Ingram School of Nursing
Educating Nurses: Innovating to advance the profession
Annie Chevrier, Rosetta Antonacci, Lia Sanzone, Hugo Marchand, Louise Murray, Oxana Kapoustina, Irene Sarasua, Laurie Gottlieb, Elizabeth Leber, Francoise Filion Maria Di Feo, Catherine-Anne Miller.
Associate Director of Education, Ingram School of Nursing
Dr. Anita Gagnon
Associate Dean and Director, Ingram School of Nursing
Ingram School of Nursing - McGill University
680 Sherbrooke West, 18th floor, Montréal (Quebec) H3A 2M7
Dear members of the general assembly committee,
On behalf of the Ingram School of Nursing, I would like to convey our appreciation of the unique consulting process that has gone into advancing the nursing profession.
We believe that together, we can advance this profession in ways that will make the nurses of tomorrow more skilled than ever. The nursing profession’s General Assembly is essential to our progress as we make these advancements together.
Anita J. Gagnon RN, MPH, PhD
Associate Dean and Director, Ingram School of Nursing
The Ingram School of Nursing (ISoN) at McGill University is a post-secondary educational institution with approximately 1,000 students annually registered in all programs and 57 full- and part-time professors. In relation to the OIIQ general guidelines, the ISoN addresses the theme, La formation infirmières : pour relever les défis du 21e siècle [Training for 21st century nursing challenges ]. ISoN believes that to ensure that up-to-date, high quality care is provided to those we serve, the nursing profession must advance our understanding of the science of nursing. University education supports this knowledge base and its application in professional practices.
ISoN asserts that, to take on 21st century challenges, our profession must support education that produces professionals who can offer strengths-based nursing on an individual and collective level, following exemplary health care practices focused on patients, their families, and community (Gottlieb, 2012). Nurses must apply their clinical reasoning to the vast repertoire of subjects that comprise the nursing sciences, i.e., biology, chemistry, psychology, sociology, research, physiology, and pharmacology. This combination of knowledge and skills are the driving force of our profession and our capacity to provide care that meets the complex challenges facing our health care system.
The subject of this advisory
The aim of this advisory is to support the advancement of the nursing profession so that nurses graduate with the knowledge, skills, and qualities that meet the complex needs of the general public and the health system. We are proposing that the baseline education for nurses be a bachelor program as a point of entry to the profession. Implementing this proposal with a unified, standardized education program will take close collaboration with the education system and with CEGEPS in particular. Pedagogical innovations such as simulations, integrated learning, and community collaborations are an opportunity to elevate the nursing profession. We are equally in favour of promoting continuing education that allows nurses to develop their skills throughout their careers.
Position and justifying arguments
A highly skilled labour force continues to be an asset and necessity in light of the growing challenges our health care system and our society as a whole are dealing with. ISoN believes that it is important to educate nurses so that they have a confident, resilient, creative, and adaptable professional identity as well as a keen sense of equity. A striking demonstration of this expertise has been seen during the COVID-19 pandemic. This crisis has made it clear that a workforce of competent, highly knowledgeable nurses with critical thinking skills have made, and will always make, a great difference to our health care system. Skills in community health, public health, and critical care were also crucial to the pandemic response.
Health care services are dealing with needs that are constantly increasing in quantity and complexity, and this directly affects nursing. Insufficient staff, limited internships, and health care reforms are among the issues that have particularly contributed to the exhaustion of personnel and significant gaps in access to health care services for particular populations. Other professions (such as physiotherapists, occupational therapists, and pharmacists, for example) increased educational requirements for entry into their professions years ago, but this hasn’t been done for nursing.
A university education in nursing sciences (an initial bachelors and the DEC-BAC pathway) provides generalist skills that meet our society’s emerging challenges. It also provides a foundation for higher education, such as the SNP, CNS, doctorate, and post-doctorate degrees. We see a baccalaureate as a requirement for entry into the nursing profession as a necessity, particularly in light of data that suggest a connection between education and experience with a reduction in morbidity and mortality as well as improvements in client safety indicators (Audet, Bourgault, & Rochefort, 2018; Haskins & Pierson, 2016). All the essential components of these programs — theory and clinical instruction, including simulations and laboratory training — must be anchored in the best pedagogical practices.
We are aware that an influx of hundreds of additional students at the bachelors level will put additional pressure on universities and internship settings. These challenges also concern the OIIQ, whose mission is to protect the public. To respond to these challenges while prioritizing equity, ISoN has made several innovations to university level education for nurses that improve its accessibility, quality, and its alignment with our social accountability.
Firstly, we are in the early stages of implementing an online bachelors program to facilitate access to technical nurses and the development of necessary skills such as critical care, public and community health, and RN prescribing. This program can address the problem of technician nurses’ limited access to training and will help develop a labour force that can fully apply its expertise.
ISoN recently adapted its bachelors program so as to better align with best training practices for nursing sciences. We recognized that making changes throughout the nursing program would benefit the profession. These changes include an alignment of courses throughout each semester and throughout the curriculum, a range of pedagogies such as didactic learning and project-based learning, the use of simulations, self-directed learning, and reflective practice. The goal of this integration is to promote critical thinking and clinical reasoning, which play a key role in the response to health care needs and the optimization of the health care system.
