The opening scene of the movie Saving Private Ryan is harrowing and hard to watch.

As the military unit approaches Omaha Beach in Normandy France, during WWII on D-Day, June 6, 1944, with bullets whizzing by and some finding their intended target, the fresh recruits quickly realize that they are no longer in boot camp.

War is a matter of life and death.

But what if the emhasis of boot camp and basic training prepared a soldier to pass a written exit examination, but not the battlefield?

This would be unacceptable. Soldiers must be prepared for the real-world realities of combat.

But take a closer look at the most common assessment of nursing programs success or failure…the pass rates of the written NCLEX® examination, with no other relevant assessment to guage the preparededness for real-world practice.

The NCLEX® assesses that students meet basic levels of safety in practice. It does not guarentee that students are well prepared for the rigors and realities of real-world clinical practice with multiple patients.

To transform nursing education, the emphasis of focusing on passing a written multiple choice test needs to change.

Like soldiers being prepared for the battlefield, nursing education needs to intentionally and practically prepare students for real-world clinical practice.

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Parallels between Combat and Nursing Practice

There are surprising similarities between soldiers being trained at boot camp and nursing students being prepared for practice. These parallels include:

1. Boot camp is about preparation for the real-world, NOT an examination. The rigors of boot camp focus on what is needed to prepare green recruits for the harsh realities of war. In the same way nursing education needs to prepare students not only to think like a nurse using clinical reasoning but emphasize practical skills such as managing several patients at a time, time management and priority setting, and how to communicate effectively with physicians. This is currently a weakness in many programs.
2.  Matter of life and death. The consequences of students who are not prepared for practice by being able to clinically reason and manage multiple patients will result in failure to rescue and can cause the needless death of a patient.
3. Casualties will result if inadequately prepared. The other casualty when students are not well prepared for practice is the nurse. Reality shock is a well documented phenomenon that takes many nurses out of practice before they even got a chance to start.

Losing Sight of the Ultimate Objective

As a newer nurse educator, but clinical nurse in practice for over twenty years, when I began to share my clinical reasoning strategies at conferences across the country, I noted that the emphasis of many conference presentations had variations of the theme of: do this or do that for… “NCLEX® success.”

I quickly realized that nursing programs live and die by the passing percentage of first time students who pass the NCLEX®.

The NCLEX® is a high stakes test for licensure. I understand. I am all for students passing the NCLEX® the first time.

But step back and reflect to determine if your program is focused PRIMARILY on passing the NCLEX®, or is it also preparing students for the rigors of real-world practice.

Steps to bring needed change

Nursing education is broken and in need of radical transformation (Benner, Sutphen, Leonard, & Day, 2010).

This has been going on for decades and is not your fault as an educator today.

Regardless of the NCLEX® pass rates of your program, step back and reflect to determine how well your program is preparing your students for real-world clinical practice.

How?

By reflecting on the following that represent clinical realities that students will encounter AFTER the NCLEX®:

1. Multiple patient assignments
2. Time management
3. Priority setting
4. Professional communication
5. Simulation opportunities
6. Emphasize clinical reasoning.

1. Multiple Patient assignments

Do you provide advanced students consistent opportunities to manage more than a one patient assignment in the clinical setting?

Though there may be limitations in the clinical setting to do so, make it a priority as a clinical educator to give your advanced students two patients as much as possible.

2. Time management

Most students can easily time manage one patient. The amount of downtime that some students have based on their patient testifies to this.

But in order to be practically prepared for practice, there is nothing that compares to a multiple patient assignment to develop this skill. It requires opportunities and experience.

3. Priority setting

Priority setting with one patient can be handles by most students. Like time management, this skill requires multiple patients in the clinical setting. Can you see the pattern!

The only time nurses in practice will have one patient is if they have an unstable critical patient in ICU. Since your students will not be starting in this setting, it should be apparent why multiple patient assignments are an essential preparation for professional practice!

4. Professional communication

Students don’t typically talk directly to primary care providers to communicate a concern in clinical. Therefore this skill that includes using the SBAR format must be consistently practiced in simulation.

Does your program incorporate and then practice the SBAR at all levels? If not, begin to do so to prepare your students for practice.

5. Simulation opportunities

In addition to practicing professional communication, simulation is essential to safely develop the nurse thinking skill of clinical reasoning…think in action, recognizing relevant data, establish correct care priorities that capture the essence of the current situation.

Clinical experiences can vary widely in the clinical setting. This problem can be minimized when simulation standardizes nurse thinking and practical priority setting.

Provide as many opportunities that you can in your program. It has been my experience that simulation is only experienced 1-2 times a semester per student. This is not enough.

6. Emphasize clinical reasoning

Written care plans emphasizing nursing process with a correctly worded three part NANDA statement that is taught as the essence of nurse thinking, is NOT how a nurse in practice thinks. (see prior blog Does a Traditional Nursing Care Plan Prepare Students to Think

Emphasizing clinical reasoning is required to radically transform nursing education (Benner, Sutphen, Leonard, & Day, 2010). I have developed a simple step-by-step template that breaks down this essential thinking skill within nursing process so students can readily understand and apply to practice (see my YouTube below for more as well as my prior blog Why Clinical Reasoning is Foundational to Practice).

I have also created numerous case studies that integrate clinical reasoning so it can be practiced in the safety of your classroom.

In Closing

Nursing education does not need to remain broken.

All it takes is nurse educators who are willing to resist the current “status quo” and step out regardless of your fears (like those soldiers stepped out of the boats on D-Day) and do things diferently to bring needed change.

It is time to replace the emphasis of “NCLEX® success” with “Prepararing for Practice” by emphasizing clinical reasoning and measuring preparation with multiple patients, using simulation to situate a multiple patient assignment is a good place to start.

The stakes are just as high as it is for soldiers on the battlefield. The lack of preparation for  real-world practice will result in casualties.

In nursing, not only can patients lives be lost because of “failure to rescue” when a nurse fails to clinically reason by recognizing a change of status, but nurses who face “reality shock” and may drop out of the profession entirely.

When clinical reasoning, multiple patient assignments, and healthy doses of simulation are the foundation of your program, you can be confident that you are not only preparing your students for the NCLEX®, but more importantly real-world clinical practice!

What do you think?
Does your program emphasize NCLEX® success or preparation for practice? What have you done to practically prepare students for real-world practice?
Comment below and let the conversation begin!

References

 Benner, P., Sutphen, M., Leonard, V., & Day, L. (2009). Educating nurses: A call for radical transformation. San Francisco, CA: Jossey-Bass.