A nursing conundrum

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Barbara Medoff-Cooper ’70, Ruth M. Colket Professor in Pediatric Nursing and Director of the Center for Biobehavioral Research at Penn

In the early days of her nursing career, while making hospital rounds on newborns, Barbara Medoff-Cooper ’70 encountered a health care challenge that both troubled and intrigued her.

“We were saving smaller and smaller babies—less than 1,000 grams [2.2 lbs.] in some cases—but there was so much we didn’t know about them,” she recalled. “We didn’t know how to deal with them or what to tell parents about raising them. We had no idea how they would develop or what to expect in terms of behavior.”

It was a conundrum that inspired a calling. Today, Medoff-Cooper is an internationally recognized expert on infant health issues ranging from neonatal brain development, to feeding behaviors in high-risk babies, to infant temperament at the University of Pennsylvania and the Children’s Hospital of Philadelphia, where she is the Ruth M. Colket Professor in Pediatric Nursing.

What is striking about her research—and unique to nursing among the scientific disciplines—is its multifaceted approach to problems that takes into account scientific factors, human behavior, and health status. Medoff-Cooper, who is director of the Penn nursing school’s Center for Biobehavioral Research, recently led a multidisciplinary team that studied feeding behaviors and energy expenditure in infants with complex congenital heart defects.

“There was a cardiologist, a psychologist, a nutritionist, a gastroenterologist and an anthropologist—a broadly integrated team—with me, as the nurse, leading it,” she noted.

Medoff-Cooper’s career illustrates the centrality of nursing research both in exploring complex health care problems, and in helping patients and families resolve them.

“From sleep apnea, to health outcomes in hospitals, to survivors of brain tumors—you name a clinical problem and we have researchers working on it, but always through the lens of a nurse,” she says. “We also look at psychological and behavioral aspects of problems. We determine what we can do to help the family improve outcomes. We take a holistic approach to the problem.”

However, while nurses assume an ever-larger role in the country’s health care system, there is mounting concern over the sector’s capacity to educate the growing number of nurses needed to meet the demands in academic and health care practice settings.

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Marcia Blicharz, Chair of TCNJ’s School of Nursing

Applications to nursing schools are on the rise, but the number of faculty teaching new students in both classrooms and clinical settings has remained roughly static, and faces a sharp drop-off with a coming wave of retirements.

In New Jersey, for example, the average age of an associate professor of nursing is 55, and more than half of nursing schools in the state say they are forced to limit enrollment because they lack sufficient faculty. At The College of New Jersey, the number of nursing students has risen steadily in recent years, doubling since the 1990s.

“We had 800-plus applications this year and are enrolling a class of 75,” said Marcia Blicharz, chair of the nursing department, who taught her first class at the College in 1975. “It’s a real problem. We don’t have enough faculty. We just did a search for the second year in a row and didn’t find a candidate. Faculty need to have a doctorate and research agenda to be eligible for a tenure-track position here.”

But while TCNJ is not insulated from the problem, its faculty, alumni, and students are playing key roles in solving it.

Susan Bakewell-Sachs, the Carol Kuser Loser Dean of TCNJ’s School of Nursing, Health, and Exercise Science, is directing an ambitious statewide project that seeks to address the shortage by recruiting faculty to New Jersey schools, providing financial support for students earning graduate degrees, and developing curricula to educate new faculty, among other measures.

The New Jersey Nursing Initiative (NJNI), launched last year by the Robert Wood Johnson Foundation and the New Jersey Chamber of Commerce Foundation, aims to keep the state healthy and productive by ensuring that residents have the skilled professional nursing care they will need, including the preventive care, in the decades to come. So far, 29 faculty preparation scholars have been enrolled in PhD and master’s degree programs at nine schools, and a second cohort of 17 master’s candidates will be enrolled during the coming academic year through NJNI, said Bakewell-Sachs.

Andrew Fruhschien ’08 is among the up-and-coming teachers to receive a scholarship from NJNI to attend graduate school. When he earns a master’s degree from Fairleigh Dickinson University next summer, Fruhschien, who is interested in teaching, clinical practice, and health care policy, will be licensed as a nurse practitioner in adult primary care, with a concentration in nursing education.

He expects to start by teaching clinical classes to students planning to work in hospitals or by overseeing a high-fidelity simulation lab, where he will use computer-operated mannequins to guide students’ responses to complex, evolving health scenarios such as heart attacks or sharp drops in blood pressure. (Click here to read more about Fruhschien’s experiences.)

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Susan Bakewell-Sachs, Carol Kuser Loser Dean of TCNJ's School of Nursing, Health, and Exercise Science

About 80 percent of TCNJ’s nursing school graduates say they plan to pursue master’s degrees, Bakewell-Sachs noted, adding that the demand for highly educated nurses extends well beyond academia and is driven by the growing complexity of practice. Vast differences among patient populations, complications arising from the proliferation in medications, and the fact that “patients are often much sicker when they come into hospitals,” as she put it, are among the factors.

