Cathy J. Thompson

Improving the educational experience for international clinical nurse specialist students, part II: attending to culturally sensitive communication.

Part 1 in this series of columns addressing the educational experience for international clinical nurse specialist students discussed the challenges that international and English-as-a-second language (ESL) students face when applying to and attending nursing programs in the United States. Acculturative stress is common among students living and studying in a foreign country and is defined as being ‘‘induced by the adaptation process due to a change of cultural environment.’’ Acculturative stressors include personal, cultural, and academic factors. Culturally competent teaching includes cultural knowledge, cultural awareness, and cultural sensitivity. This issue’s column will explore cultural differences in communication and identify strategies to improve the student experience at the school and campus level.

Improving the educational experience for international clinical nurse specialist students, part III: using culturally sensitive teaching strategies.

This column completes the current series, 1,2 addressing ways to improve the educational experience for international clinical nurse specialist (CNS) students. As noted in the earlier columns, acculturative stress is defined as stress caused by the process of adaptation that accompanies ‘‘a change of cultural environment.’’ Acculturative stressors are multifactorial and common among students living and studying in a foreign country. Understanding the cultural norms and cultural values specific to the students in your institution can help faculty teach in a more culturally sensitive manner to promote an optimal learning environment for students from other nations. Part 1 of this series discussed the challenges that international students need to overcome when applying to and attending nursing programs in the United States. Last month’s column explored cultural differences in communication from a conceptual and theoretical perspective and identified organizational strategies to improve the student experience at the school and campus level. This month’s column will present classroom and clinical strategies that faculty, and hospital educators, can use to decrease acculturative stress and assist international students to adjust to learning in a different cultural environment.

Clinical nurse specialist education: actualizing the systems leadership competency.

Purpose: The purpose of this article was to show how sequenced educational strategies aid in the acquisition of systems leadership and change agent skills, as well as other essential skills for professional clinical nurse specialist (CNS) practice. Background: Clinical nurse specialist education offers the graduate student both didactic and clinical experiences to help the student transition into the CNS role. Clinical nurse specialist faculty have a responsibility to prepare students for the realities of advanced practice. Systems leadership is an integral competency of CNS practice. Implications: The contemporary CNS is to be a leader in the translation of evidence into practice. To assist students to acquire this competency, all CNS students are expected to use research and other sources of evidence to identify, design, implement, and evaluate a specific practice change. Anecdotal comments from students completing the projects are offered. Student projects have been focused in acute and critical care, palliative care, and adult/gerontologic health clinical settings; community outreach has been the focus of a few change projects. Examples of student projects related to the systems leadership competency and correlated to the spheres of influence impacted are presented.

Disruptive Innovation in Graduate Nursing Education: Leading Change.

