Current Recommendations for Reform

in Education for Health Professionals

Seminario para profesores que instruyen
a estudiantes de doctorado
Universidad Catolica Santo Toribio de Mogrovejo
" Articulacin entre docencia e investigacin para el trabajo de
enfermera - Cmo hacer investigacin desde la docencia
Presented by:
Afaf I. Meleis, PhD, FAAN
Professor and Margaret Bond Simon Dean
School of Nursing
University of Pennsylvania

Chiclayo, Peru
October 24, 2012

THANK YOU FOR

INVITING ME

Greetings from
Pennsylvania

Greetings from
Philadelphia

University of Pennsylvania
Established in 1740

School of Nursing
Established in 1935

Plan for this Session

Identify key reports
Discuss the consensus report
Discuss recommendations from the
IOM Future of Nursing Report
Discuss the Lancet Transforming
Education for Health Profession report
Discuss action plan

Many Important Reports

IOM reports on Public Health Education

Focused on the future of global health in
21st century (2003 and 2002)

Tomorrows Doctors by the General

Medical Council of the UK (2009)

Revisiting Medical Education at a Time

of Expansion by the Macy Foundation
(2008)

Transformation of Education in
the Health Sciences

Carnegie Report on Medical Education

Educating Physicians: A Call for Reform of
Medical School and Residency
Molly Cooke, David M. Irby and Bridget C.
O'Brien (2010)

Carnegie Report on Nursing Education

Educating Nurses: A Call for Radical
Transformation
Patricia Benner, Molly Sutphen, Victoria
Leonard and Lisa Day (2009)

Doctoral Education for the Future

(Carnegie Reports)

Dr. George E. Walker

Principles
Progressive Development
Integrative Learning (research/teaching)
Collaborative Learning
Apprenticeship with several mentors
Creating and nurturing an intellectual
community

Shared purpose
Diverse and multigenerational
Flexible and forgiving
Respectful and generous
Meaningful dialogues
(Walker et al 2008)

PhD Education
Educate for highest levels of
competency and integrity
Educate for generation, conservation,
and transformation of a discipline
Understand that modern science must
confront epistemological issues of
knowledge and knowing
Interdisciplinary education is the
future
Educate for different roles

For our Discipline

3 Key Sets of Recommendations
Consensus

Report

The Future of Nursing: Leading Change,

Advancing Health (IOM/RWJ)
Health Professionals for a New Century:
Transforming Education to strengthen
health systems in an interdependent world
(Lancet)

Advanced Practice Registered

Nurse Regulatory Model

Developed by the National Council of State

Boards of Nursing Advanced Practice
Registered Nurse Committee and the
Consensus Work Group through the
Advanced Practice Registered Nurse Joint
Dialogue Group

Progress has been shared with boards of

nursing

Relationship Between Educational

Competencies, Licensure and
Certification
Measures of competencies

Competencies
Identified by Professional
Organizations
(e.g. oncology, palliative
care, CV)

Specialty Certification*

Specialty
Population Foci

CNP, CRNA, CNM, CNS

in Population context

APRN Core Courses:

Patho/phys,
Pharmacology,
Physical/health assess

Role

APRN

Licensure: based
on Education
And certification**

APRN Legislative
Language

Changes to Model Practice Act:

Prescriptive Authority
Independent Practice
Use of Dr. title
Recognition at role and population focus level
No temporary permit
Definition of APRN

Consensus Model
APRNs

will be regulated at role (CNP, CNS, CNM.

CRNA) and population focus (adult/gerontology,
across-the-life span) level.
The role and population focus level will be used for
APRN licensure purposes.
Specialty competencies (oncology, palliative care,
etc.,) can be obtained beyond the role and population
focus and will not be subject to the requirements for
licensure. Certification and other mechanisms can be
used to measure specialty competencies.

Consensus Model

For regulatory purposes, an individual must

graduate from an accredited program that
includes:
The 3 Ps (advanced health /physical
assessment, advanced physiology and
pathophysiology, advanced pharmacology)
Role Core (CNP, CNM, CNS, CRNA)
Population Foci Core

And have all 3 levels assessed by a

psychometrically sound and defensible
method. This can be done by national
certification.

