Nursing educational framework : A new nurse-driven,conceptually guided approach

Developing, using, translating, and evaluating nursing knowledge

In reality, current political, social, and economic issues sometimes pose challenges to the development and implementation of the nursing discipline. Despite the considerable achievements throughout time, it remains critical for educators to maintain a clear perspective on distinctive nursing knowledge, and to be diligent about its dissemination when preparing nursing students (Smith, 2016). The lack of emphasis on the disciplinary focus in nursing education has been defined as one of the most important threats for educators to contribute to nursing growth as a unique discipline. Many undergraduate and graduate nursing curricula do not ground student learning in the breadth and depth of nursing knowledge (Grace et al., 2016; Jones et al., 2023; Roy, 2018; Smith, 2016).

The link between the mission of the NEF—service, preservation of life, and leadership—and nursing knowledge development, use, translation, and evaluation is made explicit by being aware of the importance of using nursing theory to frame and guide nursing practice, research, education, and administration (Jones et al., 2023). As Newman (2008) noted, “nurses are thirsting for a meaningful practice, one that is based on nursing values and knowledge, one that is relationship-centered, enabling the expression of the depth of our mission, and one that brings a much needed, missing dimension to current health care” (p. 25).

From the NEF approach, educators develop knowledge within a person/family-centered humanistic perspective (Monge, 2017; Osacar, 2018; P. Diez-Del-Corral, 2013; Rumeu-Casares et al., 2017; Saracíbar-Razquin, 2009) and drive theory, practice, and research to be connected (Flanagan, 2021; Jones et al., 2023; Turkel et al., 2021). Preserving a unique nursing perspective in the development of a nursing curriculum, guided by theoretical principles that emphasize service, the preservation of life, and leadership, is essential for nursing to have a significant influence on excellent patient care. If nursing theory is not visible in practice, its unique contribution is obscured (Flanagan, 2019).

Educators conduct periodical internships to be clinically updated and translate nursing theory and research into practice. Through clinical sessions and workshops, they help create clinical educational environments in which theoretical content is effectively addressed. This intervention helps to reduce theoretical abstraction and makes theory more understandable to students and clinical nurses. The need for mutual and collaborative work among educators, nursing students, and clinical nurses remains critical (Shoghi et al., 2019).

Enhancing person/family-centeredness from a relationship-based care approach

Developing an authentic nurse-person/family relationship is essential to providing person/family-centered care (McCormack & McCance, 2006) and to achieving good health outcomes (Britten et al., 2016; McCormack & McCance, 2021; McCormack, Dewing & McCance, 2021). Accordingly, it is of the utmost importance to help students develop clinical nursing practices oriented to the establishment of caring and helpful relationships focused primarily on the person (Errasti-Ibarrondo et al., 2015).

Past research has uncovered that every authentic, specific, and unique nurse–person/–family relationship is composed of core elements. The “model of interpersonal relationship between the nurse and the person/family cared for” (Rumeu-Casares et al., 2017; Saracíbar-Razquin, 2009) highlights the values of respect, knowing the person, and intentional presence as the core elements of this relationship. Through respect, nurses manifest their genuine interest in serving the other and the awareness of not violating his or her privacy by creating safe spaces in which the patient's life remains preserved (P. Diez-Del-Corral, 2013). Respect includes advocating for the patient, promoting decision-making, and helping the person find meaning in the health process he or she is going through. Knowing the person involves knowing persons/families as unique valuable human beings who are living through experiences related to their health condition, and seeking to incorporate their personal values and goals into care delivery (Osacar, 2018; Somerville, 2009). Finally, intentional presence is described as “a consciousness and awareness that are directed toward (the person/family), with purpose and efficacy toward action, expectation, belief, volition, and even the unconscious” (Watson, 2002, p. 14). Intentional presence can also be understood as the interpersonal process characterized by the transcendent unity between two people who sustain their bond in a relationship that is satisfactory for both and in which the nurse intentionally builds a dynamic relationship with the person/family according to his or her uniqueness (Monge, 2017).

