Harmonizing Nursing Education: Theory and Practice

Marjorie E. Parks
Laura Tucker Longsworth
Isidora Espadas

Nurses are an integral part of a country’s national development since they constitute the greatest part of any healthcare delivery system that helps to maintain productive human capital. They provide healthcare services for families across the life cycle, culminating with the last developmental stage of death. Primary, secondary and tertiary healthcare services are delivered by nurses who must be scientifically and clinically prepared to address the health needs of the community. The education of an adequate cadre of nurses should be of national importance because inadequate numbers of registered nurses lead to higher morbidity and mortality rates. Aiken, Clarke, Sloane, Sochalski, & Silber (2002) concluded that “in hospitals with high patient- to-nurse ratios, surgical patients experience higher risk-adjusted 3-day mortality rates and failure -to-rescue rates and that nurses are more likely to experience burnout and job dissatisfaction” (p.1987). The minimum standard of 18 nurses per 10,000 population is required to ensure that 80% of all childbirths are attended by a professional nurse (PAHO/WHO, 2007). Belize is below acceptable standards with 15 nurses per 10,000, which should signal to all sectors that educating well prepared nurses is a matter of high priority for inclusion in national development strategies.

Nursing education has a major role to play in the development of graduates who can deliver high quality of nursing care, and to do so in a manner that harmonizes theory and practice. However, the gap between theory and practice continues to be a prevailing problem in nursing and midwifery. In addition to having to be adequately prepared for their future professional role, nursing students have to seamlessly fit into the nursing workforce. Despite much discussion and several efforts to implement various integration strategies, newly graduated nurses often confront an array of physical, technical, and mental challenges in bridging the academic and clinical divide. Bridging the gap between theory and practice has implications for recruitment of students into the nursing program, as well as retention of newly educated nurses. Reflectively, it is time for the nursing community and the University of Belize to utilize innovative strategies to expand and meet human resources in health requirements. A unified approach must be pursued to address existing challenges.

The purpose of this paper is to examine the issues and challenges related to student nurses’ professional development, focusing on mechanisms to bridge the gap between theory and practice in general, and specifically in the University of Belize’s Professional Nursing Education Program. Academic issues, including recruitment and selection of students, attrition and completion, and retention will be discussed; as well as methods used to facilitate students acquisition of technical, clinical skills. Practice issues that will be explored include quality of care issues, and bridging mechanisms including orientation, preceptoring, coaching, and mentoring.

Theoretical Framework

Today, nurses are confronted by new challenges within the health reform mandate to provide equitable, effective, affordable, and quality healthcare services. The health care environment is constantly changing and challenges abound to use computerized information systems, deliver evidence based nursing care, and participate in quality improvement initiatives. There are certain characteristics which define how nurses perceive, comprehend and interpret health situations. Four perspectives are integrated into the curricula for nursing education: (a) the nature of nursing science as a human science; (b) practice aspects of nursing; (c) caring relationships that nurses and patients develop; (d) and a health and wellness perspective (Melies, 1997). A common complaint from nurses in clinical settings and the general public is that nurses seem to lack what is considered the essence of nursing — that of human caring. Cook & Cullen (2003), propose that today the “demonstration of caring is an exception rather than the rule.”

They further state that:

increasing demands on nurses have shifted the focus from caring to curing (the biomedical model), thus educators must teach the importance of caring as a vital component of nursing and provide ample opportunities for the clinical practice of caring behaviors. (p.193)

Watson and Foster (2003) suggest that resolving issues between what nursing is and what nurses dom is important to the profession’s existence and survival during the millennium. Watson’s Theory of Human Caring (1996) encapsulates the essence of nursing and should be introduced in the first year of nursing education and threaded through the curriculum over the span of a student nurse’s education. The concept of caring takes time to be internalized which can only occur through experiential learning with exercises demonstrating the dimensions of human caring. Carative factors articulated by Watson include forming a humanistic-altruistic system of values, being sensitive to self and others, gratification of basic needs while maintaining human dignity and wholeness and other factors related to transpersonal caring. Benner (1984) warns that “caring cannot be controlled or coerced-it can only be understood and facilitated” (p. 171). Cook & Cullen (2003) propose that “caring is learned through caring practices between faculty and students and…that students learn how to care for clients by first experiencing caring from faculty” (p.194). They reiterate that teaching the importance of caring is vital and faculty serves as role models. Faculty assists students to move through the levels of affective development and provide learning opportunities that engender caring practice.

