New Wine, Old Skins
“And no one puts new wine into old wineskins. If he does, the wine will burst the skins—and the wine is destroyed, and so are the skins.”
Earthquakes
Have you noticed the academic ground shifting beneath your feet? Have you seen cracks forming in long-standing educational conventions? Were you almost hit by a gargoyle falling from the top of our ivory tower? If you’ve experienced any of these in recent months, you should take it as confirmation that you are both alive and an academician… A daunting combination these days.
Seismic shifts are taking place in higher education. Colleges and schools educating healthcare professionals are feeling the tremors more than most. Although the earthquake started with the pandemic, the fissures that became crevasses during the shake-up have been present for many years. At least two stand out in nursing. First, we have a longstanding clinical placement- shortage. In the thick of the ongoing clinical placement crisis, one education-colleague put it, “Our entire educational model is so dependent on clinical agencies agreeing to take our students… If they won’t do that, we’re sunk!” In contrast, a practice-colleague opined, “[Nursing] Programs think that if they keep growing, we’ll find keep finding spots for their students! We’re out of space and we’re out of bandwidth… We don’t have any more placements for them, especially now!”
For many years now, the problem of finding and maintaining high-quality clinical placements has been prominent in the minds of most nurse educators. It keeps current programs from expanding. It keeps new programs from starting. And, it keeps every clinical coordinator in a perpetual state of stress. Clinical placement consumes vast amounts of energy and generates vast amounts of angst through one of the most inefficient, yet essential, processes in nursing education. Despite the growth of clinical consortiums and the vastly increased sophistication in digital supports, it remains a major vulnerability in nursing education. This vulnerability was laid painfully bare when clinical sites began rejecting student placements at historical rates earlier this year.
A second fissure-now-crevasse is the longstanding shortage of nursing faculty. Less capricious and less debated than the nursing shortage, the nursing faculty shortage has created an impact similar to the shortage of clinical placements. The pandemic has only exacerbated our problem. For example, many healthcare settings are reducing the number of students that can access an institution. Clinical groups of eight have been divided into two groups of four, effectively doubling the number of faculty needed to provide oversight for the same number of students. Where do those faculty come from? Where does their pay come from?
Unfortunately, the problems do not stop with numbers of available faculty. Like so many other Americans, the realities of changes in K-12 schooling and childcare have significantly reduced the time available for faculty to work, let alone be away from home to conduct skills labs, simulations, or clinical experiences. Add to this that many faculty have been asked to step up their contribution for many months now with no extra pay, no summer pay, no certainty about contract renewal (due to the financial exigencies being encountered by universities all over the country ), and no end in sight. Under these conditions, the morale and esprit de corps among even the most stalwart faculty can waiver and in some cases fail, negatively impacting the our ability to retain our most precious resource.
Wine
And this brings us to an awkward transition from earthquakes to wine. Some will be familiar with the biblical analogy of putting new wine into old skins. In ancient times, wine was placed into flasks made from animal skins to age. Over time and with repeated use, the skins would stretch to their limit due to the fermenting process and eventually become dry and brittle. A good way to ruin a new batch of wine was to place it into an old skin that would burst under the pressure caused by the fermentation process.
The pandemic has brought us to an interesting crossroads in nursing education. We must create new wine. With the gross reduction in clinical placements and the possible increased severity of nursing faculty shortages, we have to do things in new ways… perhaps permanently. Many programs have responded with remarkable innovation in lab-based simulation, screen-based simulation, and other adaptations of clinical that have convinced even some of the stodgiest faculty critics that there may be something to these newer pedagogies. But we are still miles from fully addressing the longstanding problems of too few clinical placements and too few faculty.
As we rapidly innovate new approaches to educate our students with aspirations to improve upon our prior levels of educational achievement, will we as a profession continue to force these new ways into old paradigms? For example…
Will “clinical hours” continue to be the main unit of measurement for students’ practical learning? We are well aware that it is not time, but competency, that indicates a student’s readiness to progress. Formulas issued by regulators to convert simulation hours into clinical hours typify our new wine - old skin problem.
Will the “batched” model of clinical education (i.e. educating students in large groups on a set schedule) continue to be the norm? Different students with different life demands will progress at different paces. Are we at a point, at least in the classroom, where we can imagine a model where every student has a highly tailored learning experience that is not dependent on teaching to the aggregate? Many RN to BSN programs have demonstrated this is feasible.
Will simulation continue to be limited to low to moderate percentages of the overall clinical education? Data (and thanks to the pandemic, lots of anecdote) is beginning to accumulate suggesting that we could push even further with potential gains on our current outcomes through simulation. Remember that the industry responsible for the origins of high-fidelity simulation, flight, puts some pilots in the seat of a real 737 for the first time with a cabin full of paying passengers.
Robots
If you have children under the age of 12, it is likely you’ve seen the movie Big Hero 6. One of the main characters, Baymax, is a highly advanced robot-nurse. In one scene (see the above video clip), Baymax is clumsily using one of our most ancient tools to assess his patient, the pain scale. As you can see, it doesn’t go so well. This is new wine in old skins. As a profession, we need to be self-aware about the moment we are in. As painful and distressing as it has been, it is also ripe with opportunity for a paradigm shift in how we educate nurses. Forcing our recent and future educational innovations into our historical frameworks is likely to produce a scene as awkward and unfortunate as Baymax’s.
Let’s begin to think big… put on our design thinking caps and re-engineer the education of the nurse of the future. Nursing education has an incredible opportunity to build on its incredible past achievements. However, what is built for the future should not look like the past. Nursing education needs to change, and by all indications, the sooner the better. New wine, deserves new skins.