Considering that the way these concepts unfold in practice is nursing-specific, these three unique elements are central for the provision of person/family-centered care from a nurse–person/–family relationship perspective. From there, this theory-based framework helps educators promote students’ preparation for these attributes in their overall educational experiences overall. The NEF structure helps to teach these concepts threaded throughout the curriculum to promote greater understanding and its application. In doing so, educators create opportunities for students to expand their knowledge of the concepts to a variety of settings, populations, and experiences without needing to explicitly present its content in every course (Billings & Halstead, 2016; Giddens & Brady, 2007; Repsha et al., 2020). For example, instead of teaching about respect, leadership, or service in a variety of theoretical courses, such as ethics, adult care, and palliative care, students learn through exemplar case studies in simulation and learn how to apply its content in the corresponding theoretical courses.

Promoting personal and professional role development

From the NEF perspective, to educate students to develop a culture of service, preservation of life, and leadership, educators embrace a commitment to students’ personal and professional growth through mentorship. Nursing mentorship, which contributes to students’ development through personal motivation and nursing professional competence (Mikkonen et al., 2022), plays a central role in receiving superlative benefits from educators (Lee & Chiang, 2021). Personal mentorship allows educators gain insight into each student's unique circumstances, enabling them to provide support, motivation, and new challenges that contribute to the students’ holistic growth and leadership development during their time at the university (Lleo de Nalda et al., 2020).

Through personal periodical interviews, the relationship established between the educator and the student helps them to know each other, challenge perspectives, facilitate honest discussion, and foster their involvement in the educational community. This reinforces their inclusion in social networks enhancing the teaching message and resulting in feelings of acceptance and desire for further connections (Yousiph et al., 2023). Through mentorship, educators also reformulate and reconceptualize what is learned in the classroom and what is observed and experienced in the practice setting. When this process is not part of the educational experience, it may compromise professional role development and result in challenging transitions to the practice environment. It is therefore essential that educators are prepared to promote personal and professional student development as an ongoing process of acquiring knowledge, skills, and attitudes over time, to provide service and respond competently to person/family needs (Ji et al., 2021; Schuler, 2021).

Nursing educators often come from practice settings where work expectations and the scheduling of time are clearly delineated. However, mentoring young students presents new challenges. Within the NEF perspective, a mentoring program for new faculty is offered as they sometimes adjust to an unfamiliar role. Within this structure, new faculty have a senior mentor who provides counseling and guidance not only in the field of mentorship but also in teaching topics, such as innovative classroom management, academic advising, and scholarship (Webber et al., 2020). A faculty mentoring committee headed by the head Departments and the Dean oversee the mentoring process to provide structure, organization, and continuity, to inform and promote the mentoring process.

Enhancing the use of clinical judgment and clinical decision-making

Within the NEF, clinical judgment and clinical decision-making are core nursing processes used to enhance problem, risk, or motivation solving that is responsive to nursing action (Herdman et al., 2021). According to Tanner (2006), clinical judgment can be considered “an interpretation or conclusion about a patient's needs, concerns, or health problems, and/or the decision to act (or not), use or modify standard approaches, or improvise new ones as deemed appropriate by the patient's response” (p. 204). Clinical decision-making can be regarded as reflective strategies for improving persons’ clinical status from their current conditions to favorable conditions (Shahraki Moghaddam et al., 2016).

Based on these approaches, a key educators’ competence is the ability to make students understand the connection between the academic world and nursing practice for the development of critical thinking skills that inform subsequent clinical judgment abilities when providing excellent patient care (Schuler, 2021). As nursing students address underdetermined and ambiguous conflicts in health settings, receiving relevant theoretical and practice-integrated education to enhance clinical judgment and decision-making skills is paramount to face and address daily clinical challenges.

The linkages between and among theoretical knowledge and a practice-integrated education are critical for the successful growth of nurse-driven professional practice and the development of professional roles based on excellent practice. From the NEF perspective, educators help students establish a liaison between what is learned in the classroom and its corresponding application to patients, families, and communities. It provides specific opportunities, such as integrated theory/practice-driven training (for instance, students learn how to write reflective diaries modeled by the integration of expected competencies and practical experiences), continuous formal and informal communication between academia and practice settings, and interdisciplinary seminars (Rosa-Salas et al., 2020). Furthermore, the NEF framework generates a reflecting led context that facilitates inclusion and embeddedness through periodic shared thoughtful discussion activities, such as theoretical learning sessions, journal clubs, and lifelong learning activities. General and profession-specific educational content are combined establishing a strong inseparability between theory and practice, concomitant teaching and learning between educators and students through active teaching methodologies, and diversified evaluative processes based on performance and competence development (Franco et al., 2016). Nurse educators transcend what questions to teach the why and purpose of nursing care, to facilitate the development of critical thinking skills (Huber, 2022).