Patricia Benner (1984) adapted a model of skill acquisition which was developed by a mathematician and a philosopher. This landmark model should be understood, promoted and utilized to assist with the transition of the new graduate nurse from the classroom to the clinical setting. Benner in her book entitled From Novice to Expert describes a widely acclaimed model consisting of five stages of clinical competence:

1. Novice: Nursing students enter the clinical area as novices and have little understanding of contextual meaning of textbook learning. They need rules to guide performance and opportunity to develop skills that can only be acquired in real situations. Preceptors play key roles during this time.

2. Advanced Beginner: Nurses who can demonstrate marginally acceptable performance, and can cope with real situations are advanced beginners. Preceptors continue to facilitate the transition of the advanced beginner.

3. Competent: The competent nurse lacks speed but has a feeling of mastery and ability to cope with the demands of nursing care. Nurse attain competency after experiencing similar situation over a two year period. Nurses can benefit from decision making games and simulation exercises.

4. Proficient: Nurses who are proficient understand situations as whole with clear understanding of long term goals. Inductive reasoning is used to manage and understand clinical situations.

5. Expert: The expert nurse has enormous experience and has an intuitive grasp of situations. This facilitates rapid problem solving, decision-making and nursing interventions.

Academic Issues

One of the main goals of tertiary educational institution is to provide graduates that can adequately function in the workforce. Warner, Jellinek, and Davidson (2010) posit that universities have the responsibility of producing health care graduates that are competent and able to adapt to changing clinical environments. Nursing faculty assist in developing a workforce to provide quality care to vulnerable populations, and to generate research and evaluation data that can improve nursing service (Applebaum & Leek, 2010). The academic issues that need to be considered in addressing the challenges of bridging the theory and practice gap are related to, students, faculty, curriculum, and collaboration of stakeholders in the academic and practice areas.

On August 1, 2000, the Bliss School of Nursing was transferred from the Ministry of Health to the University of Belize, becoming the Department of Nursing in the Faculty of Nursing, Allied Health, and Social Work. The curriculum was upgraded from a three-year diploma to a four-year baccalaureate degree level which is in keeping with the mandate of the Regional Nursing Body that the baccalaureate degree becomes the entry level for professional nurse practice by 2011. For the first time, Belizean nurses were now able to obtain a nursing degree without leaving their homes and families. However, the transfer has not been without problems and the institution and its key partners have to continue to make every effort to aggressively address factors that threaten the integrity of the nursing degree. Nurses in the clinical settings are vocal about what they perceive as inadequate preparation of the baccalaureate prepared nurse to deliver minimum standard of nursing care. These may be valid concerns, as, for example, although there have been minor modifications to the curriculum, a comprehensive review has not been done since it was first implemented in 2000.

There is an ongoing debate about the merits of moving the School of Nursing into the University of Belize especially within the context of unsatisfactory pass rates for the RENR. Issues prevail about whether the former diploma program for registered nurses produced better educated nurses for the workplace than the new degree program. This is a professional issue that should be discussed in terms of the merits of a University education and the scientific preparation necessary for nurses to achieve required patient outcomes. However, this negative discussion perpetuates professional and gender discrimination (most nurses are women). Is it being implied that nurses do not need degrees? Or, is it a reluctance to upgrade pay scales of nurses? Are nurses being perceived as being subservient rather that being a member of the health team? These issues create a hostile environment for faculty and students making it difficult to harmonize their experiential opportunities in the workplace.

In the curriculum students are not introduced to the first nursing course until the second year of the program. The amount of clinical practice afforded students in the curriculum is viewed as insufficient to build students competence and confidence and facilitate a smooth transition from the academic to the practice setting. Additionally, the main clinical practicum sites are in Belize City, while the theoretical aspects of the nursing programs are delivered at the main campus in Belmopan, which creates logistics and other challenges to integrate theory and practice. The inadequate number of qualified nurse educators is another factor that has impeded the bridging of the theory practice gap and will be discussed later on in the presentation.

