Course Portfolio

Introduction

The course I have chosen for this Portfolio is NURS 223 Maternal Child Health Nursing. This portfolio will allow others to view and critique my teaching methods. It will also serve as a means to demonstrate my scholarly and effective teaching methods.

Course Description

NURS 223 Maternal Child Health Nursing is offered in the second year of a two year associate degree program in nursing at Name Withheld Community College, located in north eastern Pennsylvania. It is the third clinical nursing course offered in a sequence of seven. This course provides an emphasis on providing nursing care to the childbearing family through the nursing process; exploration of the role of the registered nurse related to pregnancy, childbirth, and newborns in acute care and community settings.

Prerequisites are BIOS 204 Anatomy and Physiology I, BIOS 254 Anatomy and Physiology II, PSYC 103 Introduction of Psychology, NURS 101 Introduction to Nursing, NURS 210 Nursing Care of Patients with M/S Problems I, NURS 211 Nursing Care of Patients with M/S Problems II. Corequisites are BIO 202 Microbiology, SOCA Sociology elective, NURS 224 Mental Health Nursing. (Name Withheld Community College, 2006)

Course Objectives

Upon completion of this course, the student will be able to:
· Demonstrate critical thinking utilizing the nursing process to plan and provide care for the childbearing and childrearing families.
· Apply knowledge of nursing principles to provide safe and effective nursing care to maternity and pediatric patients.
· Utilize principles of communication to establish a caring, therapeutic relationship with patients and families.
· Communicate effectively with supervisors, peers, coworkers, and members of the health care team.
· Utilize legal-ethical principals in providing care for childbearing families and childrearing families.
· Provide preventative and restorative health education to patients and their families for common health problems.
(Name Withheld Community College, 2005)

Teaching Philosophy

I believe that becoming a nurse is more than just learning nursing tasks and theories. It is a way of thinking and a way of life. One of the key elements of a nurse is the skill of critical and analytical thinking. In keeping with the philosophy of the Allied Health and Science Division of Name Withheld Community College (2006) to taking a student-centered approach to teaching, I choose to teach this course using a holistic constructivist approach. I believe this is the best way for nurses to be taught and developed.

Constructivists believe that teachers cannot give students knowledge, but facilitate learning. A learner’s knowledge is constructed or built upon their existing knowledge. Learning is a collaborative effort between student and teacher. They follow the belief that each learner is an individual, is responsible for their own learning, learns through social interaction, and is motivated by positive learning experiences. (Young, L. E. & Paterson, B. L., 2007)

My goal is for my students to gain empowerment through their education, and a desire to continue educating themselves once they leave the classroom. I believe this is accomplished through self directed learning and self accomplishment. My teaching and course design is based on the four principles of holistic constructivist approach to education:

1. Student work must be individualized and actively involve students in projects that they develop to be meaningful to their professional work and development, based on their experiences and background knowledge.
2. Student work should address problems encountered in the student’s classroom, school, and community and should have an audience beyond the teacher and beyond the university.
3. Student work should develop through collaboration and problem solving with faculty and peers.
4. Evaluation procedures should be based on authentic assessment of student work, involve self-reflection, and provide an opportunity to learn from mistakes.
(Bacon, E.H. & Bloom, L.A., 1992)

These four principles are addressed in my course through active, engaging lectures and discussions, case studies, role-playing, group work, ethical exploration paper, presentations, journaling, and evaluations.

Using the holistic constructivist theory, my goal is also to be a mentor to my students. Mentoring is dynamic and is very different than preceptorship. Mentors assist mentees in discovering and developing their own strengths. Many who have experienced a mentoring relationship find that the “mentor’s influence transcends space and time and helps to guide a ‘mentee’ long after the mentor and mentee no longer work with each other.” (Thomka, 2006, p. 54) Instead of imparting information to the class, my role is to mentor and coach the students, listen to their interactions, and provide meaningful feedback. If they become “off track,” my role is to help them get “back on track.” Each day of class I will engage my students in active thinking and provide opportunities for them to practice thinking and reasoning, and to also develop these skills. This will be accomplished through different teaching methods such as engaged lecture, case studies, group activities and discussions, role-playing and self reflection.

I believe in taking a nurturing approach with students, and providing a safe environment for learners. I provide an environment of caring, trust and support where students are encouraged for their efforts, not just their achievements. They are encouraged to “think out loud” and think spontaneously. Their efforts are supported both by their peers and I, and students learn that their achievements come from their own abilities and efforts, not from my teaching skills. (Pratt, D. & Collins, J., 2001)

I also believe in stimulating students regarding social values and ideas. Students are encouraged to challenge the status quo and take social action to improve their lives and that of others. As I believe that nursing will become part of all aspects of their lives, issues such as horizontal hostility and the image of nurses in the media are areas that my students will be made aware of and left to contemplate. My goal is that they will develop into not only patient advocates, but nurse advocates as well.

As a nurse educator and a mentor, I am well respected by my peers and members of my healthcare team for my knowledge and my nursing skills, and I consider myself an expert in Maternal/Newborn nursing. I believe it is essential to demonstrate positive leadership and mentorship to students and in my life. I am devoted to the field of nursing and the education of nurses.

