Talking with Nursing Professor Pamela Jeffries

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Interviewer: Let’s step back in time. How did you know you were interested in health care or nursing?

Pam: I remember being a senior in high school thinking to myself that everybody was making their career choices and I didn’t know what I wanted to do. Back in the ’70s, quite truthfully, women were becoming teachers, nurses, or secretaries. Of course, I wasn’t limited to those choices, but those were the choices I thought I had. At the same time, I had a friend whose father had been in the hospital, and I had been in the hospital with her a lot, visiting her father. I loved the environment at the hospital. I loved the caring, passionate nurses that I saw taking care of her father. I knew I wanted to be around people. I loved the hospital environment and that led me to the profession. I had no nurses in my family. I wasn’t raised in a health care background, but I did know I wanted to care, to be service-oriented, and be around people.

Interviewer: Was the nursing profession and working in health care all sort of new to you?

Pam: Not having a history in health care or seeing a parent as a nurse made the experience totally new. I think that helps me be understanding of students. I can put myself in students’ shoes and look at it from their perspective. I’m a student advocate as well as a faculty advocate; I can see both angles, if you will, because I’ve experienced both. I recall, vividly, some of those moments at the beginning I went through and how I was struck by my lack of knowledge and what I had to learn. I remember the caring of my instructors, and I want to replicate that.

Interviewer: You pioneered a whole new model of nursing education. I’d like to know how it is you’ve been so innovative in your career.

Pam: What initiated my ideas had probably been there all along. I’m part right brain, part left brain, but I’ve always been interested in learning and how to help students learn better. I’ve been an educator for over 30 years. When I started, instead of doing the same old teaching strategies, such as “sage on the stage” and teacher-centered learning models, I always wanted to try something different. I wanted the students to be engaged and interactive, so early on I started doing creative activities. What I learned from this is you have to get the evidence. You need to ask yourself, “Is it working or not?” because you don’t want to harm students. I was always looking at the latest literature, reading books on creativity, figuring out what I could do differently to engage students. Even as a child I was always making my own jewelry or creating, so I always had that creative ability.

Interviewer: Were you frustrated when you were going through school with the way you were being taught?

Pam: A bit. When I went for my doctoral studies the learning model was very passive in terms of the learner. I’d sit around a table and we would talk, or I would sit in the lecture and listen to the instructor. I’m a very visual person, and I’m also kinesthetic. Therefore, I wanted hands-on activities because I like to learn in those ways. So, yes, I did feel some frustration.

Interviewer: Nursing has not traditionally had a strong emphasis on science. It’s been a very service-oriented profession. Somewhere in the past 10 to 15 years that’s started to change, and your work has been really important for that change. I’m trying to get a sense of the intellectual climate that led you to think about how to create a different way, even from an early age.

Pam: If you look at the history of nursing, it started out very much hospital-based, and we had a lot of diploma nurses. Then it moved to a university level, to higher education, and that’s where it needs to be. Nurses must have a background in sciences and must appreciate and understand it, whether it’s the anatomy, the physiology, or the pathophysiology. The science of nursing education is really built upon these sciences as well as other humanities that we bring in. There are a lot of prerequisites in our program, and we use this knowledge and these skills to intervene, implement, and care for our patients.

It is often said that “it’s just a caring profession,” but you’ve got to be quite clever, you’ve got to apply the sciences. Go over to Johns Hopkins Hospital, go on the unit and watch a nurse in intensive care or on a medical/surgical floor or in a pediatric unit. Quick assessments are needed. Decisions are made all the time. Nurses are at the bedside 24/7 with patients. We have to work collaboratively, of course, with the health care team, but we’re a primary player.

Interviewer: As you were going through your training did you start seeing deficits in the way nursing education was being carried out?

Pam: At the doctoral level everybody was looking at clinical science and bench scientists, but I think we lost the science of nursing education. Fortunately, in the 1980s I took some courses on how to teach and how to develop a curriculum, which all turned out to be necessary. You’ve got to have the proper curriculum and the proper roots as the foundation for our students, as well as excellent teachers. You need educators who are able to disseminate the knowledge and teach skills. We’re doing a better job now. The science of nursing education has risen, particularly with the Institute of Medicine report that’s come out and the Robert Wood Johnson Foundation Future of Nursing Education report that came out just this last year. It is revolutionizing nursing education, and I think it’s making it more prominent, putting it more in the forefront.