GOAL

Development of
LACE (Licensure,
Accreditation,
Certification, and
Education) as an
integrated
educational and
regulatory
model.

APRN Regulatory Model

Licensure occurs at
Levels of Role &
Population Foci

APRN Specialties
Focus of Practice beyond role and population focus
Linked to health care needs Examples include but are not limited to:
Oncology, Older Adults,
Orthopedics, Nephrology, Palliative care
POPULATION FOCI
Family/Individual
Across lifespan

AdultGerontology

Womens Health/
Gender Related

Neonatal

Pediatrics

Psych/Mental
Health

APRN ROLES
Nurse
Anesthetist

Nurse
Midwife

Clinical Nurse
Specialist ++

Nurse
Practitioner +

+The certified nurse practitioner (CNP) is prepared with the acute care CNP competencies and/or the
primary care CNP competencies. At this point in time the acute care and primary care CNP delineation
applies only to the pediatric and adult-gerontology CNP population foci. Scope of practice of the primary
care or acute care CNP is not setting specific but is based on patient care needs. Program may
prepare individuals across both the primary care and acute care CNP competencies. If programs
prepare graduates across both sets of roles, the graduate must be prepared with the consensus-based
competencies for both roles and must successfully obtain certification in both the acute and the
primary care CNP roles. CNP certification in the acute care or primary care roles must match the
educational preparation for CNPs in these roles.

APRN Regulatory Model

Challenges and Opportunities

in our Discipline

Consensus Report

The

Future of Nursing:
Leading Change,
Advancing Health
(IOM/RWJ)

Health Professionals for a New Century:

Transforming Education to strengthen
health systems in an interdependent world
(Lancet)

The Future of Nursing

land
g
n
E

tes
a
t
dS
e
t
i
n

Institute of Medicine
and
he Robert Wood Johnson Foundation

Donna E. Shalala
Committee Chair
RWJF Initiative on
the Future of Nursing

Issues

Recommendations
1.
2.

3.
4.

5.

6.
7.

8.

Remove scopeofpractice barriers.

Expand opportunities for nurses to lead and diffuse
collaborative improvement efforts.
Implement nurse residency programs.
Increase the proportion of nurses with a
baccalaureate degree to 80% by 2020.
Double the number of nurses with a doctorate by
2020.
Ensure that nurses engage in lifelong learning.
Prepare and enable nurses to lead change to advance
health.
Build an infrastructure for the collection and analysis
of interprofessional healthcare workforce data.

Key Messages
1. Nurses should practice to the full extent of

their education and training.

2. Nurses should achieve higher levels of
education and training through an improved
education system that promotes seamless
academic progression.
3. Nurses should be full partners, with physicians
and other health care professionals, in
redesigning health care in the United States.
4. Effective workforce planning and policy making
require better data collection and in improved
information infrastructure.
(IOM, 2011. The Future of Nursing,)

Goal #1 Create a professional

workforce with the skills and
knowledge to meet the needs of
PA citizens for improved access,
high quality and value care

Outcomes
Increase the proportion of BSN prepared
nurses by 10% every two years to reach
80% by 2020.

Ensure that at least 10% of all BSN

graduates matriculate into a masters or
graduate nursing programs within 5
years of graduation.
Develop and Implement plans/models
for nurse residency programs.