Course Design and Teaching Approach

NURS 223 has an average class size of 40 students. The course takes place the first eight weeks of the semester, and is followed by NURS 224 Mental Health Nursing for the remainder of the semester. The class meets twice per week on campus for the didactic portion of the course. They also meet once per week off campus for the clinical laboratory portion of the course. Clinical laboratory takes place in various local hospitals for 10 hours per week, a total of 80 hours for this course. Classroom learning takes place a total of 5 hours and 40 minutes per week. During the semester, the class will meet for a total of 24 times, including Clinical Laboratory. The content of the course in broken down into four units and each unit has its own designated objectives. By providing specific learning objectives for each unit, students are able to better understand what is expected from the learner and are then able to focus their learning based on these objectives. Content covered appears in Table 1:

Table 1:

1. Unit 1 - Introduction to NURS 223, Family Planning, Infertility
2. History of Midwifery, Prenatal Nutrition, S/S of Pregnancy
3. Clinical Laboratory
4. Fetal Development
5. Ante-Partum Complications
6. Clinical Laboratory
7. Exam 1
8. Unit II - The Laboring Patient
9. Clinical Laboratory
10. Maternal Fetal Monitoring, Maternal And Fetal Assessment In Labor
11. Maternal Complications In Labor
12. Clinical Laboratory
13. Unit III - Post-Partum, Infant Nutrition
14. Post-Partum Complications
15. Clinical Laboratory
16. Exam 2
17. Unit IV - The Newborn
18. Clinical Laboratory
19. High Risk Newborn
20. Ethical Paper Presentations
21. Clinical Laboratory
22. Ethical Paper Presentations
23. Final Exam
24. Clinical Laboratory

Students are required to purchase the NURS 223 Maternal Child Health Study Guide. This study guide provides students with the course and unit objectives, required readings, case studies, and role-playing activities. Students are expected to be prepared for each class by performing the required readings. Students are required to take three exams during this course consisting of 50 questions each. These exams are modeled after the NCLEX examination. This consists of 75% of the student’s course grade, 25% allotted for each exam. The ethical paper and presentation are allotted 20% of the course grade and the case studies and role playing activities are allotted the other 5%.

Using the strategy of Text Interaction (DeYoung, S., 2003), each student is encouraged to write down a question or questions regarding the information covered. Areas such as the material being unclear, conflicting information, and differences from their clinical experiences are addressed. Students read their questions aloud and explain the information they are seeking. Fellow students will help provide the answers as I help to facilitate this interaction. An example of Text Interaction is as follows:

Student: “What are some of the more common complications of receiving an epidural? When I was in clinical I heard the physician tell the patient that it is safe and complications were so rare. He asked her if she wanted him to explain the complications. The patient was in labor and could care less, she just want to be relieved of the pain. Our text book states several complications relating to an epidural, but which ones, if any, are most often seen?”

Fellow students would be encouraged to explore the answers. I would direct the discussion by asking such questions as:

“Knowing what you know about epidurals, which do you think are the most common?”

“In your clinical experiences, what have you seen the nurses do prior to, during, and after a patient receives an epidural?”

“What is the rational behind these actions?”

“What is the difference between spinal anesthesia and epidural anesthesia?”

“When would be the better time to explain the risks to the patient?”

“Instead stating that an epidural is ‘safe,’ what other ways could the physician explained it to the patient that would enable the patient to make a more informed decision?”

This interaction not only helps to facilitate social learning and critical thinking, it also provides me the opportunity to explore the student’s explanations and rationales, and their interactions with each other. It also allows me to gauge if the students are “on track.” I will use this time to determine if an individual student is in need of more individualized coaching.

Class will consist of an engaged lecture where students will provide explanations for the material to be covered, and be encouraged to ask questions and stimulate open discussions. A case study and role-playing activity will occur for each unit and will focus on the information in the required readings. The case studies activities will take place in assigned groups of six students and are presented in class on designated days. Students will work together as a group outside of class and then present the case study and their findings to the class. Discussion regarding the groups findings and other possible scenarios will be discussed. For the role playing exercise, students are selected randomly that day and perform the exercise for the class spontaneously. The class then discusses what occurred and alternative ways to approach the situation. This teaching approach provides social interaction learning opportunities, and also provides students with a more realistic application of their learning.

Students are required to write a paper based on an ethical situation that they have witnessed or experienced regarding Maternal Child Health. The student is also required to present the information to the class in a 10 minute presentation. A 10 minute discussion will then ensue after each presentation. The time allotted is strictly enforced to ensure all students are granted the same opportunity for their presentation. The requirements for the ethical paper are:

1. Determine a situation that deals with the area of maternity and newborns that you have personally observed or experience.
2. Develop an ethical question based on this observation or experience. Present both sides of the issue and its reasoning.
3. Provide supporting data for each side.
4. Present your personal views.
5. Determine the nurse’s role regarding this ethical question.
6. Identify a societal value or view regarding this issue that you believe is unjust. As a nurse, what can you do to change this or bring about awareness?

The ethical paper provides the opportunity for the student to self reflect on their own views and values and how these affect their patients. It will help them to realize their ethical and moral responsibility as nurses and to respect their patient’s views and values.

Clinical Laboratory provides nursing students with the opportunity to observe and participate in nursing practice in an authentic environment and context. This is an essential part of nursing education. In Clinical laboratory, students are able to integrate theoretical teachings with real situations. Clinical laboratory is conducted using a cognitive apprenticeship approach, a type of constructivist teaching, as described by Brown, J.S., Collins, A. & Duguid, P. (1988) and cited by Cope, P., Cuthbertson, P. & Stoddart, B. (2000). Instruction is provided to the students to develop their competence through modeling, coaching, scaffolding, fading, articulation, reflection, and exploration. Students are also required to maintain a clinical journal for each clinical day. This journal will promote self reflection, critical thinking, and self confidence. Each journal entry will address the following four questions:

1. What did you learn today?
2. Describe how your experience was different or the same as to what you have learned in class or in the readings?
3. What did you do well today?
4. What would you do differently next time?

