Inaugural cohort offers students ‘a more holistic and patient-centered approach’
Robert Atkins, PhD, RN, FAAN, went to nursing school in the 1990s, his mother went to nursing school in the 1960s, and he is executive vice dean at the Johns Hopkins School of Nursing today.
In all that time, nursing education has changed very little. For example, even though nursing care is increasingly provided outside of hospitals, nursing clinicals for entry-level students still reflect the focus of the early 20th century hospital-based nursing program: preparing nurses to deliver care in hospitals. That creates operational and programmatic challenges.
For one, hospital-based clinical placements and clinical faculty are scarce resources, which limits the number of students that schools of nursing can accept and enroll into nursing programs. It’s an untenable challenge in the middle of a nursing shortage. Furthermore, today’s hospitals are increasingly emergency and acute care centers—even patients undergoing surgery frequently go home the same day. To prepare nurses to change the world tomorrow, JHSON focuses on real-world nursing today, and that means enlarging the experience pipeline to include outpatient clinics, schools, hospice facilities, and even virtual reality.
“We’re trying to prepare practice-ready nurses for as many diverse nursing roles as possible.”
A new track in the MSN (Entry into Nursing) program—the Outside Track—is expanding the pipeline to practice, preparing students for RN licensure through clinicals conducted entirely outside of the hospital setting.
The Outside Track “represents a fundamental change in how we train future nurses,” explains Assistant Professor Laura Lucas, DNP, MS, RN, director of MSN programs. “As the demand for nursing grows in community settings, there is a need for schools of nursing to provide students with clinical opportunities to learn how to care for individuals in their homes, schools, churches, outpatient centers, and many other spaces. These students are prepared to be generalist nurses, capable of working in various settings and contributing to a more holistic and patient-centered approach to health care.”
“Our graduates will be prepared to fill critical nursing demands in the community and promote our profession of nursing.”
Students meet the same course objectives as their peers who train in inpatient settings, but conduct clinicals in outpatient settings providing care to people with congestive heart failure, for example, as well as wound and end-of-life care. The approach addresses the gaps in traditional nursing education and equips graduates to be practice ready by graduation, in whatever setting they choose.
How it works: The pilot includes seven students who started their clinical rotations in spring 2024. They were selected through a competitive application process, then assigned to a clinical placement and paired with a preceptor on site. The approach is doubly beneficial; in contrast to traditional clinicals, students are paired with a nurse already employed on site, so the program is sustainable. Then, students are precepted one-on-one instead of the 1-to-8 ratio in hospital settings.
Real-world impact
With more clinical time spent delivering care, students in the Outside Track are making an impact right away. Student India Grant of Victorville CA was able to intervene and conduct a health assessment, ultimately identifying the correct cause of a new challenge: patient falls.
“I attended clinicals at a mental health facility,” Grant says. “Our patient recently started having falls, and others on the care team wanted to change her medicine. I intervened, checked the person’s feet, identified bruises and cuts, and found out she also had diabetes. We were able to intervene appropriately with diabetic foot care rather than changing this person’s psychiatric medication.”
Student Christian Opia, a native of Nigeria, says the program has been even better than expected, particularly his clinical shifts at an oncology infusion center. “I never imagined it would be like outpatient setting and community put together,” he says. In inpatient, he explains, many individuals being cared for are too sick to talk or are sleeping.
“But outpatient, they’re going to be asking you questions about the care plan, the medication, what to expect during treatments, and what not to expect.” And if the patients don’t ask, the preceptors will. “So outpatient will challenge you to have a deep dive into the material or the topic that you need to know.”
Ready to practice anywhere
“We’re trying to prepare practice-ready nurses for as many diverse nursing roles as possible.” says Atkins, an architect of the Outside Track and Anna D. Wolf Endowed Professor at JHSON. “The nation needs nurses to provide acute care both in hospitals and in the community.”
Already, 4 in 10 nurses work outside of the inpatient setting. Studies have shown that clinical care determines only around 20 percent of a person’s health, while social determinants of health, things like where people live, work, their education and income, determine 50 to 80 percent. Nurses are already the largest segment of the health care workforce; with more nurses in communities, in more places along the pipeline of care, they can intercede upstream—before health concerns become an inpatient problem.
Competency-based education
The Outside Track is just one arm of the school’s push to redesign nursing education in alignment with the current and future needs of health and health care systems. It’s important to expand the clinical pipeline, and clinicals remain a vital component of nursing education, accounting for around 1,000 hours of pre-licensure student education, but they are a “black box.”
“We can’t be sure what students will encounter, or how their clinical experiences contribute to the development of their competency and practice readiness,” says Atkins.
In addition, JHSON is implementing new, high-fidelity simulations using virtual and augmented reality. It all falls under the umbrella of “competency-based education,” an approach that enables students to understand up front the core competencies they need to master to be a successful nurse, and then practice the skills until proficiency.
“We have to ask ‘why are we doing it this way?’ ” says Atkins. “And then be prepared to reimagine nursing education to train a larger and even more prepared generation of nurses that contributes to a healthier, more resilient nation.”◼