Goal #2 Prepare and

enable nurses to lead
change to advance health
care in Pennsylvania

Outcomes
Development and implementation of performance
measures to reflect the contributions of nurses and care
team to ensure better-quality care.
Nursing education and other graduate programs
integrate leadership theory and business practices across
the curriculum, including clinical practice.
A compilation of research on models of care and
innovative solutions, including technology, that will enable
nurses to contribute to improved health and health care.
Public, private, and governmental health care decision
makers should include representation from nursing on
committees and boards, on executive mgmt. teams, and
in other key leadership positions.
Use clinical outcomes data to drive emulation and
transparency among healthcare organizations

Goal #3 Collect
workforce data that is
consistent across states

Outcomes
Develops baseline dataset

Develops a plan based on the

baseline data set

Data will be used to develop policy

and strategies

Goal #4 - Foster an
environment that provides
consumers with access to
high-quality care that meets
their needs for affordability

Outcomes
Recruit Additional
stakeholders
Participation of legislators, staff,
administration officers in state coalition
events, meetings, briefings
Build relationships with stakeholders for
ongoing collaboration toward better
regulatory environment

Data collected, synthesized, and

published
See the recommendations through to
enacted policy

Goal #5 Provide oversight for

Regional Action Coalitions

Outcomes
RACs develop strategic plans to meet IOM
recommendations on education, leadership, data
collection and residencies based on characteristics of
the region
Quarterly reports submitted to Steering Committee in
advance of Steering Committee meetings

Attainment of goals for each recommendation with

estimated time frames

Challenges and Opportunities

in our Discipline
Consensus Report
The Future of Nursing: Leading Change,
Advancing Health (IOM/RWJ)

Health

Professionals for a New

Century: Transforming
Education to strengthen
health systems in an
interdependent world (Lancet)

Health Professionals for a New Century:

Transforming Education to Strengthen Health
Systems
Co Chairs:in an Interdependent World
Julio Frenk, Dean, Harvard School of Public Health
Lincoln Chen, President, China Medical Board
Members:
Jordon Cohen, Professor of Medicine, George Washington
University Medical Center
Tim Evans, WHO Assistant Director-General
Patricia Garcia, Professor, Universidad Peruana Cayetano Heredia
Richard Horton, Editor-in-Chief, The Lancet
Patrick Kelley, Director, Boards on Global Health & African Science
Academy Development, IOM
Barry Kistnasamy, Executive Director, National Institute for
Occupational Health, South Africa
Afaf Meleis, Dean, University of Pennsylvania School of Nursing
Ke Yang, Executive Vice President, Peking University
Huda Zurayk, Director, Center for Research on Population and

Health, University of Beirut

The Commission

Advisory Inputs
Scientific advisors
Youth
commissioners
Papers
Consultations
Research

Commission
ers

Education of
Health
Professionals
for the 21st
Century
Global
Multiprofessional
Evidence-based
Instructioninstitution

34

Knowledge and Global Health

Revolution in the life-sciences

Genomics

Revolution in telecommunications
Expanding access to care in underserved
populations

Revolution in systems thinking

Comprehend and transform complexity

Revolution in knowledge management

Behavior modification of the people
Quality improvement from the providers
Enlightened
decisions
from policy makers
Rights
revolution
Turning abstract declarations into concrete
entitlements
Julio Frenk, 2009

Problems
Series of studies about education for
health professionals are about 100
years old
Contributions helped double life span
during the 20th century
Inequities exist in sharing advances
New health challenges emerged

environmental
new infections
behavioral and lifestyle risks

Health systems are struggling

Shortage in health professionals
Professional education does not
creating a crisis keep pace with challenges

Millennium Development
Goals
1.
2.
3.

4.
5.
6.

7.
8.

Eradicate extreme hunger and poverty

Achieve universal primary education
Promote gender equality and empower
women
Reduce child mortality
Improve maternal health
Combat HIV/AIDS, malaria, and other
diseases
Ensure environmental sustainability
Develop a global partnership for
development

MDG
10
year
s
later

Source:
UN Data

Status of MDGs
Disparities between rich and poor
countries make it difficult for poor
countries to achieve these goals.
Health goals are competing for money,
human capacity, and other resources.
Recommendation:

Implement an integrated funding approach

(Frenk, Quick, Pablos-Mendez, 2010)

Flexner, Welch-Rose, and Goldmark reports

40

Milestones
Flexner,

Welch-Rose, and
Goldmark Reports
100 years of Florence Nightingale
Health Care Reform
WHOs renewed focus on primary
healthcare (PHC)
Millennium Development Goals
(MDGs) Dialogues