Nursing Students

As the current nursing shortage increases, the need to recruit, select, and retain suitable candidates to nursing education programs at the UB is vital. The recruitment of nursing students is done on an annual basis at the various high schools and junior colleges throughout the country; with students being drawn from diverse ethnic, cultural, and social backgrounds. Students range in ages from 17 to 45 years and an increasing number of males have been a welcome addition to the still predominantly female profession. There has also been an increase in the number of Practical and Auxiliary Nurses enrolling in the degree program. These students are often faced with the challenge of securing paid study leave and the resultant need to balance work with class attendance. Candidates who apply to the Bachelor of Science in Nursing Program go through the same recruitment and selection process as all other university students. An interview, which used to be a part of the selection process at the now defunct Belize School of Nursing is absent from the current UB selection process. Interviewing prospective nursing students provides the opportunity to evaluate whether they possess the required mental, emotional, and attitudinal values to remain dedicated, caring, and committed to the profession.

Nursing students of today have multiple roles; parents, worker, community activist, religious leader, to name a few. Their time has to be divided among all these roles, sometimes to the detriment of the student role. In the past, nursing students were all unmarried women who lived in dormitories, with their main responsibility being to dedicate all their time to successfully completing the nursing programs. In the Belize situation, the Bliss Residence for Nurses was in close proximity to the main clinical practice area, which facilitated easy access and increased learning opportunities for students, and allowed for timely practical application of the theoretical information. Today, students commute to school from all over the country, which may negatively impact their education in terms of the time available for study and practice.

Traditionally, student nurses acquire clinical skills in laboratories and through ward simulation, which are later expanded and consolidated during clinical rotations in health care facilities. Students need to have diverse and clinically challenging placement opportunities where they are able to work in a familiar environment supported by academics and laboratory staff that foster interdisciplinary collaboration and inter professional learning (Warner, Jellnek, & Davidson, 2010). At the UB, students are prepared for the professional practice of nursing in a variety of settings such as hospitals, home care agency (Sr. Cecilia Home), and community- based health care facilities. In addition to the nursing skills laboratory, which is located on campus, the Nursing Department collaborates with the national referral hospital, Karl Heusner Memorial Hospital (KHMH), regional, and district hospitals for clinical rotations. The regional hospitals, however, require upgrading to truly qualify as suitable clinical practice sites for students.

Students in the clinical setting are supervised by clinical instructors from UB, but because of the shortage each clinical instructor may be responsible for approximately twenty students when the standard is to have no more than nine students in a clinical group. Major support is given by practicing nurses from the various institutions who serve as clinical preceptors; but they are also faced with limitations of human resource. Many of these experienced nurses have however been leaving the bedside in search of better professional and economic opportunities, leaving student nurses and new graduates with few mentors. Although it is a responsibility of professionals to mentor their young, it is unreasonable to expect an already burdened registered nurse to become a preceptor without monetary compensation and institutional recognition. A formal preceptorship program must be established to address compensatory mechanisms for preceptors. A formalized preceptoring program is also needed to ensure that preceptors are kept abreast of what students are learning in order to assist them in the application of theory to practice. Students become confused as the practice on the unit may differ from what has been taught in the classroom.

Within classrooms, one can expect to find Baby Boomers (born 1943-1960), Generation Xers (born 1961-1981), and Millenials (born 1982-2002). Baby Boomers are said to learn best when their wealth of personal experience can be tied to the subject matter; Generation Xers learn quickly and want to learn what will benefit them directly; and the millenials prefer experiential activities, are technologically efficient and learn immediately from their mistakes (See Table 1).

The literature on generational diversity proposes that each generation has its own sets of values, ethics and culture and that within every classroom there are generation differences. It is further proposed that if teachers understood the theoretical underpinnings of generational differences, they would be able to use appropriate teaching/learning strategies to meet the learning needs of stuudents If the underlying principles of generation diversity are utilized in the workplacce, it would facilitate understanding of differences, eliminate biases, and foster appreciation for the eexpertise thaat nurses brinng to the worrkplace. Similarly, embracing the principles of generation diversity could facilitate a smooth transitionn into the workplace for the recently graduated nurse as well as the orientation of newly employed nurses (Johnson & Romannello, 2005).