In the context of the nursing process (Caro & Guerra, 2011), elements involved in clinical reasoning, decision-making processes, and nursing care delivery focused on identifying and measuring patient responses are based on thorough and comprehensive nursing assessments (Gordon, 2014; Flanagan, 2021). Educators incorporate this evaluative holistic gaze in every course in such a way that students come to accurately identify patient problems, risks and motivation to address, outcomes to achieve, and patient-tailored interventions to develop. Again, this is the work of nursing disciplinary knowledge, and it is why this work impacts persons/families and the nursing discipline's scientific advancement (Flanagan, 2021).

Communicating about the discipline through standardized nursing languages

SNLs represent nursing clinical judgments communicated through diagnostic terminologies, which are terms or concise phrases identified through clinical reasoning and validated by assessment evidence, where the idea or concept that represents the care problem, risk, or health motivation is condensed (Herdman et al., 2021). SNLs offer a way to investigate, demonstrate, and communicate the scope of the discipline of nursing. The diagnostic statements thus provide a common name that the whole community can use to express themselves, register in clinical records, and evaluate (Herdman et al., 2021).

The International Council of Nurses (ICN) considers SNLs use to be an essential strategy for nurse qualification and for the advancement of the profession as the development of a particular vocabulary promotes the strengthening of professional identity, the organization of clinical reasoning, and the improvement of practice (Figueir, 2018; Gómez-Salgado et al., 2018; Silva et al., 2020). Within the NEF perspective, the integration of SNLs in the nursing curriculum provides the use of a standardized vocabulary to communicate nursing visibility in the delivery of patient care among educators, students, and other healthcare professionals. By providing higher evidence-driven quality care, SNLs help to define problems, risks, and health motivations; choose the best interventions; and plan expected outcomes. Integrating this approach across the curriculum, programs, and courses also benefits nursing documentation, as it provides reliable valid approaches to record, organize, and analyze nursing information that is gathered in electronic healthcare records, which facilitates data compilation for nursing research (Gómez-Salgado et al., 2018). Documentation using SNLs aids communication among the various healthcare providers (Olatubi et al., 2019). Incorporating SNLs into the electronic documentation system provides nurses with a data base that makes visible the patient's experience and nursing's contributions to care.

From a person-centered relationship–based care perspective, incorporating nursing-specific descriptions of delivered care into healthcare daily records in a way that maintains the uniqueness of the concepts that represent nursing care (Rutherford, 2008; Schwiran & Thede, 2011; Olatubi et al., 2019) helps students understand patients’ needs with precision and formulate accurate nursing diagnoses, which facilitates the selection of more effective nursing interventions that lead to better outcomes (Olatubi et al., 2019; Rivas et al., 2016).

When educators use NANDA-International (NANDA-I), Nursing Interventions Classification (NIC), and Nursing Outcomes Classification (NOC), the nursing diagnoses, nursing interventions, and nursing outcomes are specifically defined and concreted. NANDA-I is a nursing language used widely for communicating patient problems, potential risks, and readiness for health promotion by nursing professionals who provide bedside care (Herdman et al., 2021). NIC is a classification in which each intervention has a unique identifier to facilitate computerization, a definition, and a detailed set of activities that describes nurses’ activities to implement the intervention. NOC helps to evaluate the effects of nursing interventions (Othman et al., 2020).

Scientific literature states that the use of SNLs increases evidence-based nursing care and improves efficient decision-making and critical thinking in the nursing process, which leads to positive effects on patient healthcare outcomes (Zhang et al., 2021). From there, the NEF framework threads and defines its curriculum through the integration of NANDA-I, NIC, and NOC (NNN) terminologies, which help educators, students, and clinical nurses deliver excellent and rigorous nursing care, lead the development of the nursing process, and be creative in solving patients’ problems through the use of critical thinking (Olatubi et al., 2019). The school organizes updated periodical training for educators and clinical nurses—seminars, online courses, and participation in research groups—to be prepared to develop, use, and apply NNN terminologies to the reality of nursing practice. Students learn to contribute to the nursing profession conducting didactic and interactive case studies to develop care plans and apply NNN in varied settings and populations.