D isruptive innovation. It sounds messy, and rebellious. You may have run across this term in the leadership or business literature. Although disruptive innovation seems to be the new buzzword, the concept itself has been around a long time. For example, ‘‘creative destruction’’ defined businesses that took advantage of new technology and was coined by Schumpeter in the 1930s; in 1989, ‘‘permanent white water’’ denoted the turmoil and chaos in a changingworld, and the use of terms such as reengineering, reinvention, and healthcare reform in recent decades brings visions of change and chaos. However, the goal of disruptive innovation is not to bring chaos but to provide value to underservedmarkets. The innovation’s purpose is to transform an existingmarket or sector by introducing simplicity, convenience, accessibility, and affordability where complication and high cost are the status quo. Initially, a disruptive innovation is formed in a niche market that may appear unattractive or inconsequential to industry incumbents, but eventually the new product or idea completely redefines the industry.6({2) Personal computers, cellular phones, and the Internet are examples of disruptive innovation. In fact, the Internet has been identified as the number 1 disruptive force in recent history. The theory of disruptive innovation was created by Dr Clayton Christensen from Harvard University and posits that transformation in any industry occurs when small entities disrupt larger ones by focusing on efficient and economical processes and procedures as simpler solutions for complex problems; the disruptors also focus on a new or underserved market of consumers. It is important to note that the impetus behind the disruption is not to improve a product, but to meet consumers’ unmet needs. Because these innovations upset the status quo, they are resisted and frequently ignored by those stakeholders, as inconsequential. However, disruptions can also cause the larger entities to innovate to defend theirmarket sector. The goals of both types of innovations (disruptive and defensive), if successful, lead to positive outcomes for the consumer. Disruptive innovation is not confined to the business world, though; so let us talk about disruptive innovations in healthcare and education. The passage of the Patient Protection and Affordable Care Act in 2010 was, and remains, the impetus for much disruption in healthcare deliveryVand ultimately for nursingeducation. Theestablishmentof clinical nurse specialists (CNSs), nurse practitioners, and other advanced practice nurses to address unmet consumer needs has also been labeled as a disruptive innovation in healthcare delivery. Indeed, CNSs have been at the forefront of disruptive change by challenging the status quo and designing innovative processes and procedures to improve the delivery of healthcare and promote positive patient outcomes. The growth of independent primary care andurgent care clinics in retail establishments (increasingly staffed by nurse practitioners and/or physician assistants) and telehealth applications in rural and remote areas of the country are other examples of disruptive innovation in healthcare. In response to the growing recognition of this phenomenon, the Journal of Nursing Administration is implementing a new column to identify the process and impact of disruptive innovations occurring in healthcare institutions. Author Affiliation: President and CEO, CJT Consulting & Education, South Fork, Colorado. The author reports no conflicts of interest. Correspondence: Cathy J. Thompson, PhD, RN, CCNS, CNE, CJT Consulting & Education, PO Box 1263, South Fork, CO 81154 (cathyj. thompson@hotmail.com). DOI: 10.1097/NUR.0000000000000199

Educational considerations for international clinical nurse specialist students: part I.

The growth of advanced practice nursing has been described as a ‘‘global trend.’’ ‘‘As clinical experts, leaders, and change agents, APNs (advanced practice nurses) are recognized as an important human resource strategy for improving access to high-quality, costeffective, and sustainable models of healthcare.’’ The demand for APNs is stimulated by multiple factors, including societal demands for healthcare services; local system, cultural, and environmental influences; government priorities; and the nursing and advanced practice communitiesat-large. Althoughmore than 50 countries have developed, or are developing, advanced nursing roles, many barriers to the education and worldwide acceptance of APNs exist. Many international students come to the United States for graduate nursing education. This type of educational outreach is encouraged by universities interested in increasing internationalization within the nursing curricula. A major benefit of internationalization is to increase cultural awareness and promote personal and professional bonds between US and international clinical nurse specialist (CNS)/APN colleagues. However, the education of students from other countries presents unique challenges that require special consideration from US faculty. This article is the first in a series that will focus on issues significant to the facilitation of the educational experience for select student populations. Advanced Practice Nursing as a Global Movement The International Council of Nurses defined the nurse practitioner/APN as a registered nurse (RN) who has acquired the expert knowledge base, complex decisionmaking skills, and clinical competencies for expanded practice, the characteristics of which are shaped by the context and/or country in which he/she is credentialed to practice. A master-level degree is recommended for entry level.11({1)Of the 4 recognizedAPN roles, nurse practitioners and CNSs are the most common roles instituted globally. TheCNS roleVemphasizing theory-guided andevidencebased practiceVbenefits patients, nurses, and organizational systems. Many countries have developed or are developing APN educational programs. Although the operationalization of the CNS role varies across the United States and the world, and the more generic title of APN may be used in some countries, evidence has shown the value of the CNS/APN to improving healthcare in the United States and abroad. The expectations of APN programs in the United States differ from those in other countries, although commonalities exist. Advanced practice nurses are leaders in healthcare, expertly integrating theory, practice, and research to provide high-quality nursing care and promote positive patient outcomes. International APN programs have these principles in common, although the literature describing programs in detail is scarce. In Europe, opportunities for nursing education at a master’sor doctoral-level are growing, but at this time are limited to a few programs; this fact, and the excellent reputation of the US higher education system, is a big draw for international students, with ‘‘more students worldwide choosing to study in the United States.’’5({5) In the United States, the numbers of international students are increasing, and the numbers of international Author Affiliations: Student (Ms Terada), Adult-Gerontology Clinical Nurse Specialist PostYMaster’s Certificate Program, and Associate Professor (Dr Thompson), College of Nursing, University of Colorado Anschutz Medical Campus, Aurora. The authors report no conflicts of interest. Correspondence: Cathy J. Thompson, PhD, RN, CCNS, College of Nursing, University of Colorado Anschutz Medical Campus, 13120 E 19thAve, Room4211, Aurora, CO80045 (cathy.thompson@ucdenver.edu). DOI: 10.1097/NUR.0b013e318267c2ec