Table 1: Generational Learning Styles andd Activities
Source: Johnson & Romanello (2005, p. 215).
Generation Learning Style, Preferences, Characteristics Examples of Generation-appropriate Learning Activities
Baby Boomers
  • Contact with faculty
  • Lecture
  • Learn best when their wealth of personal experience can be tied to the subject matter
  • Want to learn in a caring environment
  • Enjoy positive reinforcement for their efforts
  • Lecture
  • Detailed handouts
  • Note-taking
  • Write a personal story related to content
Generation X
  • Learn quickly and efficiently
  • Only want to learn what will benefit them directly
  • do better when they learn on their terms
  • Enjoy flexible learning times
  • See class assignments as someting necessary to obtain their degree but it is different from work that is necessary to get the job they desire
  • Distance learning courses
  • Programmed instruction done independently, at their own pace, on their own time
  • Detailed study guides and test reviews that focus on what they will be tested
  • Enjoy working in groups, teamwork
  • Use technology whenever possible
  • Experiential activities
  • There is zero tolerance for delays
  • Strengths are multitasking, goal orientation, positive attitudes, collaborative style
  • Learn immediately from their mistakes (as they did when playing a Nintendo game)
  • Simulations with immediate effect on how the student did
  • Group activities, solving a problem or answering questions to a case study in a small group
  • Creative, innovative interactive exercises, e.g. have each student personify a birth control method by saying 3 things that this method would say to describe itself; have the students bring in some inanimate object that is consistent with the method's qualities
  • A Jeopardy-style game, played with teams for a test review

Nursing Faculty

While nurse educators are striving to respond to changes in education the dichotomy between the theoretical inputs taught in the classroom and what is practiced or experienced in the clinical settings continues to be a problem. Many of the initiatives that have been introduced in an effort to bridge the theory-practice gap have revolved around the role of the nurse educator. Landers (2002) suggests that the presence of the teacher in the clinical area is necessary if learning is to be facilitated and that that nurse teachers must be clinically skilled in order to support their claim to be able to integrate theory with practice. This requires an adequate number of nurse educators to supervise students in the clinical areas,which is certainly not the case at the UB where there is a shortage of nurse educators and clinical instructors.

During the amalgamation process, it was recognized that priority attention was necessary to facilitate the upgrading of nurse tutors to Master’s and Doctoral levels, since most tutors at the time had a one year certificate in nursing education from the University of the West Indies. Shortly after the transition, the University reneged on this agreement which resulted in the loss of experienced teachers and failure on the part of the University to recruit qualified and competent nursing faculty who are versed in teaching/learning methods. Of concern also, is the lack of sufficient attention to teaching methodologies that are used to deliver the curriculum which has implications for the ability of students to be successful at the RENR. Because of the shortage of lecturers, there has been the need to rely on adjunct faculty and clinical instructors. Lecturers are not assigned to specific programs but teach across programs. There is an urgent need to increase the number of qualified lecturers and clinical instructors. Currently, only five lecturers are trained as nurse educators at the baccalaureate and masters’ degree level. Five faculty members are qualified at the master's level; two of those persons have no background in nursing education; two (2) are trained at the Post RN Bachelor's level with training in nursing education; two are trained at the Diploma level and one at the generic bachelor's level with no training in nursing education. The University has advertised vacancies regionally and internationally without success, which is believed to be related to an unattractive, unacceptable remuneration package.

Registered Nurse Curriculum

The stated goal of the professional nursing education program at UB is to prepare nurses who have knowledge of the profession’s heritage, are prepared for contemporary nursing practice, and have a vision for the future that will broaden their personal and professional perspective on how they can influence the delivery of nursing and health care. The graduates of this program are eligible for licensure as registered professional nurses in Belize and the other CARICOM countries and have the foundation for graduate study. This goal is achieved through the implementation of a four year curriculum. Year I of the curriculum is general education and supporting courses that are designed to contribute to the formation of a well-rounded educated individual by introducing students to the three major branches of human knowledge- Humanities, Mathematics, Natural Sciences and Social Sciences.

In Year II, semester I students are introduced to the first nursing course, Nursing Concepts and the basic nursing skills, which are practiced in the laboratory setting. Because of other courses offered in this semester; it has been difficult to schedule student to practice these skills in the clinical setting. Students therefore are required to practice in the nursing laboratory which is deficient in terms of space and teaching models. Prior to the commencement of year III, students should have completed all general and supporting courses. Years III and IV constitute all major professional nursing courses. Students receive the theoretical component and laboratory skills prior to the extended clinical practicum. This is to ensure that students have the appropriate theoretical knowledge and skills for better integration and application in the clinical setting (see Appendix A).