Measurement of Outcomes

Classroom assessment and evaluation of learning will be assessed through: 1) Informal anonymous questions 2) Likert scale evaluations 3) Pre and post-test 4) Text Interaction 5) Group assignments 6) Multiple choice exams 7) Ethical paper 8) Criterion-Referenced Clinical Evaluations 9) Informal ongoing clinical evaluation.

Informal questions will be asked once per week at the last five minutes of class. Students will be asked to anonymously answer the following questions:

1. What aspect of the class do find most helpful for your learning?
2. What aspect of the class do you find the least helpful?

These questions will allow me to determine if my teaching approach is working and areas that I may need to expand or change.

A Likert scale type questionnaire will be given to students at the end of each unit to determine if my teaching approach is allowing students to meet my goals and learning objectives through the student’s perspective. An example of this questionnaire appears in Table 2:


Table 2
Class and Teaching Evaluation NURS 223 MCH Nursing

To provide you with the best learning experience, please answer the following questions. Your evaluations are will be kept anonymous and will help me to improve this class. Thank you.

Rating Scale: 1 = Disagree 2 = Somewhat Agree 3 = No Opinion 4 = Agree 5 = Strongly Agree

1. Do you feel that the Unit Objectives have been met?

1.) О 2.) О 3.) О 4.) О 5.) О

2. Do you feel that the Case Studies helped you to meet these
objectives and facilitated your learning?

1.) О 2.) О 3.) О 4.) О 5.) О

3. Do you feel that the Role Playing helped you to meet these
objectives and facilitated your learning?

1.) О 2.) О 3.) О 4.) О 5.) О

4. Do you feel the required readings helped you to meet these
objectives and facilitated your learning?

1.) О 2.) О 3.) О 4.) О 5.) О

5. Do you feel the lectures helped you to meet these objectives
and facilitated your learning?

1.) О 2.) О 3.) О 4.) О 5.) О

6. Do you feel the class discussions helped you to meet these
objectives and facilitated your learning?

1.) О 2.) О 3.) О 4.) О 5.) О

7. Do you feel the instructor is well prepared?

1.) О 2.) О 3.) О 4.) О 5.) О

8. Is the instructor willing and available for help?

1.) О 2.) О 3.) О 4.) О 5.) О

9. Does the course demand you to think and arouse your interest?

1.) О 2.) О 3.) О 4.) О 5.) О

Please comment on the following:

10. Are the instructor’s methods appropriate to the size and type of class? If not, in what ways could they be more effective?
_________________________________________________________________________
_________________________________________________________________________
11. Comment of the quantity and quality of the exam(s):
_________________________________________________________________________

_________________________________________________________________________
12. Comment on likes and dislikes of the course:
_________________________________________________________________________

_________________________________________________________________________
13. Do you have any suggestions for changes or improvements of the course?
_________________________________________________________________________

_________________________________________________________________________



A short test consisting of 20 questions is given on the first day of class, and the same test is given on the last day of class. The test questions are multiple choice and pertain to the main learning objectives of the course and/or each unit. This will allow me to evaluate how knowledgeable the students were regarding maternal child nursing before participated in NURS 223, and how much they learned from the class. Using Text Interaction, as described in the Course Design and Teaching Approach of this portfolio, I can to evaluate how well students are assimilating their new knowledge and if my teaching techniques are accomplishing my goals and the course objectives. Group assignments will allow me to determine if the students are learning and also how well they work with others. Multiple choice exams give students the opportunity to experience a NCLEX type exam and to evaluate their knowledge of the material and their ability to pass the NCLEX. The ethical paper allows me to evaluate the student’s ability for self reflection and their ability to learn through this reflection.

Clinical laboratory will be evaluated through Criterion-Referenced Clinical Evaluations (DeYoung, S., 2003) that will be formal given mid-term and end of term. This method of evaluation incorporates a pass/fail grade and provides specific criteria that they students must accomplish in order to pass the clinical portion of the class. A copy of this evaluation is given to each student on the first day of clinical laboratory. The evaluation is reviewed with students by the instructor to ensure the criterion is clear to the students. Students will also receive ongoing informal evaluations that will occur as an interaction between student and teacher. Students will be made aware of areas that need improvement and areas they are excelling in. The criteria is broken down into the following areas: 1) Assessment 2) Nursing Diagnosis 3) Planning 4) Implementation 5) Evaluation 6) Communication 7) Professionalism 8) Accountability 9) Participation and 10) Progression. An example of an evaluation of one criterion is provided in Table 3.

Table 3
Criteria:
Communicates therapeutically with patients (Select one):

- Communicates only when absolutely necessary.
Information provided is sometimes accurate. Does
not engage in active listening.

Points = 1

- Communicates on a social level. Information given
is accurate. Actively listens to patient concerns.

Points = 2

- Actively listens and responds to patient concerns in
a professionally helpful and accurate way.

Points = 3
(DeYoung, S., 2003, p. 251)


Reflection

I was first asked to teach this class in the fall semester of 2005. I was given the daunting task to be the lead instructor one week before the class began. I had no previous experience teaching in a college or university setting and had no formal schooling regarding teaching. What I did have was the strong desire to teach and I felt extremely honored to be asked to take on this tremendous challenge. The only tools I was given was the text book, the course objectives, and the class schedule.