“There is also an enormous amount of technology that nurses have to understand and use,” she added. “More than ever, nurses are knowledge professionals and the connection to education is essential.”
An example, Blicharz noted, is the growing use of simulation as a teaching strategy.

“Students need to think critically and make clinical reasoning decisions in a changing situation. We have been actively developing the use of scenarios for about the last five years,” she said, but added, “There are not enough faculty to develop scenarios; it is a very time-consuming project that requires experience and expertise.”

Nurses are also playing an ever-larger role in the delivery of care as well.

“It’s pretty clear that with the new health care bill there will be more access to health care, and not a lot of physicians are going into primary care,” Medoff-Cooper noted. “This is an area in which studies show that nurse practitioners do just as well as doctors—and their education is cheaper.”

Theresa Valiga ’70 has spent the last several decades preparing nurses to assume leadership roles, particularly in the academic arena.

As the director of the Institute for Educational Excellence at Duke University, she oversees a comprehensive initiative to develop innovative nursing curricula, help faculty develop the knowledge and skills they need to be excellent teachers, and prepare nurses to play leadership roles in academia and throughout the health care system.

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Theresa Valiga ’70, Clinical Professor and Director of the Institute for Educational Excellence at Duke University

“There is a growing recognition of the uniqueness of what nurses bring to the health care team. The team, if not led by the patient, should often be led by the nurse, whose holistic perspective takes into account the patient’s emotional and social, as well as physical needs,” said Valiga, who was recruited by Duke in 2008 to create and direct the institute. Her book, The New Leadership Challenge: Creating the Future of Nursing In Education, challenges nurses to take on the mantle of leadership—even if they are not in positions of authority—and guides them in doing it.

“If you wait for people in positions of authority to say what needs to be done, you become a cog in the wheel. You need to take risks, challenges—and responsibility—for quality of patient care and for better collaboration among nurses and doctors, because people’s lives are at risk,” she said, adding that it is particularly important now for nurses to assume leadership roles.

“Things are changing so quickly around us. It would be easy to just sit back and wait for others to orchestrate new roles and responsibilities for nurses. But we’re at the frontlines of health care and need to step up to the plate, expressing our vision for a better world and working to turn that vision into a reality,” she noted.

“Nurses must also play an active part in research, not just in designing and carrying out studies, but in raising questions, from the patients’ bedsides, about what we know and don’t know about clinical care.”

Within the sphere of nursing education, Valiga said she believes it is important to teach nurses to question current practices, particularly as the complexity of care and demands for nurses’ expertise increase.

“We have to get away from the focus on covering content and really focus on how to learn and where to find answers, on thinking skills and how to get information rather than on memorizing factoids,” she said. “We may require 100 hours of clinical practice in a given area, but we do not really know if 50, or even 30, hours would be sufficient to meet learning needs? And boards of nursing often regulate curriculum requirements, numbers of clinical hours, or the percentage of clinical time that can be ‘replaced’ by simulation, but none of these standards have any basis in evidence. They are based on tradition and gut feelings, and they tend not to be challenged. We need leaders who are willing to raise these kinds of difficult questions.”

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Veronica Garces ’11, Nursing student, 2009 recipient of the Helene Fuld Health Trust Scholarship

Valiga noted that nursing professors are preparing diverse student populations to work in settings that did not even exist 20 years ago in some cases, adding, “the potential for where nurses practice is unlimited.”

Tiffany Dovydaitis ’04, a PhD student at the University of Pennsylvania, represents the scope of possibilities.

“I want to work in an interdisciplinary setting, where I bring nursing to the table as an expertise, including my ability to work with physicians, social scientists, and advocacy groups,” says Dovydaitis, whose research focuses on health challenges faced by immigrant workers. (Click here to read more about Dovydaitis’s experiences.)

Veronica Garces ’11, said she, too, is eager to embrace a multi-faceted nursing career.

“When I thought about the future, I wanted to do so many things. I was interested in nursing, but also in teaching. And then one of my professors suggested I come back and teach, and I realized I could do both,” she said.
Garces is interested in pediatrics and oncology, and expects to spend the next several years juggling school and work. It will be difficult, she notes, “but not impossible.”

“I want to get involved in my area of practice first, work in a hospital for a year or two, and then go back to school for my master’s degree. I want to keep going to school, but also work at the same time. The nursing faculty here have a strong clinical background that supports what they teach. They can easily recall clinical situations, and I want to be able to do that as well.”

“I see myself as a lecturer, but also as a clinical professor. If I can come back here I will,” Garces said. “I want to be a support for other nursing students.”

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