After ten years of implementation of the Bachelor degree nursing curriculum, a program review under the guidance of the Office of Quality Assurance will be conducted. The curriculum review will reveal the strengths and weaknesses of the program which will lead to a restructured, reorganized, dynamic curriculum that is sensitive to the health care needs of the community. Although this is the first program review since the amalgamation, course offerings were re- sequenced to make the experiences of the nursing students more meaningful.

Practice Issues

Preparation for RN Practice

Delivery of healthcare in many institutions in Belize is adversely affected by the shortage of nurses (Ministry of Health, 2006). This situation requires a concerted response to the critical issues of recruitment, retention, and replacement of nurses (Buchan & Calman, 2005). The number of nurses that graduate annually from the University of Belize (UB) is not enough to fill the vacancies in the MOH institutions. Enrollment in the Bachelor of Science Degree in Nursing program is consistent, with intakes ranging between 20 and 40 students annually. However, student attrition is high and according to data obtained from the University of Belize, only between 5 and 15 students successfully complete, and graduate from the program yearly (University of Belize, 2008).

To mitigate the shortage of nurses the MOH has been employing a number of non- Belizean nurses, mainly from Guyana, Nicaragua, Cuba, and Nigeria, and more recently, from India and the Philippines to fill vacancies. In 2007 30.9% of nurses employed in the MOH were non-Belizeans (MOH, 2007). The employment of foreign nurses, while addressing the immediate need for nursing service, has a myriad of associated problems, including cultural differences and language barrier. Additionally, experienced nurses are required to oversee the orientation of these foreign employees and serve as mentors and preceptors to them while concurrently discharging the same responsibility for students and new graduates.

The Nurses and Midwives Council of Belize (NMCB) is the legal body that registers and licenses nurses and midwives to practice in Belize. Consistent with the CARICOM agreement, nurses must sit a standard examination, the Regional Examination for Nurse Registration (RENR) to ensure consistent educational standards across the region. The RENR, which is based on the Regional Blueprint/Curriculum, has provided a tool that measures RN proficiency and quality of care, and facilities the free movement of nurses in the Region under the CSME Mode IV. After initial admission to the Council’s Register, nurses are required to participate in 60 hours of continuing education every two years for relicensing. Of great concern is the high failure rates of nurses, including UB graduates who sit RENR. Data from the NMCB reveal that over the past 10 years the percent of nurses that pass the RENR ranged between 6.2 and 81.6, with an average of 47.2 percent (see Appendix B). Plans are underway for the Council to conduct a comprehensive review of the examination process, including the curriculum and its delivery, to identify areas of weakness and to make recommendations for strengthening of the process.

Strategies for Bridging the Theory Practice Gap

A number of strategies have been put forward to reduce the practice-theory divide and to consolidate student learning. These innovative strategies can assist nursing students to develop their clinical skills. Implementation of comprehensive orientation programs, mentoring, preceptoring, and coaching are strategies that focus on supporting student learning in the clinical area so that theory learned in the classroom is reinforced through direct application to practice (Landers, 2000). As suggested in the theoretical perspectives presented, reorganization of teaching/learning methodologies can greatly assist in bridging the academic and clinical divide. A fully equipped modern laboratory where students can conduct simulation exercises must be acquired. The laboratory will enable skill acquisition with the attainment of a minimum level of competency prior to repetition of skill in the clinical setting. Students can test their knowledge, and sharpen reasoning skills through integration of principles and concepts needed to make clinical judgments. Student nurses should receive clinical assignments one day before entering the clinical setting. Nursing care plans must be formulated and presented to the clinical instructor and/or preceptor and must be used to guide the nursing care of assigned patients.

Placement sites for students should be balanced with placements in primary healthcare settings and hospital settings. Early introduction to hospital settings perpetuates the biomedical model, limits students’ sensitivity to the social determinants of health, and impedes understanding of their role in providing culturally sensitive services in primary healthcare settings. The biomedical model focuses on diagnosis and treatment with minimal attention to the carative factors proposed by Watson’s theory of Human Caring (Fawcett, 2003), which illuminates the nursing model of human caring! Of equal importance is a need to determine whether the practice element of the program is equal to the theoretical component as it is important that equal emphasis is placed on theoretical and clinical teaching and learning. Efforts should be made to ensure that students satisfactorily complete competencies associated with specific study areas. Orientation programs that are designed to assist in skill development will reduce the stress and frustration of new nurses. Teaching new nurses how to use equipment and machines in their assigned unit/s would fast track skill acquisition, protect the patient from undue delays, and increase the confidence of the new nurse.