Since I had little time and guidance, I began to create the lectures for the class, summarizing the key points of the required readings. This is how I was taught in nursing school, and I found it comfortable to mimic this behavior. After my first week of teaching, I realized I have chosen the right vocation. After teaching my second and third week, I began to notice student’s eyes drifting, and the appearance of boredom. I realized that I was “spoon feeding” them, summarizing the chapters for them, but not truly teaching them. I began to change my style, and incorporate personal stories in my lecture. I began to ask students questions regarding what they were experiencing during their clinical laboratory. I include visual aides that were not included in their required readings. I also began to engage students in my lectures, having them “filling in the blanks.” What I soon discovered was the student’s appeared to enjoy class now. I also discovered that I enjoyed class and felt a greater enthusiasm than I did earlier.

An evaluation at the end of the course was given. The college created questionnaire consisted of 14 questions that were answered based on a Likert scale, and then nine questions were students had to write comments. Interestingly, most students did not answer the first 14 questions, but answered most of the nine questions. Some student comments were:

“I liked how the teacher brought personal stories to reinforce concepts.”

“Always willing to answer questions.”

“Susan was very knowledgeable on subject and offered interesting personal examples.”

“This teacher is extremely prepared and includes all class in discussion.”

“This professor is professional, organized, thorough and knowledgeable. This semester
has been an exceptional learning experience.”

“The teaching methods were good. Videos, slides and pictures help with learning.”

“Susan facilitated an excellent learning environment.”

“The teacher is very helpful and seeks out the students that may need help.”

These comments inspire me and also reinforce that my student centered teaching style allows me to accomplish my goals. By the end of the class, eight weeks later, I found that I was the one who learned tremendously that semester. I discovered that lecture I was originally giving was fruitless and non-fulfilling, compared to engaging students, helping them to think and discover on their own, and sharing discussions and stories. Although I knew nothing about constructivism, I now realize that I had incorporated this style of teaching in this class and it naturally fit. This is why I am a true believer in this theory of teaching.


References

Bacon, E.H. & Bloom, L.A., (1992). Beyond the herring sandwich phenomenon: A holistic constructivist approach to teach education. Journal of Learning Disabilities, 28(10), 636-645.

Cope, P., Cuthbertson, P. & Stoddart, B. (2000). Situated learning in the practice placement. Journal of Advanced Nursing, 31(4), 850-856.

DeYoung, S. (2003). Teaching strategies for nurse educators. Upper Saddle River, NJ: Prentice Hall.

Name Withheld Community College, 2006. Course Descriptions. Retrieved on November 14, 2006 from http:// www. NameWithheld.edu/Academics/Course_descriptions/ nursing.htm.

Name Withheld Community College, 2006. Nursing Department Philosophy. Retrieved on November 14, 2006 from http:// www. Name Withheld.edu/academics/divisions/alliedhealth.

Name Withheld Community College, 2005. Nursing Department NURS 223 Maternal Child Health Nursing Fall 2006 & Spring 2007 Cluster. Name Withheld, PA: Author.

Pratt, D. & Collins, J. (2001). Teaching Perspective Inventory. Retrieved on September 24, 2006, from http:// www. teachingperspectives.com.

Thomka, L. (2006, February). Are we there yet? The long and winding journey of mentoring. MODRN Nurse Magazine, 2(1), 49-55).

Young, L.E. & Paterson, B.L. (2007). Teaching Nursing: Developing a Student-Centered Learning Environment. Philadelphia: Lippincott Williams & Wilkins.

Module Developed for Online ADN Program

Maternal Child Health Nursing – Online ADN Program

Module 10
Care of the Patient During Labor and Delivery.

Objectives:
1. Demonstrate knowledge of the labor and delivery process.
2. Describe the signs of true labor.
3. Differentiate between true and false labor.
4. Demonstrate knowledge of infant presentation and its effect on the labor and delivery process.
5. Identify the nurse’s role in the labor and delivery process.

Readings:
Chapters 21 and 22 in textbook

Videos:
View the following videos:
http://pregnancy.about.com/gi/dynamic/offsite.htm?site=http://www.lamaze.org/video/institute.cfm
http://www.geocities.com/4birthing/childbirth_videos.html - view all three videos on this site.

The videos are short and may need to be viewed several times.

Assignment:
1. After viewing the videos, comment on nurse’s role. What is the nurse doing and why?
What is your reaction to the births on the videos? Are they similar to what you have experienced in your clinical setting? What is the same and what is different?

2. Case Study: A woman is in the L&D unit and is in labor. The infant is in a frank breech presentation. The patient has a birth plan and wants her entire family present which includes her mother, father, siblings, husband and her five year old child.

Answer the following questions:
How do you know the patient is in labor?
Name three ways that determine the infant’s presentation.
In delivering a breech infant, what types of problems may the infant encounter both during delivery and after delivery? Why?
What types of problems may the mother encounter and why?
What is a birth plan and what is the nurse’s role regarding this plan?
How would you, the nurse, handle the presence of the family and 5 year old child?

Answer the above questions for Assignment 1 and 2 and post in the digital drop box. You have one week to compete this. Cite all references using APA style.

Discussion Board:

What labor experience(s) have you seen during your clinical time in the hospital that were different from what you expected before you started this class? What was your reaction and feelings regarding the experience(s)?



