Alabama, when this article was written. Marilyn K. Rhodes, EdD, RN, CNM, is assistant professor at the Auburn Montgomery School of Nursing, Michelle S. Schutt, EdD, MSN, RN, CNE, is now nursing education coordinator, University of Virginia Children's Hospital and Women's Health Division, Charlottesville. Ginny W. Langham, MSN, RN, is an instructor, Auburn University at Montgomery. Diane E. Bilotta, MSN, RN, is education coordinator, Franciscan Health System, Tacoma, Washington. For more information, contact Dr. Rhodes at email@example.com.