Shaping the Future of Nursing Education and Practice: AACN Essentials Revision and the Next Generation NCLEX

In support of our mission “to advance the discipline of nursing/nursology through equitable and rigorous knowledge development using innovative nursing theory in all settings of practice, education, research and policy,” the Nursing Theory Collective (NTC) emailed the workgroup chairs of the American Association of Colleges of Nursing (AACN) Essentials Task Forces on September 16th, 2019. In this email, we as the NTC advanced our support for a strong nursing perspective and theoretical orientation in the planned revisions to the Essentials documents that form the basis for nursing education at all levels of study. To date, we have received positive responses from the chairs of the baccalaureate, master’s, and DNP essentials revision workgroups. We understand that AACN has invited nursing faculty to have discussions regarding the Essentials, both at their universities and future conferences. We have provided our letter below to foster open dialogue regarding the importance of nursing theory in the future of nursing education. Please join these conversations as you are able and feel free to use the points we have developed as a starting point for your thoughts as well.

In addition to the effort regarding the Essentials revision, we also reached out to the National Council of State Boards of Nursing (NCSBN) regarding the Next Generation NCLEX Project (NCSBN, 2019). As you are likely aware, the NCLEX is currently under revision with an eye toward ensuring novice nurses possess the necessary skills to detect the subtle changes in patient status, preventing deterioration, as well as avoiding errors. In pursuit of this project, the NCSBN has underscored the importance of clinical judgment and decision making in the safe practice of newly registered nurses. It is our concern that due to the absence of a framework founded in nursing knowledge and theory, the disciplinary perspective is lost such that clinical reasoning and clinical judgment devolve from a nursing skill to a generic biomedical task orientation (Bender, 2018). Moreover, the absence of nursing theory in the foundation of the Next Generation NCLEX project begs questions about our core values, how we value nursing knowledge, and to what regulation we agree to adhere (Perron & Rudge, 2015). Email communication with NCSBN about theory content and a guiding theoretical framework belied a lack of interest on their part in engaging in discussion of this issue, at least at this time. Given the role that the Essentials play in nursing education, the NTC has decided to focus on our efforts with the Essentials. We hope that, in time, with revision to the Essentials NCSBN will be motivated to consider the role of nursing theory in NCLEX and more readily engage. 

Appended below you will find our Essentials letter to the DNP workgroup, which is similar to the other two Essentials letters. Please share our letter among your colleagues to assist in the facilitation of discourse on this important topic.

Dear members of the DNP Essentials workgroup,

            We are writing to you today because of your role in the workgroup for the Revisions of American Association of Colleges of Nursing (AACN) DNP Essentials. We represent the Nursing Theory Collective. Our collective membership, made up of experienced nurse clinicians, researchers, educators and scholars, as well as graduate students, emerged from the landmark nursing conference that was held at Case Western Reserve University called Nursing Theory: A 50 Year Perspective, Past and Future in March, 2019. 

As future educators and scholars, we represent the next generation of nurses who will implement the DNP Essentials in the process of educating nurses in the decades to come. We recognize that the DNP Essentials will have a substantive influence on the future of nursing education.

We appreciate your efforts as in the DNP Essentials workgroup and the challenges inherent in taking on the task of creating this powerful and empowering nursing document. We understand that this document, when finalized, will significantly influence the curriculum and the education of thousands of nurses in our country for many years.

It is the recognition of the lasting power and influence of the DNP Essentials recommendations that brings us to write to you today. We join with the American Holistic Nurses Credentialing Center and nursing leaders from institutions of nursing education across the country to respectfully ask that you consider the following points of concern:

1. Theory and Competencies
Nursing theory, representing the wide variety of theories, frameworks, and models used in nursing and including those that provide the historical foundations of nursing, are missing from competencies within the DNP Essentials recommendations. We request that nursing theory and nursing history be included in the Essentials at every level because it is anchors us to our past, present, and future knowledge of nursing. Nursing theory, including knowing the connections to its philosophical roots, shapes who we are as nurses and highlights the critical and distinct human service of nursing that is not met by other disciplines. Education in nursing theory, along with other essential educational content, ensures a solid foundation in disciplinary knowledge and perspective for future nurses, nurse scientists, and scholars. The ongoing development of nursing theory can also lead to the creation of knowledge that can be shared across disciplines. 

2.  Disciplinary Perspective
Competency-based education in nursing must reflect our unique disciplinary perspective with a focus on protecting, promoting and restoring health and well-being, the prevention of illness and injury, the alleviation of suffering (ANA, 2015, p.1) and perspectives on humanizing the health experience (Reed, 1997; Willis, Grace & Roy, 2008). The provision of nursing theory as a foundation for nursing education reinforces our discipline-specific perspective. Nurses need to be competent in articulating the history, voice, and vision of nursing. 

3. Nursing-Centered Frameworks 
Competencies derived from the biomedical models like the Interprofessional Domains of Practice (Englander, Cameron, Ballard, Dodge, Bull, & Aschenbrener, 2013) minimize 100 years of knowledge building that evolved within nursing to define the discipline specific contributions nursing brings to the patient care experience as a science and a discipline. This undermines the existence of the historical work that has been done in nursing theory development, and impedes the future progress of our discipline.

4. Nursing Identity
Interprofessional collaboration must be built upon a strong identity as nurses, so that each nurse can articulate what they bring to the healthcare team, highlighting the priorities that are different from but complementary to the interprofessional team. Without this perspective it will be all too easy for nurses to lose sight of their unique contributions to the interdisciplinary team.