We need to do a better job of teaching our nurses because we do have evidence that when nurses graduate—and this is not just here at Hopkins, this is nationally—many times our nursing graduates are not meeting the needs of our clinical facilities as reported by national leaders in nursing, whether it’s community-based or acute care. We’ve heard for years and years that we need to produce better graduates. The question is, What does a qualified, skilled graduate look like? We need to align better with our practice partners. That’s where leaders need to come to the table. Where are the gaps? Let’s identify the gaps. What can we do in education to improve that transition to practice? Into this come a couple of innovations that we’ve made at the School of Nursing, such as clinical simulations. Then there’s the inter-professional work—working as a team, developing health professionals who work in teams with the physicians so that we don’t take care of the patient in a silo.

Interviewer: Tell me more about these innovations.

Pam: Clinical simulations have been around for a long time. If you look at the world of aviation, for example, pilots practice on simulators, thank goodness, before we get in an airplane. They simulate the bad weather and all these complications that they have to endure in flying. We’re doing the same thing. There’s an explosion, actually, of clinical simulations within not only nursing but across the health care profession. In education, how can we develop safe, nonthreatening care environments to practice in, to teach in, before we actually get in the real environment where they’re taking care of human beings? This can be extremely problematic if it’s the first time they’re intubating a patient or doing similar procedures. Simulation centers are being built worldwide. They can be interdisciplinary, but many times they’re just in the School of Nursing or just in the School of Medicine. Here at Hopkins we do have our School of Nursing Sim Center and there’s a Medical Sim Center, but now we’re looking at being an inter-professional sim center.

What I love about the concept of clinical simulations is that we can now set this environment and standardize some of the education. We can develop the scenario where we immerse students for 15 or 20 minutes in care of, say, a myocardial infarction patient. With that, the students go in and they play the role within their scope of practice. We have a student playing the role of an RN; another student may be an orientee working with that RN. We have a student maybe playing a family member and another observing the encounter. Within that scenario, the student has to assess the patient having chest pain, they have to assess the chest pain, manage the pain, and have clinical reasoning skills. In 15 or 20 minutes, we can see this because the educators are watching through a one-way mirror or watching on remote video. We can see how that nurse is thinking on his or her feet, how they’re caring for that patient, how they’re assessing. Do they have the acute knowledge, skills, and attitudes that we want? After the simulation event for 20 minutes, then we debrief. The instructor is there in the debriefing with the students. It’s in an advocacy/inquiry encounter. It’s not threatening. It is not, “Why didn’t you do that? Why didn’t you do this?” but rather, “Help me understand why you prioritized in this manner.” Students let you know why they did what they did, and as an instructor, I am listening. Their answers, their framing, their perception help inform my practice as an educator. If there are gaps in the curriculum, I need to redo, I need to fix those gaps.

We are immersing the students in their scope of practice in a safe environment. We’re letting them think spontaneously in acute settings. Or it can be a community setting; you can really develop any type of setting. We’re actually giving the students opportunities to solve problems and make decisions in this environment, and then we transition them to practice. In a simulation environment, students have the opportunity to put everything together. They have real clinical time, but they’ve practiced; we’ve given them opportunities. In the real clinical setting students have to behave as students. There are many skills they can’t do because hospitals have regulations. Many times students can’t use a glucometer to get a blood glucose, so we have to bring that back to the education sector. And clinical sites are becoming scarce. We all vie, within the state of Maryland, within the city of Baltimore, for appropriate, quality clinical sites. That’s the purpose of simulation, to carry that one step further with the interdisciplinary work. At a national level there’s a movement from the Institute of Medicine that came out with various competencies, one being Inter-professional Education. We in the health professions need to start learning and working together.