I chose to use a video clip for this module because it allows the student to view the videos several times so that they may see the details regarding the nurse’s role during the labor and delivery process. Sometimes in a clinical situation there is so much activity (such as a birth!), that the student may not be paying close attention to what the nurse is doing. It allows the student to spend time analyzing and taking apart the minute details and then deducing the rational behind the actions. I believe it is important for the nursing student to understand what the nurse is doing and why the nurse is doing it. This exercise will help the student to develop critical thinking skills. I also developed a problem-based learning case study that will also promote and develop critical thinking skills. (Young & Paterson, 2007) The student will need to use their past knowledge and the new knowledge acquired from their readings to complete this module.

I also asked the students questions regarding their reactions and their beliefs. This will help promote self-reflection and also brings in the human element often missing from online courses. It also helps to promote independent thinking and discussion among the group. (Shovein, Huston, Fox & Damazo, 2005) Cultural diversity can also be explored during this discussion.

Sharing experiences and knowledge among educators regarding online education encourages collaboration among peers not only within the college, but within the profession itself. It also helps foster a mentorship. Many educators struggle with inventing an online course, where others who have already experienced it can provide useful suggestions and information to help alleviate some mistakes and frustration. (Ryan, Carlton, & Ali, 2004) This collaboration can only help to uplift the nursing profession and its educational process.


References:

Ryan, M., Carlton, K.H., Ali, A.S. (2004). Reflections on the role of faculty in distance learning and changing pedagogies. Nursing Education Perspectives, 25(2), 73-80.

Shovein, J., Huston, C., Fox, S., & Damazo, B. (2005) Challenging traditional teaching and learning paradigms: Online learning and emancipatory teaching. Nursing Education Perspectives, 26(6), 340-343.

Young, L, & Paterson, B. (2007). Teaching Nursing. Philadelphia: Lippincott, Williams and Wilkins.

A Perspective on the History of the Nursing Shortage

After reading through the New York Times archives, it became evident to me that nursing shortages have been around for a very long time, possibly since the beginning of nursing. A number of shortages took place from 1873-1970, and I specifically chose an article that addressed the shortage of nurses during the 1960’s. At this time, report on the nursing shortage was performed by the Medical Society of the County of New York. The physicians offered some solutions to the nursing shortage. One solution is that nursing programs should by expanded by 10 to 12 percent per year over a ten year period. They recommend this to be done in hospital based schools, rather than colleges, so that the student nurses can begin to work at the hospitals. (Haily, 1960) As the head of the committee, Dr. Willam A. Cooper rebuts later in a letter to the editor, “While all can agree that in Utopia every nurse should and would have a degree from college, that day has not arrived.” (Cooper, 1960)

Another recommendation he offers is to relax the regulation that nurse educators must have a bachelors of science degree in order to teach nursing students until the shortage is rectified. In an open letter to Dr. Cooper, Louise McManus, a nursing educator, remarked that the shortage was due to the fact that women now had many more career choices and lowering the standards “would only make recruitment more difficult and lead to greater attrition than exists today.” (Haily, 1960) Another remarked that, “We must make nursing a real profession, not just a bed-making, back-rubbing job.”

While Dr. Cooper was addressing the issue at hand at that moment, the nurse educators and the NLN were looking at the whole picture. Lowering standards may supply people in the hospitals to fill the vacancies, but by lowering the standards, the field of nursing would be going backwards. In my view, the physician and his team did not see the role of nursing as a profession, and did not respect the profession. Would he expect medical schools to lower their standards if there was a shortage? What about the public – would they want the standards lowered?

It is interesting to find how far we have come and also how much we have not changed. Nursing shortages have been around, probably since the beginning of nursing. As I glanced through other articles addressing the nursing shortage from 1873 through the 1990’s, there appeared to be issues that kept persisting. Some issues I noticed were the image of nurses, the oppression of nurses by the hospitals and doctors, low pay and long hours, and lack of desire to pursue a career in nursing. Of course, these issues still exist today. Another interesting note was that they found most shortages were regional, as they are today.

References:

Hailey, F. (1960, July 4). Nurse shortage still acute here. The New York Times. Retrieved September 25, 2006 from ProQuest database.

Cooper, W.A. (1960, July 26). Letter to The Times: For more nurses. The New York Times. Retrieved September 25, 2006 from ProQuest Database.

Nursing Uniforms and Rituals

I explored the history of the nursing uniform. Since the white uniform and cap has become synonymous with "nurse," I believe it is important to explore its history to learn where we came from and where we are going. The nurses began to wear uniforms largely due to its roots in religion and the military. The nurse uniform has evolved and changed along with the evolution of the field of nursing. Nurses themselves have different opinions of the traditional uniform versus the new scrub versus no uniform. Many are traditionalists and believe we should go back to wearing all white and even the cap, while others believe that uniforms affect our professionalism, represents our past oppression, and "encourage psychological barriers" (Pearson, Baker, Walsh & Fitzgerald, 2001) and perhaps we should wear no uniform at all. Others believe nursing rituals, such as uniforms and pins, are "irrelevant and even detrimental to the professionalization of nursing practice" (Catanzaro, 2002), while others believe that symbols and rituals strengthen the field of nursing.

In the article written by Catanzaro, the author points out the nursing profession have two large challenges that need to be resolved. She states that nursing will never be perceived as a profession if first we don't work to change the public's negative opinion of nurses and second if we continue to allow physicians and hospitals to have control over nurses by using the uniform as a form of control and also preventing nurses from "attaining professional autonomy" (2002).