5.  Healthcare Trends 
Healthcare trends and expectations will influence nursing’s roles and practice within healthcare delivery for the next decade, as AACN has articulated, making our strong nursing identity and unique perspective on patient care more important than ever. We are concerned that some current trends in healthcare may emphasize profit, technology and disease over the importance of nursing care, including an alarming shift away from the caring, holistic, scientific, and relationship-based nature of nursing and towards an often profit-driven, technical and biomedical model of interdisciplinary focus where nurses becoming identity-less “health care professionals.”

We envision harnessing the power of nursing through carefully constructed educational essentials to actively shape a just and equitable healthcare service model in the United States of America, and provide future nurses with a clear identity as nurses. However, our future nurses must be educated in the fundamental theoretical and philosophical foundations of nursing in order to preserve the character and ethos of our profession. 

In summary, nursing has always embraced interdisciplinary teamwork. However, we believe that our essential educational competencies must remain firmly grounded in nursing values, nursing theory, and nursing history. Educational essentials and nursing competencies must first reflect our nursing perspective, not those of other disciplines. 

We are nurses and our educational competencies should reflect nursing knowledge and nursing theory. We urge you to consider our recommendations, and how framing of the DNP Essentials within a biomedical, interdisciplinary model would minimize over 100 years of scholarly work by nurses to advance a unique disciplinary perspective and identity. We further recognize the impact that DNP-prepared nurses will have in the future of nursing and the future of healthcare, underscoring the urgency of our concerns.

We acknowledge and appreciate all of the hard work your committee has put forth on this important topic. We hope that you will consider our position in your future revisions of the DNP Essentials. If you wish to have further dialogue on this issue, we as future and present nurse leaders would appreciate the opportunity to engage further.

With gratitude,
The Nursing Theory Collective   

Cosigned by:
Brandon Brown, EdD Student, MSN, RN-BC, CNL 
Ellen Buckner PhD, RN, CNE, AE-C, FNAP
Clare Butt, RN, PhD 
Jill Byrne, MSN, RN, CNOR, PhD Student
Gayle L Casterline, PhD, RN, AHN-BC
Peggy L. Chinn, RN, PhD, DSc(Hon), FAAN
Da’Lynn Clayton, PhD, RN 
Catherine Cuchetti, RN, MSN
Jessica Dillard-Wright, PhD Candidate, MA, CNM, RN
Margaret Erickson, PhD, RN, CNS, APRN, APHN-BC
Rosemary W. Eustace, PhD, RN, PHNA-BC
Jacqueline Fawcett, RN; PhD; ScD (hon); FAAN, ANEF
Pamela Grace, RN, PhD, FAAN
Consuelo Grant, PhD Student, BSN, RN
Debra R. Hanna, PhD, RN, ACNS-BC
Jane Hopkins Walsh, PhD Candidate, PNP-BC, RN
Yuanyuan Jin, PhD Student, MSN, RN
Amy Kenefick Moore, PhD, RN, APRN, CNM, FNP-BC, APHN-BC, HWNC-BC
Kan Koffi, RN, AD, B.Sc., M.Sc.
Carrie Langley, PhD Student, MSN, MPH, RN 
Patricia Liehr, PhD, RN
Chloe Littzen, PhD Student, MSN, RN, AE-C
Colleen Maykut, RN, BScN, MN, DNP
Melissa McCoy, MSN, RN
Angela Norton, PhD Student, MSN/Ed, RN
Christina Nyirati, PhD, RN
Judith Pare, PhD, RN
Marilyn Ray, RN, PhD, CTN-A, FSfAA, FAAN, FESPCH (hon.), FNAP
Pamela Reed, PhD, RN, FAAN
M. Kay Sandor, PhD, RN, LPC, AHN-BC
Phyllis Shanley Hansell, DdD
Mike Taylor RN, MHA, CDE
Billie S. Vance, MSN, FNP-BC
Sylvia K. Wood, DNP, ANP-BC, AOCNP
Rorry Zahourek, PhD, RN, PMHCNS-BC (ret), AHN-BC, FAAN

References

American Nurses Association. (2015). Nursing scope and standards of practice (3rd ed.). Silver Spring, MD: American Nurses Association.

Bender, M. (2018). Re-conceptualizing the nursing metaparadigm: Articulating the philosophical ontology of the nursing discipline that orients inquiry and practice. Nursing Inquiry, 25(3), 1-9. doi: 10.1111/nin.12243

Englander, R., Cameron, T., Ballard, A. J., Dodge, J., Bull, J., & Aschenbrener, C. A. (2013). Toward a common taxonomy of competency domains for the health professions and competencies for physicians. Academic Medicine, 88(8), 1088-1094. doi: 10.1097/ACM.0b013e31829a3b2b

NCSBN. (2019). Next generation NCLEX project. Retrieved from https://www.ncsbn.org/next-generation-nclex.htm 

Perron, A., & Rudge, T. (2015). On the Politics of Ignorance in Nursing and Health Care: Knowing Ignorance. New York, NY: Routledge.

Reed, P. G. (1997). Nursing: The ontology of the discipline. Nursing Science Quarterly, 10(2), 76-79. doi: 10.1177/089431849701000207

Willis, D. G., Grace, P. J., & Roy, C. (2008). A central unifying focus for the discipline: facilitating humanization, meaning, choice, quality of life, and healing in living and dying. Advances in Nursing Science, 31(1), E28-E40. doi: 10.1097/01.ANS.0000311534.04059.d9.