If you look just 10 years ago, nursing schools many times would graduate nurses where they wouldn’t even be talking to a physician until the first time on the job, after they graduated. If you look at a traditional clinical model, if a student needs assistance with a patient, they need to first go to their instructor, then they go to their primary care nurse and then, if time warrants, maybe they can call the physician. There may be a rule that they can’t call the physician. In simulations, we’re building handoffs so the physician and nurse communicate with each other. We’re building those scenarios where there’s actually teamwork based around all these inter-professional education competencies that include teamwork, communication, values and ethics, and roles and responsibilities. That’s so crucial to our work today in providing a quality, safe patient care environment.

Interviewer: When you were trying to increase national awareness for the use of these emerging methods, did you feel like there was resistance from the existing establishment?

Pam: There still is resistance; anytime you have change—within the health care profession or any profession—yes, you’re going to have your early adopters, your late adopters, and then just the naysayers.

Emerging technologies are so important with this generation of learners. They’re already coming in with advanced technology skills, but when you look, the average age of associate professors within nursing is 54 years old. We’ve got an older teaching workforce, and many of them didn’t grow up with technology. It’s a skill set they’re learning on the job. Our learners are coming in with more technology knowledge skills than we have. There are ways to remedy that, of course, through faculty training and development. Yet there is much resistance.

I like to define simulation as an activity or event that replicates the clinical environment. When we replicate that, we want to replicate it in a realistic manner so we really are giving the students the optimal opportunity to practice. And it is also an opportunity to practice using the technology of the clinical information systems such as Eclipse, or EPIC, the system we’re moving to over at the hospital. We as nurse educators have to incorporate all this technology that the students are going to experience during their clinical rotation in the school now and when they graduate. We always have to be mindful that the practice is ever changing—it’s always dynamic, never static. We have to keep up.

Interviewer: I trained in surgery. I remember when I was a surgical intern literally for the first month or two, I was thinking to myself, “Wow. I just never learned any of this in school. There must be a better way.” What do you think separates good use of these methods from poor usage?

Pam: A simulation is not just a simulation. If you look across the United States, there are no standards in how you develop a simulation and implement it with students. We do have a simulation framework from a national organization that we follow. We designed features that are evidence-based. They are continually being studied. We’re also evaluating the competency of the debriefing because the simulations follow with a debriefing. So we’re trying to maintain the standard and ensure the integrity. But at many schools of nursing across the nation, the faculty haven’t had the training. They’re picking it up from a conference or they’re reading a book or an article. If you want to draw the line between good performance and bad performance, faculty development is crucial.

There are some state boards of nursing that are establishing guidelines saying, “If you are going to incorporate simulation in your curriculum, you have to meet the standards of our regulatory boards and accreditors.” Some boards believe that, yes, you need to include faculty development and debriefing when you embark on simulations. Some states across the United States are saying that you can only substitute 25 percent of clinical time in simulation. They’ve drawn that line, that arbitrary line, without evidence.

That’s why the current National Council of State Boards of Nursing study that’s under way is very important. We don’t have the evidence on the dosing: how much simulation is optimal? We also want to make sure simulation quality and standardization are there. We’ve surveyed educators across the nation. If you’re a pediatric instructor, you know the 20 most essential behaviors you want students to demonstrate within your pediatric course. We developed simulations or bought commercially made ones for the simulation curriculum for the National Council study. I’ve been consulting on that study, which is why I’m talking about it. They’re very enthusiastic, and Hopkins does happen to be one of those programs being studied.

Interviewer: Are you seeing differences right away in the maturity level or the comfort level of your graduates? Are they able to go out and work effectively?

Pam: The students here at Hopkins are just wonderful. They’re bright. They’re inquisitive. They want to learn and they want to learn more. They want to continue to go to that higher level. We admit many of our students on a track from bachelor’s to master’s. They’re just on that trajectory. And then we have a B.S. to Ph.D., a bachelor’s to doctorate, track.