I believe that we need to continue to progress as a profession and move forward. Symbols have power and can help to raise us up or bring us down. We need to decide what symbols and rituals have great meaning to nursing as a profession and what symbols and rituals need to be discarded. But no matter what side of the fence you are on, the uniform - whether it stays or goes or changes - should be our decision and in our control.

References:
Catanzaro, A.M. (2002). Beyond the misapprehension of nursing rituals. Nursing Forum, 37(2), 17-27.

Pearson, A., Baker, H., Walsh, K., and Fitzgerald. M. (2001). Contemporary nurses’ uniforms – history and traditions. Journal of Nursing Management, 9(3), 147-156.

Links:
http://web.ebscohost.com.rlib.pace.edu/ehost/pdf?vid=20&hid=117&sid=4aff4623-ffdb-4a7f-af3b-c27cd7aeb044%40sessionmgr101

http://web.ebscohost.com.rlib.pace.edu/ehost/pdf?vid=34&hid=117&sid=4aff4623-ffdb-4a7f-af3b-c27cd7aeb044%40sessionmgr101

ADN vs. BSN

Even though I am a graduate from an associate degree program and never received my bachelor’s degree in nursing, I am a true advocate of ending the associate degree programs in nursing. In the excerpt from “A Curriculum Guide for Schools of Nursing” (1937), it was recommended that nursing students have a least one to years of education beyond high school before entering the nursing program. They also recommended that the nursing education should lead to a bachelor’s degree.

Frances Reiter also believed that nurses need a bachelor’s degree level of education. She believed that “nurses, to be truly profession practitioners, required as broad an education as those entering other health professions.” (Hiestand, 2006). I absolutely agree with her. The associate degree program was started to help with the nursing shortage. The nurses graduating from these programs were supposed to be considered technical nurses and to work under advanced degree nurses, namely a BSN. Today, more nurses graduate from an associate degree program than a bachelor’s degree program. (Meyer, 1997) I know from my experience, I do not work under an advanced nurse and the hospital does not pay a higher rate for those with advanced course work.

I asked myself these questions: So why have we gone backwards? Because there is a nursing shortage, is it okay to allow this to occur? Would you want your physician to graduate medical school sooner because there was a shortage? What are we then saying about nursing - that level of education for a nurse is not that important? How will nurses ever be looked at as professionals, if we and others in the health field have this opinion? If the public was made aware of this study, how would they feel?

There was a study by Linda Aiken, et al (2003) which found that “in hospitals with higher proportions of nurses educated at the baccalaureate level or higher, surgical patients experienced lower mortality and failure-to-rescue rates.” There was much talk after this study came out, especially because we all know, and may be ourselves, associate educated, and are excellent nurses. But my education was lacking greatly. The program tried to cram all the requirements into four semesters and it is just not possible. My cultural education was lacking, my community health education was lacking, my nursing history was lacking, and overall, my nursing education was lacking. The nursing program I graduated from had a 98% pass rate on the NCLEX exam, but I soon realized that I was not well prepared. As stated by Meyer (1997), “Educators in AD programs often increase the content to prepare student for more advanced roles, however this is frequently at the expense of other course content.”

Many students apply for AD programs because of the same reasons I did. The first reason is time, second is money, and my third reason was why would I go through the time, money and effort to get a bachelor’s degree, when I can make the same money and do they same type of work with an associate’s degree. Many of my students today feel the same way. There is no incentive to strive for a bachelor’s degree, and many have no desire to further their education in the future. When asked why, their answer is “For what?” Until there is a forced change, AD programs will continue to exist and expand. In the journal article by Meyer (1997), it cited the PEW Health Professions Third Report (1995) which “recommended closure of 10-20% of AD nursing programs.” Meyer also called for nursing organizations to differentiate practice. AD graduates would be technical nurses, while BSN graduates would be professional nurses. I don’t know if this alone would work. I believe that AD programs will not go away. But AD graduates should be required to finish their bachelor’s degree in a required amount of years, and until then only be allowed to work in certain areas of nursing. This will help fulfill the need for nurses, it will differentiate practice, and it may drive many nurses to achieve higher education.

References:

Aiken, L. H., Clarke, S. P., Cheung, R. B., Sloane, D. M., & Silber, J. H. (2003). Educational levels of hospital nurses and surgical patient mortality. JAMA, 290(12), 1617-1623.

Committee on Curriculum (1937). A Curriculum Guide for Schools of Nursing (copy 3-52)
select readings from this section.

Hiestand, W.C. (2006). Francis U. Reiter and the Graduate School of Nursing at the New York Medical College, 1960-1973. Nursing History Review, 14, 213-226.

Meyer, C.L (1997). RN, ADN, BSN: clarifying differentiated practice. Kansas Nurse, 72(9), 1-2.

Horizontal Violence Experienced By Student Nurses at a community college

This post shares information regarding a community college in NJ where I percepted this summer. I was to review their public data and determine a "problem" and come up with a "solution." I determined that Horizontal Violence was quite evident at their clinical facilities. I recommended to develop a seminar for the nursing staff at these facilities to increase awareness of HV and hopefully change the behavior. This seminar will also be beneficial for the nursing students to attend.


The data collected from the community college's Clinical Facilities Evaluations demonstrate the apparent existence of what is termed horizontal violence, or Nurse-to-Nurse Hostility. One particular comment that is a prime example of this hostility is number 2, “One RN on 2E was impolite and criticized students in front of other students and staff re: administration of Digoxin. I felt like she was a drill sergeant and not a good role model. My answers were right, but she kept criticizing me all day.”