Problems

Mismatch of competencies of
professionals to needs
Professionals work in silos
Poor team work
Gender stratification and divide
Narrow specialization
Episodic care rather than continuous care
Hospital orientation rather than
community orientation
Weak leadership

Tribalism of
Professions

Issues
Number of medical schools does not match
with the number of medical graduates
Number of medical and nursing-midwifery
graduates does not equal the number of
employed doctors, nurses and midwives.
Explanations:

Lack of available jobs in certain markets

Non-degree holders performing medical and
nursing-midwifery jobs
International migration

World Map Resized: Burden of Disease / Medical Schools

Professions: Two Sides

Darker

Brighter

Knowledge broker
Care-giver
Technology
Quality
Team leader

Advancing Health

Monopoly knowledge
Financial self-interests
Professional chauvinism
Over-specialization
Urban preference

Inequities in Health

Three Generations of Reform

2000+

Institutio Instructi
Institutio
Instructi
nal
onal
nal
onal

1900

46

Scientific
Scientific
Curriculum
Curriculum

University
University
Based
Based

ProblemProblemBased
Based
Learning
Learning

Academic
Academic
Centers
Centers

CompetencyCompetencyDriven
Driven
Local-Global
Local-Global
HealthHealthEducation
Education
Systems
Systems

Levels of Learning
Objectives

Outcomes

Informative

Information &
skills

Experts

Formative

Socialization &
values

Professionals

Transformative

Leadership
attributes

Change Agents

Competency-based education
Traditional Model
Curriculum

Educational
Objectives
Assessment

Competency-based Education Model

Health Needs
of Society

Competencies
Outcomes
Assessment

Curriculum

Seeds of innovation

Vision

Transforma
tive
Learning

Interdepend
ence in
Education

Health Equity
Individual
PatientCentered

Population
-Based

50

Systems Framework

Supply of health
workforce
Provision

Labor
market for
health
professional
s

Education
System

Provision

Health
System

Demand

Demand

Needs

Needs

Population
51

Demand for health

workforce

Challenges: 4 Cs

52

Recommendations
Reform
Instructional
Competency-driven

Action
Mobilize leadership

Local-Global
Inter + transprofessional
IT empowered
Educ resources

Enhance investments

New professionalism

Align accreditation

Institutional
Joint planning
Academic systems
Networking
Culture critical
inquiry
53

Fortify global
learning

Outcome
Professional
education for
health equity

Recommendations
Mobilize
Enhance
Align

Leadership

Investments

Accreditation

Fortify

Global Learning

Mobilize Leadership

Philanthropic leadership for financing.

Ministerial summits - to share perspectives

and promote stronger inter-sectoral coordination

National forums on professional education

- to share perspectives on instructional and
institutional reform

Academic summits - to engage university

leadership

Recommendations
Mobilize

Leadership

Enhance
Align

Investments

Accreditation

Fortify

Global Learning

Enhance Investments

Public financing - most important source

of sustainable funding in all countries, poor or
rich

Donor funding - for professional education

in developing countries

Private financing - is necessary because

public sources cannot meet all gaps

Recommendations
Mobilize
Enhance

Align
Fortify

Leadership
Investments

Accreditation

Global Learning

Align Accreditation

National accreditation
develop criteria for assessment
define metrics of output
shape the competencies of graduates

Global cooperation
be promoted by WHO, UNESCO, ICN, and others
set standards that can function as global public goods
assist countries in developing the capacity for local
adaptation and implementation
facilitate information exchange
promote shared responsibilities for accreditation

Recommendations
Mobilize
Enhance
Align

Leadership
Investments

Accreditation

Fortify

Global Learning

Fortify Global Learning

Metrics on professional education - define,

collect, assemble, analyze, and make widely
available

Evaluation - what has worked, what has not

worked, and why the knowledge foundation of
all enterprises

Research in professional education - expand so

that the field steadily builds the knowledge
required for continuous improvement

Recommendations
Reform
Instructional
Competency-driven

Action
Mobilize leadership

Local-Global
Inter + transprofessional
IT empowered
Educ resources

Enhance investments

New professionalism

Align accreditation

Institutional
Joint planning
Academic systems
Networking
Culture critical
inquiry
62