Now are we producing better students, different students? That’s evidence we need to get. I’ll tell you at the School of Nursing we have just embarked on a three-year study through the National Council of State Boards of Nursing beginning just a few months ago. We are looking at the amount of dose of simulation. How much simulation time can we substitute for real clinical time? And are we producing better graduates when we standardize some of those clinical situations, those learning opportunities? In addition, are they better prepared using simulations before we ever get them to clinical practice? In the study, we’ve randomized the students into three groups. One is a control. One is getting a 25 percent substitution of simulation time for real clinical time, and the third group is at 50 percent. At the end of two years—four semesters—we will look at that high-dosing group. We’re measuring clinical competency, knowledge, skills, and other outcome measures. What we need to know is, Does it make a difference in our graduates when you’re substituting X amount of simulation across the seven core clinical courses? Truthfully, we don’t have that evidence yet. Right now, schools of nursing across the nation have different doses. Some have simulations in three courses, some have it across two semesters—it’s very fragmented. I applaud the National Council of State Boards of Nursing because they have put up millions of dollars in funding for this national multi-site study across 10 schools.

Johns Hopkins happens to be fortunate. We’re one of those schools selected to look at the dosing, to look at the outcome, specifically to look at clinical competency. Can nurses translate that competency into better practice? Are we going to prepare better graduates ready to embark on practice? During the third year of the study, we will look at cohorts of students from 10 different schools that are in the study and look at their transition. Was their orientation time diminished? Is their clinical competency more retained and sustained? Are they more efficient at three months, six months, nine months out? So we’re going to track that over the year.

Interviewer: Tell me a little bit about what brought you to Hopkins.

Pam: I will be at Hopkins three years in February, and I’ve enjoyed every moment and every opportunity that Hopkins has made for me. I cannot stress that enough. It’s afforded me great opportunities and possibilities since I’ve arrived. I was recruited here as an associate dean for academic affairs. That’s my current role, and I’ve enjoyed the change, the transition. I came from a large state school in the Midwest. The students are eager to learn. They’ve studied nursing—not formally, but when they come in, they’re very goal-directed. They know what they want. Even those students going from bachelor’s to master’s, they know if they want the nurse practitioner role or the clinical nurse specialist. They’re like sponges. They’ve soaked up all this information. They know what trajectory they want to be on.

Being close to Washington, D.C., has made a difference too. It’s easy to go be involved with different organizations because we are located near so many of them and their leaders. I’ve enjoyed that. And I’ve enjoyed working with Dean Martha Hill and the opportunities I’ve had within the school. We’re looking at innovation and how we can be leaders in this. For example, at the master’s level, we now have two programs that we’ve put entirely online. Now students have this opportunity and no longer have to be face to face. It provides the educational mobility that we need for today’s learners, particularly at the graduate level. I can speak for nurses; they’re trying to balance family life, they’re trying to work full time, and then squeeze that little educational piece in. Many of these students couldn’t obtain their master’s without that.

Interviewer: You mentioned taking a leadership role in order to be innovative. How do you see that happening or unfolding over the next five to 10 years?

Pam: Now is a wonderful time to be in nursing education—it is being revolutionized. We can be leaders in this here at Hopkins and nationally because we’re looking at new models for education. We have been conducting nursing education probably the same way for 40 or 50 years, and we already have the evidence that we’re not producing, nationally, the graduates that we need. So in come different models. The clinical simulations are just one redesign being tested through the National Council of State Boards of Nursing. We need to look at other innovations in preparing our students. What other ways are there?

We also have new programs. We have a new degree called the Doctor of Nursing Practice, the D.N.P. We started that at Hopkins in 2007. If you look at doctoral nursing practice education across the United States, it varies all over. It’s hard to find one model, one excellent model. We are continually striving to improve the rigor of our graduates. What does that look like? I’ve been working with Dr. Mary Terharr, our program director. She and the faculty are making great strides establishing the D.N.P. role. What are the opportunities and what’s the scope of practice? What are we delivering with the D.N.P. once they graduate?

Interviewer: Have there been obstacles or things you feel Hopkins could do better?