After meeting with the Chairperson of the Nursing Program and discussing the data reviewed, it was agreed that the one of the most prevalent issue that the Nursing Program is facing currently is that of Nurse-to-Nurse Hostility at their four main clinical facilities. Before seeing the data this author collected, she mentioned a community hospital in New Jersey as the site that she felt demonstrated this behavior most predominately.

Nurse-to-nurse hostility is most commonly termed as horizontal violence, but it is also referred to as horizontal hostility, horizontal aggression, lateral hostility, bullying and interpersonal conflict. It is aggressive behavior by an individual or several individuals that is directed towards another member or members of the same group. It is an inter-group conflict (Hastie, 2002). Matthew-Blanton (2002) as cited by Conti-O’Hare (2002) provides a more descriptive definition of horizontal violence:

"Horizontal violence is a harmful behavior, via attitudes, actions
words and other behavior, that is directed towards us by colleagues.
It controls, humiliates, denigrates, and injures the dignity of another.
It indicates a lack of mutual respect and value for the worth of the
individual and denies another’s fundamental human rights. It is a
self-serving, nonproductive response that perpetuates an escalating
cycle of resentment and retaliation. When practiced by healthcare
professionals, horizontal violence can be deleterious to patient care." (¶ 10)

Horizontal violence is often manifested as behaviors such as sarcastic remarks, intentional rolling of ones eyes, ignoring, gossiping, exclusion from activities and/or conversations, lack of support, unfair assignments, fault finding, intimidation, controlling behaviors, and rudeness (Hastie, 2002).

In a study conducted in Tasmania, the results indicated that nurses who experienced horizontal violence named it as the greatest reason for their work distress. This type of aggression ranked higher than aggression from patient’s family members, doctors, and patients themselves. The type of horizontal violence or hostility experienced most was rudeness, abusive language, and humiliation (Farrell, 1999). Other studies have shown that nurses who experience workplace bullying exhibit symptoms of Post Traumatic Stress Disorder (Tehrani, 2004) and other physical stress reactions such as stomach and back pain, heart palpitations and dizziness. Many experience feelings of helplessness, hopelessness and powerlessness. Bullied employees reported greater levels of mental fatigue and burnout, and also have a higher incidence of sick leave (Agervold, 2004). Horizontal violence can also result in sleeping disorders, anxiety, depression, lack of motivation, lack of emotional control, hypertension, apathy, low morale, poor concentration, eating disorders, disconnectedness, low self-esteem, self-doubt, indecisiveness, impaired personal relationships and even suicide (Hastie, 2002). As reported by Taylor (2004), 153 nurses and midwives killed themselves between the years 1990 and 1992 in the United Kingdom. This demonstrates “that nursing is one of the most stressful occupations, with nurse suicide the highest rate for female suicide” (p. 118).

Student nurses also experience and are affected by horizontal violence. In a study conducted in the United Kingdom, it was concluded that the students had started their studies with normal self-esteem. When their nursing studies were complete, results showed a below average self-esteem and 95% of the participants rated themselves as anxious, depressed and unhappy. The study concluded that “the process of becoming a nurse has a dramatic, negative effect on some aspects of student’s self-esteem” (Randle, 2003a, p. 143). Interviews from the students “illustrate dramatically the distressing experience that students reported from their clinical placements” (Randle, 2003a, p. 143). The author concluded that this decrease in self-esteem and unhappy feelings were largely due to horizontal violence (2003a).

Many of these students related stories when they felt “bullied” by other nurses, both at the clinical sites and by their instructors. These actions made them feel powerless and, in order to cope, they began to exhibit behaviors that would allow them to fit in with and become more like their aggressor. By the end of their coursework, the behaviors of horizontal violence that they initially experienced by other nurses, where now the same behaviors they exhibited to others. They identified the bullying behaviors as part of becoming a nurse (Randle, 2003a). Their attitude towards bullying behaviors changed during their course work, and they “seemed to be blind to the conflicts and anxieties they had first experienced, and not speaking about their anxieties become part of their repertoire” (Randle, 2003b, p. 397). One student stated, “You just have to fit in and get on with the work really.” Another student said, “I make myself do what basically everybody else does. I do what they do” (Randle, 2003b, p. 397).

One common theory regarding horizontal violence is that nurses, just as women, are an oppressed group and are acting out as such. An oppressed group is “people who share with others low status, absence of power, low autonomy, reduced mobility, limited access to resources, and other disadvantages” (Lee, 2001). As cited by Lee (2001), Paulo Freire (1968) described horizontal violence as a behavior that oppressed people exhibit. In order to deal with feelings of powerlessness, the oppressed group would displace negative emotions and aggressiveness onto each other instead of their oppressor, or dominant group. Oppressed groups exhibit behaviors of self-hatred such as lashing out at each other, remaining silent due to shame and embarrassment of their status, and attempting to act and/or befriend their oppressor. Over time, oppressed groups begin to believe and support their oppressor’s beliefs and behavior towards them. They help to fulfill their oppressor’s prophecies about them, and act and behave as their oppressor would expect. They internalize their oppression and believe that they are deficient and deserve this treatment. They develop self and group hatred, low self-esteem, powerlessness, low self-confidence and hopelessness (Lee, 2001). The culture of nursing has many of the attributes stated for oppressed groups, and is portrayed by not only the females, but their male counterparts (Bartholomew, 2006).