Fortify global
learning

Outcome
Professional
education for
health equity

Components Education System

Structure

Process

Institutional Design

Financing
Stewardship
Accreditation
Collaborations
Metrics

Instructional Design
Context
Global-Local

Criteria admission
Competencies
Channels
Career pathways

Outcomes

Interdependence
in Education

Transformative
Learning

An Action Plan
Areas of Innovations in Interprofessional
Education
Curricular Innovations
Pedagogic Innovations
Cultural Elements
Human Resources for Health
Metrics (IOM 2012)

DRIVING
FORCES

Outcomes

RESTRAINING
FORCES

POPULATIONS
Lack of Expertise

ORGANIZATIO
NS

Interprofessio
nal practice,
education,
research

Cultural Silos

STRUCTURES

Reimbursement

POLICY
(Young, Siegel, McCormick, Fulmer, et al, 2011)

Commission Report Outcomes:

Publications
Translations of the
Commission report
currently available in
Spanish, Vietnamese,
Chinese, German, and
Portuguese
Translations of the
Commission report
into French and
Arabic are currently in
the works.

Patricia J. Garcia, MD, MPH, PhD

Commission Report Outcomes:

Models of Implementation
Formation of Asian Network to catalyze
reform
Launch of Chinas own commission for
reform
Making of incremental changes in
competency-based curriculum and
experimental leaning in Thailand
Implementation of major changes
recommended by the Commissions report
forthcoming in Thailand

IOM Global Forum on Innovation

in Health Education
Purpose: to take the strategic level ideas
of the Commission Report and foster further
development for actual implementation
Membership: includes disciplines from
government, academia, foundations,
industry, and professional associations
Activities: several meetings per year to
sponsor state of the art workshops on
innovations in health professional education

Innovations

Passio
Passio
n
n

c
i
o
V
a
e
v
a
H
To
a
s
e
k
a
M
t
a
h
T
,
e
c
n
e
r
Diffe
a
e
t
a
v
i
t
l
u
C
t
s
l
a
i
c
We Mu
o
S
e
h
t
r
o
f
n
o
i
s
s
a
P
e
h
t
f
o
n
o
i
s
s
i
M
d
n
a
s
n
o
i
s
s
e
f
Pro
s
t
n
e
d
u
t
S
r
e
w
Empo
t
I
e
s
U
to

Commission Report Outcomes:

Publications

Lancet Editorial
(Social Accountability in Health Professionals Training; L.S. Wen,
S. R. Greysen, D. Keszthelyi, J. Bracero, P.D. G deRoos)

Five steps to better align training with societal

needs
1. Establish an explicit social mission.
2. Integrate community learning and service into the
curriculum.
3. Emphasize the importance of primary care.
4. Establish a service option in exchange for free
medical education.
5. Engage young doctors in social accountability
throughout medical training.
(www.thelancet.com, published online April 7, 2011)

COLLABORATION
PARTNERSHIP

TEAMWORK

At the crux of
creating safe
and quality
healthcare are
teams,
partnerships,
and
collaborations

Nurses + empowerment + leadership =

higher patient safety, quality and outcomes

What is Needed:
Collective concern
for global healthcare
and role of nurses in
providing
quality
care

We Nee
d to Pre
pare
a Gene
ration o
f
Gradua
tes
Wh o W
i l l H av e
a Voice
an d W h
o Use T
heir Vo
to Make
i
ce
a Differ
ence
in the W
ell-bein
g of
Populat
ions

LETS FORGE A FUTURE OF

COLLABORATION
PARTNERSHIP
INTERPROFESSIONAL
TRANSFORMATION and
EQUITABLE HEALTHCARE
GLOBALLY!

Gracias