Clinical laboratories are also needed to develop the excellent technical skills and dexterity required to excel at complex nursing clinical practice. The use of simulations, whether they are virtual or run via OSCE or other modalities, have a great effect on increasing students’ self-confidence and on their acquisition of knowledge and skills (Moran, Wunderlich & Rubbelke, 2018). At this time, the OIIQ does not recognize hours spent on simulations as internship hours, although studies have shown that they could make an acceptable replacement for up to 50% of the time that goes into an internship (Hayden, Smiley, Alexander, Lardon-Edgren and Jeffries, 2015). Research has also shown that one hour of simulation is equivalent to two internship hours (Sullivan et al., 2019). We propose that the OIIQ recognize an acceptable percentage of hours spent on simulations in order to reduce the pressure on internship settings. We also propose that the OIIQ should encourage the use of simulation modalities in continuing education. Simulations expose our students to unusual situations that they may not encounter during a clinical internship. Finally, we believe that simulations increase public safety by preparing students in a controlled, safe environment.
Aligning courses with simulations and laboratory activities helps develop clinical reasoning, critical thinking, and skills. Inquiry-Based Learning as a pedagogical approach is research based learning that helps students develop their why and when thinking and apply what they have learned in their courses. The third element is the clinical internship, where, under supervision, they apply what they have learned while providing personalized care, in real time, in the context of their patients’ lived experience. Currently, most educational institutions use the group model, with a clinical monitor or preceptorship. These two clinical learning models have been in use for decades. It will be important to consider whether they should be innovated upon to create new clinical education models.
Innovations in training content must take into account the population’s changing needs, and in particular the needs of underserved populations, within their own environment and not just in hospital environments. This can only be done with innovations made through ongoing community partnerships. ISoN was able to create sustainable partnerships within clinical environments and with communities so that the experiential element of our programs could respond to the needs of learners, the clinical settings, and the Quebecois and international populations. We have a social responsibility to take part in an ongoing reflection with the community to overcome the problem of limited health care access and assert social equity at every level. A university education is a springboard that encourages nurses to adopt this awareness within their professional identity.
Training never ends for nurses. The innovations discussed above could also support a culture of continuing professional development within the profession. Beyond providing initial training, universities could provide certification in specific domains, such as wound care and population health, to meet the population’s varied and prioritized needs. Universities also offer post-secondary programs aimed at ensuring a significant presence of advanced practice (SNP and CNS) nurses throughout the province.
In conclusion, as a post-secondary teaching institution that educates future nurses, it is our responsibility to prepare competent, dependable, ethical practicians who will take into account the health issues of patients and their families while developing their strengths. We are also obliged to speak up for the cause of high quality health services for the entire population of Quebec. We believe that well-prepared nurses who have a baccalaureate are particularly well-positioned to make a meaningful contribution to the health of populations in Quebec and throughout the world. Nurses — empowered with all their strengths and expertise — are the cornerstone of the response to these complex needs.
Following our discussions, ISoN has recommended the three (3) following measures:
- A baccalaureate should be established as the point-of-entry into the nursing profession. This would mean that there would be two points of entry: the initial bachelors and the DEC-BAC pathway. To accomplish this measure, we propose that we continue to work with the CEGEPS through the consortiums to revise and integrate the two programs. We also propose that the OIIQ professional exam be developed for the bachelors level. For students who choose the DEC-BAC option, a status similar to the CPN would be awarded between the end of CEGEP and the completion of the bachelors program.
- We recommend that, to respond to the continuously evolving needs of the population, in collaboration with the OIIQ, the universities offer continuing education diplomas in nursing sciences. Among other things, we propose that training be offered in cultural safety in health, community health, critical care, harm reduction, mental health, dialysis, infection control, and wound care. We ask that the OIIQ recognize these certificates and inform employers that it is important that they also recognize them. These certificates will also help develop a culture of continuing education throughout the profession. The use of online instruction could allow new programs to be integrated within training institutions with a minimum of resources.
- Finally, we recommend that the OIIQ recognize simulations as a valid replacement for internship hours according to a ratio of one hour of simulation to two internship hours, and that it recognize an acceptable percentage of internship replacement hours based on solid evidence. This will take pressure off the institutions that offer internships while standardizing particular kinds of internships. The OIIQ may also recommend simulation scenarios for different internship levels. This standardization and these scenarios will offer the public greater protection while ensuring that all students gain the required minimum of skills.
- Establish a bachelor’s degree followed by the professional exam as the standard requirement for entry into the nursing profession by creating partnerships between CEGEPS and universities with a range of points of entry (an integrated DEC and BA and the initial baccalaureate).
- Formally create and recognize continuing education programs and diplomas for clinician nurses and adapt them to specialized fields such as oncology, geriatrics, and mental health. This training would take the form of university level certificate programs.
- Encourage technician nurses with over four years of previous experience to return to school for a continuing education diploma, regardless of how long ago they received their DEC.
- Encourage clinical and government sectors to recognize these training programs and certificates in relation to skills, job creation, and salaries for these specializations.
- Provide more encouragement for the development of online programs to make education more accessible.
- In light of the limited availability of internships, recognize a percentage of simulation training as an innovative means of replacing internship hours and a valid, safe learning technique.