Currently, this community hospital is striving for Magnet Status. Two of the 14 forces of magnetism as identified by the American Nurse Credentialing Center (ANCC) that relate to the interaction and relationship between staff nurses and student nurses are numbers 11 and 13. Number 11 states, “Nurses as teachers: Nurses are permitted and expected to incorporate teaching in all aspects of their practice.” Number 13 states, “Interdisciplinary relationships: Interdisciplinary relationships are positive and show mutual respect across all disciplines.” (American Nurses Credentialing Center, n.d., p. 4) The Chairperson stated that the ANCC organization questions them regarding how the nursing staff at a particular clinical site behaves towards and regards the students and the faculty. ANCC takes this interaction into consideration when granting or renewing its Magnet designation.

Nurse-to-Nurse hostility affects the goals of the Nursing Program because it affects the student’s learning experience and learning abilities. The studies mentioned above have shown that nurses exposed to horizontal violence exhibit symptoms such as indecisiveness, poor concentration, self doubt, depression and the inability to handle stressful situations. The studies have also demonstrated that it can lower the self esteem of the student nurse. It also may contribute to the attrition rate seen in the first two semesters at this community college.

Professional nurses can empower themselves by joining nursing organizations, becoming involved in committees at work, changing their “put down” language, continuing their education, motivating other nurses, breaking the silence regarding horizontal violence, engaging in self-caring activities such as exercise and good nutrition, becoming politically involved, and engaging in reflective practice, such as journaling, to promote personal growth and emotional competence. Most important, nurses can empower themselves by acknowledging their participation in and then no longer engaging in horizontal violence (Hastie, 2002).

Many agree that the key to overcoming disempowerment within nursing is empowerment. Nursing students and novice nurses can be empowered by other nurses through positive or active mentoring. The role of the mentor is that of a supporter, an assessor, and a role model. Mentorship has shown to lead to empowerment and “is one of the most effective methods to promote excellence within the nursing professional…In light of the current volatile state of healthcare, mentoring can empower inexperienced nurses to experience more self-confidence in environments which oftentimes impede growth and development” (White, 2001, ¶ 9-10).

A seminar for staff nurses at the community hospital can be developed to help raise the awareness of the issue of Nurse-to-Nurse Hostility and prepare them to become positive mentors to student nurses, new graduate nurses, and nurses with less experience. Many hospitals today pair new nurses with an experienced nurse. The nurses work the same shifts and this is often referred to as preceptorship. Precepting is limited in its scope. It has defined learning goals and is expected to occur for an allotted period of time. Mentoring is quite different from precepting. It has no time limit and there are no set learning goals. Mentors are described as an “expert in their chosen area of practice, are well respected by all members of the treatment team for their knowledge, caring and compassion towards patients and their families, and have intense commitment to the discipline of nursing.” (Thomka, 2006, p. 53) Mentoring is complex and dynamic and their influence continues to affect and guide the mentee positively for a long time, perhaps the rest of their lives. Another positive outcome of mentorship is that the mentee will eventually become the mentor to a new nurse, hopefully leading to the end of the cycle of horizontal violence.

References
Agervold, M. & Mikkelsen, E.G (2004). Relationships between bullying, psychosocial work environment and individual stress reactions. Work & Stress, 18(4), 336-351.

American Nurses Credentialing Center. (n.d.). Introduction to the Magnet Recognition Program
for Students of Nursing. Silver Spring, MD: Author. Retrieved on August 8, 2006 from
http://www.nursingworld/.org/ancc/magnet/forms/studentmanual.pdf.

Bartholomew, K. (2006). Ending Nurse-to-Nurse Hostility: Why Nurses Eat Their Young and Each Other. Marblehead, MA: HCPro, Inc.

Conti-O’Hare, M. & O’Hare, J.L. (2002). Don’t Perpetuate Horizontal Violence [Electronic Version]. Nursing Spectrum. Retrieved from http://community/. Nursingspectrum.com/
Magazinearticles/article.cfm?AID=5708

Farrell, G.A (1999). Aggression in clinical settings: nurses’ views – a follow-up study. Journal of Advanced Nursing, 29(3), 532-541.

Hastie, C. (2002, August). Horizontal violence in the workplace. Birth International. Retrieved from http://www.birthinternational.com/articles/hastie02.html

Lee, M.B., & Saeed, I. (2001). Oppression and Horizontal Violence: The Case of Nurses in Pakistan. Nursing Forum, 36(1), 15-23.

Randle, J. (2003a). Changes in self-esteem during a 3-year pre-registration Diploma in Higher
Education (Nursing) programme. Journal of Clinical Nursing, 12, 142-143.

Randle, J. (2003b). Bulling in the nursing profession. Journal of Advanced Nursing, 43(4), 395-
401.

Taylor, B. & Barling, J. (2004). Identifying sources and effects of career fatigue and burnout for mental health nurses: a qualitative approach. International Journal of Mental Health Nursing, 13, 117-125.

Tehrani, N. (2004). Bullying: a source of chronic post traumatic stress? British Journal of Guidance & Counselling, 32(3), 357-366.

Thomka, L. (2006, February). Are we there yet? The long and winding journey of mentoring.
MODRN Nurse Magazine, 2(1), 49-55).

White, M.A. (2001). Is “Eating Our Young” contributing to the nursing shortage? [Electronic Version]. Nursing Spectrum. Retrieved from http://community/. Nursingspectrum.com/
Magazinearticles/article.cfm?AID=3364