According to Locke (2008) leaders of successful organizations are cognizant of the value of workforce engagement and learning and realize that theoretical input alone is not enough to ensure the transfer of theory to practice. This reality has triggered interest in developmental coaching, an educational tool that aims. It is primarily focused on developing the technical competency of novice employees, creates an opportunity for reflective learning, and the application of new knowledge. Coaching is a strategy that may be used in nursing education to bridge the gap between knowledge and performance. Coaching new nurses through patient care procedures reduces eliminates fearfulness and signals to the new nurse that she is not expected to function at the level of an expert nurse. Coaching is an innovative management tool that has the potential to improve performance and promote overall well-being. Through the recognition of weaknesses and strengths, the novice nurse can chart the way forward towards developing levels of competency.

Dracup and Bryn–Brown (2004) assert that preceptors need to guide new nurses skillfully and with empathy through the seemingly daunting practice areas. Developing preceptors and mentorship programs is an effective way to integrate and support neophyte nurses. Preceptors in the clinical setting are needed to provide support for the novice nurse. A preceptorship program should be formalized in collaboration with the University of Belize and the practice sites where nurses will be pursuing clinical experience. Training of preceptors and the development of preceptor manuals are important if students are to benefit optimally from their practical experiences in the workplace. Institutions benefit from preceptorship programs because preceptors are exposed to best practices which immediately impacts positively on patient care. Remuneration and other incentives should be formalized to ensure that preceptors feel appreciated and are recognized for the benefits that will be derived by the students.

Mentorship is integral to students’ clinical placement experiences; it has the capacity to increase job satisfaction for the novice nurse. A mentor in the clinical practice setting is able to aid students in the development of competence and confidence. The nurse mentor helps the novice to understand the dimensions of caring, manage the emotional trauma during dying and death process, and assists in the development of clinical reasoning and critical thinking skills. Undoubtedly the role of mentor is pivotal to students’ clinical learning experiences; it is therefore imperative that mentors are given adequate and ongoing support and preparation in carrying out their role so that they can in turn support students to become confident and competent practitioners. For this to be achieved there needs to be a move away from the reliance on inherent goodwill of mentors that has characterized the system in the Ministry of Health. Instead, it requires the recognition of the importance of the role reflected in organizational support, which allow mentors time to attend training programs and updates. Additionally, effective partnership and good communication and collegial relationships between academics and clinicians responsible for the education of nursing students is paramount (Myall, Levett- Jones, & Lathlean, 2008).

Other Considerations for Harmonizing Nursing Education

The severe nursing shortage has made it critical to have new nurses quickly develop the clinical judgment, technical skills, and the critical thinking required to function in the practice areas. Godinez, Schweiger, Gruver, and Ryan (as cited in Haag-Heitman & Schedler, 2004) posit that the shift from new graduate to the RN role is the most stressful and crucial part of the transition into professional practice. The stress is heightened as, in many cases, once the formal orientation period is over the new nurses often experience a drastic decline in the guidance and support they receive from experienced nurses. Clinical practice development requires adequate resources including time, equipment and supplies, and the support of committed and empathetic coaches, preceptors, and mentors who serve to support and validate new nurses as they navigate the often unfamiliar and challenging practice settings. Coaches, mentors, and preceptors also help the novices to develop competence and confidence. In order to harmonize the academic and practice aspects of nursing education and facilitate a smooth transition from novice to expert, it is important for professionals to be good role models for new nurses in the academic as well as the clinical settings (Haag-Heitman & Schedler). While having good role models, mentors, coaches,and preceptors to support new nurse graduates is the ideal, this is often not the reality. Many nurse supervisors are graduates of the diploma program and a few of them adopt the attitude that, since these new nurses have graduated with a degree, they should be able to fend for themselves.