Implementing teaching strategies in the classroom and simulation

Nurse educators need to align innovative teaching–learning technologies with the principles of focused person/family-centered care to prepare students more effectively to transition into diverse nursing roles and practice settings (Sanders & Stappers., 2008; World Health Organization, 2015). Nursing students must be prepared to reason like nurses, practice like nurses (Foronda et al., 2017), and manage the complexity of contemporary and essential nursing care (Benner et al., 2022). Considering the changing expectations of millennial students (Williams, 2019), this framework provides technologically advanced experiential learning opportunities in classroom, simulation, and clinical settings (Delaney et al., 2022). These elements are described as highly interactive holistic experiences attending to the intellectual, physical, and passionate components of learning through active participation (Benner et al., 2010).

Simulated experiences can contextualize learning experiences for students, as students have the opportunity to practice skills, apply theoretical principles, and develop clinical competences (Menard & Maas, 2019). Often, nursing students are faced with these new simulated or real practice scenarios and appear to have difficulties making the connection between what has been taught and what is being experienced (Schuler, 2021). Within the NEF, the value of simulation and the interest in generating innovative learning experiences to shape students’ future nursing identities are reinforced, as students are given an opportunity to integrate disciplinary knowledge in light of what is learned in the classroom (theoretical context), in simulations, and in practice settings. Utilizing multidimensional active learning methodologies with a combination of lectures, simulation, and clinical practices, the complexity of a real and sincere nurse-person/family relationship remains enhanced. Teaching innovation projects, such as the introduction of virtual reality for competency development or the implementation of objective structured clinical evaluation teaching in clinical simulation are deliberate actions that help to change teaching with the effect of contributing to students’ professional development (Tesouro & Puiggalí, 2015).

Curriculum: undergraduate and graduate programs

Curriculum design is a complex process that may include a variety of implementation approaches based on different categories (Annala et al., 2016). The NEF advocates for the integration of a humanistic relationship-based care approach to nursing education focusing on service, the preservation of life, and nursing leadership, for undergraduate and graduate programs.

Based on never-ending changes in science, healthcare systems, technology, and current models of curriculum design, curriculum revisions are periodically rigorously conducted following national, National Agency of Quality Evaluation (ANECA), and international, International Honor Society (SIGMA), nursing associations’ baseline agendas. The redesign and update of nursing curricula is continuous and needs to reflect the integration of newly generated knowledge, evolving human needs, and innovative learning methodologies consistent with the language proposed in the official standards of the institutions’ accrediting bodies, and the state boards of nursing (Giddens & Mullaney, 2023).

Although the acquisition of knowledge and skills is important to professional practice, nursing students are also required to develop attitudes, beliefs, and values that are central to the humanistic perspective of nursing (Brown, 2011). Incorporating the process of nursing knowledge development, use, translation, and evaluation through clinical judgment and clinical decision-making skills in all the constituent curricular elements helps to support a paradigm shift to a person/family-centered relationship–based nursing approach.

Research

Nursing research must be the foundation of comprehensive, evidence-based clinical practice (Lal, 2021), thus rendering it an essential component of the educational process (Tingen et al., 2009). The NEF advocates for not only introducing the research process into undergraduate and graduate nursing curricula but also making nursing research a tangible and more integrated experience for students, as an essential part of the evidence needed to identify problems, risks, and health motivations and guide interventions that promote nurse-sensitive outcomes. It is only with exposure and experience to research that students begin to understand the concept and importance of nursing research (Tingen et al., 2009). Creative strategies, including research fellowships and specific research programs, provide students opportunities to become more familiar with nursing research through involvement as team members working with educators, and to recognize the full scope of their future professional possibilities.

The NEF also provides opportunities for impactful and focused research that is committed to responding to current and pressing health challenges and anticipating future health challenges and priorities aligned with national and international associations, such as Joanna Briggs Institute and the National Institute of Nursing Research's (NINR) 2022–2026 strategic plan (National Institute of Nursing Research, 2022), mission, and guiding principles. The NEF offers guidance to foster a robust research agenda that contributes to knowledge development, use, translation, and evaluation, while supporting and nurturing the educational process.

Ultimately, the NEF research lens is one that is relationship-centered, that is based on a nursing person/family-centered conceptual approach, and that promotes service, the preservation of life, and leadership. Research and theory development focus on the person/family experience from a holistic and unitary perspective, while considering the dynamic and transformative nature of health-related lived experiences and the interconnectedness of human health with the multidimensional environment from a positive health approach.