Pam: I know where I came from—again from a state system from the Midwest—many, many activities and services were centralized. I come to Hopkins and suddenly lots of it is decentralized. A lot of people work in silos. There are nine degree-granting divisions, nine different ways. I know that since President Daniels has come in, he’s looking to be more effective and efficient in providing some centralization, or promoting some efforts in that direction. That would be helpful. I’ve been at the table talking about how we can work collaboratively as a group. We don’t need to replicate different teaching centers nine different ways. We should have one center for teaching excellence where we prepare better educators, where there is some faculty development, and where teaching is visible and recognized, and there’s an award system for teaching excellence made at the central level, not at nine different divisions. That’s one area that needs improvement, but I see forward movement in it. And as we move into interprofessional education, with the health care disciplines coming together to teach and facilitate our students, this notion of collaborative teaching and learning is very important.

Interviewer: There’s sort of a tension in all health care between being conservative and being innovative. There’s a standard of care that gets established, and it takes a long time for that standard to be improved upon or changed. How would you encourage students to think that innovation is a feasible reality in their lives and careers?

Pam: I believe that in nursing you can be innovative and creative—whether it’s within the education sector, or in teaching students and bringing the classroom alive, or in the laboratory. Nurse educators can be innovative and creative. There are all sorts of creative ways that we can work with our patients. Many times, we have to bring that element of creativity in working with some clients and families because so often it’s quite complex. For example, many families are somewhat dysfunctional in terms of compliance issues. Is there a tracking device that we can send home, either through the Internet or a mobile device? Can we bring innovations not only to track but to care for our patients better, so that we can be alerted about health promotion and prevention issues instead of waiting for that patient to come into the hospital through the emergency room? Maybe their blood sugar is really way too high, and we could have known it earlier if only we knew their signs and symptoms better.

Nursing is an avenue where students and working RNs can be innovative and creative in many, many ways, whether it’s through education, service, or on the unit, or even in the area of leadership and managing your team and getting people on board around teamwork. With the whole inter-professional education movement, this is not just training better nursing students, medical students, social workers, and pharmacists; getting them all together to work as teams is important. You’ve got your practicing nurses, practicing physicians, residents. What’s the innovation out there that managers can do? If there’s a unit problem—say there’s difficulty in the OB unit with near-misses and errors occurring—a lot of times if you look at the root cause analysis, it’s about communication across disciplines. Can we be creative and set up simulations, even at the unit level, where people need to learn together? Then look at outcomes pre- and post-the innovation. Are we making a difference with it, or not? There are all kinds of opportunities to be creative, innovative. We’ve got students who come in for a second degree, and many times they’ve been in technology, they’re from computer science. They’ve got all this technology background. Look at the programs they could innovate—whether it’s learning about how to read an ECG to do an arrhythmia analysis, to a program on patient teaching, to learning about the ventricular device that was implanted—there are all kinds of possibilities to be creative and innovative in our profession. I hope students do know that. If not, we need to make that more apparent.

Interviewer: I think you have to be optimistic to have a vision like that.

Pam: I’ve never regretted my decision to be a nurse, and that decision took place over 34 years ago. It’s a wonderful opportunity to be involved with patient care, with families, in counseling and teaching and traveling, and just being a nurse educator. We actually have a shortage, now, of nurse educators. Many are getting older, and many of the young nursing graduates aren’t coming into our profession. I did bedside care, I worked in critical care. I love that side of the world in nursing. Then when I came into the education side, I found that it’s very rewarding as well. Working with students, working with faculty, I guess I just would advocate that our profession in nursing is a wonderful career trajectory. In addition, the teaching side, being the faculty, there are so many opportunities, and many times I think we as educators don’t make that visible. We’re always in a hurry, we’re very busy. I think we just need to take time and work with some of our younger graduates, our nurses, and talk more about what we do and the opportunities and rewards that our profession does bring us. Not just at the bedside or in critical care, or at the nurse practitioner level, but at the education level. It’s just something I’m very proud to be—proud to be at Johns Hopkins University as a nurse educator leader and an associate dean at the School of Nursing. I love what I do. In fact, I remember when I first started teaching; I even forgot to pick up my paycheck. It just doesn’t even seem like a job, many times, just because it’s your passion. It’s what drives you. Many times people say, “Wow, you’re working so hard.” It’s not work to me. It’s pleasure, and I love giving back. I love to empower faculty and see where they grow. I love to see students grow. It’s very, very rewarding.

Interviewer: Fantastic. Thank you so much.