Higher education institutions are required to engage in participatory review and discussion with their stakeholders, as they strategically plan to respond to the changing environment and create equitable access to relevant education to meet workforce demand (Rowley, Lujan, & Dolence, 1997). Wilson (2008) proffers that nursing education is the responsibility of a number of key players, which includes the student, the university, and clinical practitioners all collaborating to achieve the ultimate goal of delivery of quality nursing care. Wilson (2002) suggests that nursing education is the responsibility of three keys players: the student, the university, and the clinician. The student must be motivated to learn and reflect on practice. The university is responsible for providing accurate, evidence based teaching that reflects the current clinical environment. This includes consideration of staffing levels, financial constraints, and a strong awareness of the importance of fitting within the context of the clinical setting. Teaching must be more than imparting a collection of facts; successful students are able to apply those facts in each unique clinical setting they encounter. The clinician has a responsibility to support student development. The clinical role model is highly influential in the development of the student nurse and midwife. Certain skills can only truly be learnt in the workplace and students must be empowered to take on this responsibility.

The need for stakeholders’ participation is recognized, and the Ministry of Health (MOH), the Ministry of Education (MOE), and the UB collaborate to prepare the nurses required to meet the needs of both the public and private health sectors. For example, if the MOH has a need for a certain category of nurses that is not a part of UB’s annual program offerings, UB would make that program available through financing by the MOH. In addition to meeting program cost, MOH would facilitate study leave for the students, and pay a monthly stipend to students. Additionally, through a Cabinet agreement, the MOE provides tuition and fees scholarship to 25 students in the Bachelor of Science Degree in Nursing Program at UB that are recommended by the MOH. UB strives to offer nursing programs as requested by the Ministry of Health. However, one major limitation that may hinder any new program offering is the lack of human resource. This shortage has placed the department in a position of not being able to respond in a proactive manner.

The MOH recently completed a Health Workforce Strategic Plan (2010), which addresses the need for recruitment, development, and retention of human resources for health, particularly nurses. Strategies for the strengthening of cooperation between education institutions and the health sector are also recommended in the plan. Globally, regionally, and nationally, the nursing workforce is aging which highlights the need for succession planning. There has been a steady decline in the number of expert nurses who are available to assist with skills acquisition necessary for students to become competent, proficient or expert nurses. All nurses have the responsibility to advance the nursing profession.

The use of technology to assist in bridging the theory practice gap may also be considered. Today technology allows nursing students to practice on make-believe patients so they can learn, sharpen and improve skills. Mannequins are programmed to act and react like humans. They breathe, talk and make other sounds. More and more nursing schools have invested in high-tech mannequins to simulate real-life patient situations where students can learn simple techniques, such as how to bathe patients and more complicated techniques before practicing on live patients. As technology permeates every aspect of our lives, it is imperative that nursing students be knowledgeable about computers as more hospitals are now turning to the automated system of documentation. One of the requirements of the Bachelor degree nursing program is Introduction to Computer Studies. Students who have mastered some aspects of computer studies have the option of taking this course on line.

Recommendations and Conclusion

It is evident that nursing education requires innovative strategies to transform the teaching/learning environment for nursing students. Clinical placements in rural and urban primary health settings will foster the understanding of providing culturally sensitive nursing care. To support skills acquisition, a modern simulation laboratory with automated equipment is needed. Memoranda of understanding between UB and selected clinical sites must be formalized so that both parties are clear on their responsibility to students.

The Regional Nursing Body should be asked to conduct an expedited enquiry to determine factors that are negatively impacting on the students’ ability to pass the licensing exam. Since this Body is responsible for administering the licensing exam, they can offer insights into the design of the curriculum, methodologies, cite best practices, and make recommendations based on lessons learnt. The public should be sensitized on the importance of nursing education, recruitment and retention of nurses, and the need to invest in the education of nursing students and Faculty.

Combining face to face lectures with online offerings would be a welcome alternative for the generation Xers and the millennial students; this method also reduces the demand on already burdened nursing faculty. Exploratory discussions should be held with the University of the West Indies School of Nursing since they have converted many of their nursing subjects to online offerings.

The UB, in collaboration with the MOH should create accelerated nursing programs, which have the capacity to rapidly increase the number of registered nurses needed to provide health care services. This will require the recruitment of students who have an Associate’s degree in the core subjects which would enable the completion of the nursing degree in 18 to 24 months. An internship program for new graduates would provide extended clinical practice to facilitate the acquisition and application of skills and the development of critical thinkers.