Disruptive Innovation in Graduate Nursing Education: Tipping the Scales for Online Education.

In previous columns, I started a conversation about disruptive innovation (DI) in higher education and about the disruptive trajectory of online education, in particular, to traditional college course offerings. The rise of online education and the growing acceptance of online courses among students are a fact. Of the 5.8 million US college students enrolled in online courses in 2015, 48% were taking online courses exclusively; in 2013, only 13% of students were enrolled exclusively in distance education courses. However, despite the rapid increase in the demand for online learning, faculty and administrators have been resistant to the pedagogical approach of online learning, even questioning the ‘‘legitimacy of online education.’’ When online nursing education was in its infancy, faculty had legitimate concerns about teaching onlineVsome of those concerns were due to inadequate guidance and development of how to create a quality online course. However, as we see from student satisfaction studies, faculty have become more skilled with the online learning environment and the quality of current courses is the same or better than that of traditional face-to-face courses. Admittedly, there still are obstacles to teaching online; however, as distance education rapidly becomes the learning format of choice, faculty must be proactive in preparing for this new reality. In response to a 2015 survey of online education, 71% of faculty indicated that online learning was not a valid form of education. We can use Rogers’ innovation adoption bell curve transposed with the cumulative S-shaped curve of adoption to look where we might be, for the acceptance rate of online education. The innovators and the early adopters would make up 16% of the faculty population adopting online learning, with the additional 13% reflected in the leading edge of the early majority (29% total; Figure 1). The ‘‘take-off point’’ (aka threshold point or tipping point) for diffusion of an interactive innovation within a system is frequently reported in a range of 10% to 20%, although it is well known that the rate of adoption for healthcare technologies varies widely. Rogers found that because there is great variation in diffusion depending on the innovation itself and the sector forwhich it is intended, there seemed to be no magic number at which an innovation always takes off. However, scientists at Rensselaer Polytechnic Institute have reported that just 10% of a defined population committed to ‘‘an unshakeable belief’’12({1) is all that is needed to trigger the adoption of that belief in the rest of the populationV‘‘where minority belief becomesmajority opinion.’’12({1)Committed is the keyword here. This percentage holds regardless of ‘‘the type of network inwhich the opinion holders are workingIor where that opinion starts.’’12({5) Social channels have a great impact on the diffusion rate. According to Rogers, individual adoption is more likely to occur when other individuals, especially opinion leaders, within the adopter’s network are also using the innovation. The Babson and Quahog research group’s survey noted that the acceptance of online education coincided with the institution’s online learning offerings, so those institutions without a critical mass of faculty advocating for online education will likely have a slower rate of adoption. If we apply the evidence though, if at least 10% of the faculty is committed to online education, that 10% minority can prevail to become the majority opinion. As the predictions of online education point toward its upending of the traditional college model of education Author Affiliation: President and CEO, CJT Consulting & Education, South Fork, Colorado. The author reports no conflicts of interest. Correspondence: Cathy J. Thompson, PhD, RN, CCNS, CNE, CJT Consulting & Education, PO Box 1263, South Fork, CO 81154 (cathy@ nursingeducationexpert.com). DOI: 10.1097/NUR.0000000000000228