Public relations campaigns highlighting nursing education are needed to dispel myths about the merits of obtaining a degree. UB should provide opportunities for professional development of nurses in the clinical setting, especially for experienced nurses without degrees. Retention strategies should be adopted so that younger nurses can have mentors who will help them grow and inculcate values of the profession and remain in the nursing profession. Campaigns to sensitize the public on the importance of nursing education, factors related to recruitment and retention of nurses, and the need to invest in the education of nurses can attract more members to the profession and strengthen the capacity to deliver quality nursing care.

Bridging the theory/ practice gap benefits students, clinicians, and most importantly, patients. Students gain improved learning opportunities, clinicians benefit from improved working conditions from having increased numbers of competent practitioners, and the patient is ensured quality nursing care from caring and competent providers (Wilson, 2008).


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Appendix A

Faculty of Nursing, Allied Health & Social Work
Table 2: Bachelor Degree in Nursing Program
Sequence of Courses
Semester I
ENGL1014 College English I 3
CHEM1015 General Chemistry I 3
CHEM 1015L General Chemistry I Lab 1
BIOL1015 General Biology I 3
BIOL1015L General Biology I Lab 1
MATH1014 Intermediate Algebra 3
PHIL1014 Ethics3
CMPS1004 Introduction to Computer Studies 3
Semester II
ENGL1025 College English II 3
BIOL2015 Human Anatomy & Physiology I 3
CHEM1032 Introduction to Organic Chemistry & Biochemistry 3
CHEM1032L Introduction to Organic Chemistry & Biochemistry Lab 1
PSYC1014 Introduction to Psychology 3
SOCL1014 Introduction to Sociology 3
Semester I
BIOL 3402 General Microbiology3
BIOL 3402L General Microbiology Lab1
BIOL2025 Human Anatomy & Physiology II 3
MGMT1014 Applied Management 3
HIST1014 Belizean History 3
SPAN 1025 Lower Intermediate Spanish 3
NURS2051 Nursing Concepts 3
NURS2051L Nursing Concepts Lab1
Semester II
NURS2102 Pharmacotherapeutics 3
RSCH2014 Research Methods3
NUTR2055 Food, Nutrition and Health3
NURS2152 Current Issues in Nursing 4
NURS2202 Physical Assessment 3
NURS2202L Physical Assessment Lab1
Semester I
NURS3051 Nursing Care of Infants & Children 5
NURS3051L Nursing Care of Infants & Children Lab 1
NURS3101 Care of Adult Population 5
NURS3101L Care of Adult Population Lab 1
SWRK4101 Family Violence 3
Semester II
NURS3051P Nursing Care of Infants & Children Practicum 7
NURS3101P Care of Adult Population Practicum 7
Semester I
NURS4051 Reproductive Health Care5
NURS4051L Reproductive Health Care Lab 1
NURS4051P Reproductive Health Care Practicum 3
NURS4101 Community Health Nursing 6
NURS4101P Community Health Nursing Practicum 3
Semester II
NURS4152 Promoting Mental Wellness 6
NURS4152P Promoting Mental Wellness Practicum 3
NURS4202 Nursing Management & Leadership 6
NURS4202P Nursing Management & Leadership Practicum 3

Appendix B

Table 3: Regional Examination for Nurse Registration (RENR) Results –Belize, 2000 to 2010
Compiled from information received from the Nurses and Midwives Council of Belize
Year No of Candidates Passes Percentage
Oct 2000 22 13 59.0
April 2001 8 5 62.5
Oct 2001 22 13 59.0
April 2002 12 5 41.6
Oct 2002 33 20 60.6
April 2003 11 7 63.6
Oct 2003 4 2 50.0
April 2004 2 0 0
Oct 2004 10 6 60.0
April 2005 No Exams
Oct 2005 11 9 81.8
April 2006 4 2 50.0
Oct 2006 3 0 0
April 2007 NA NA
Oct 2007 17 0 0
April 2008 14 6 42.8
Oct 2008 27 5 18.5
April 2009 29 20 68.9
Oct 2009 32 2 6.2
April 2010 29 3 10.3

© Marjorie E. Parks, Laura Tucker Longsworth, Isidora Espadas

HTML last revised 9th November, 2011.

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