ANNUAL REVIEW of
NURSING EDUCATION
Volume I, 2003
EDITOR Marilyn H. Oermann, PhD, RN, FAAN Professor, College of Nursing Wayne State University Detroit, Michigan ASSOCIATE EDITOR Kathleen T. Heinrich, PhD, RN Professor, Division of Nursing University of Hartford West Hartford, Connecticut ADVISORY BOARD Belinda E. Puetz, PhD, RN President/CEO Puetz & Associates, Inc. Editor, Journal for Nurses in Staff Development Pensacola, Florida
Diane M. Billings, EdD, RN, FAAN Chancellor's Professor Professor of Nursing and Associate Dean, Teaching, Learning, and Information Resources Center for Teaching and Lifelong Learning Indiana University School of Nursing Indianapolis, Indiana
Jo-Ann L. Rossitto, DNSc, RN Dean/Director, Nursing Education San Diego City College San Diego, California
Peggy L. Chinn, PhD, RN, FAAN Professor University of Connecticut School of Nursing Editor, Advances in Nursing Science Manchester, Connecticut
Suzanne P. Smith, EdD, RN, FAAN Editor-in-Chief Journal of Nursing Administration &> Nurse Educator Bradenton, Florida
Margaret A. Hamilton, DNSc, RN Assistant to the Vice President for Curriculum and Instruction Camden County College Blackwood, New Jersey
Christine A. Tanner, PhD, RN, FAAN Professor and Director, Undergraduate Nursing Program Oregon Health and Sciences University Editor, Journal of Nursing Education Portland, Oregon
Elaine Mohn-Brown, EdD, RN Professor, ADN Program Chemeketa Community College Salem, Oregon Nilda Peragallo, DrPH, RN, FAAN Associate Professor, School of Nursing University of Maryland Baltimore, Maryland
ANNUAL REVIEW of NURSING EDUCATION Volume I, 2003
Marilyn H. Oermann, PhD, RN, FAAN, Editor Kathleen T. Heinrich, PhD, RN, Associate Editor
AnnualReview of
NURSING EDUCATION
Springer Publishing Company
Order ANNUAL REVIEW OF NURSING EDUCATION, Volume 2, 2004, prior to publication and receive a 10% discount. An order coupon can be found at the back of this volume. Copyright © 2003 by Springer Publishing Company, Inc. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of Springer Publishing Company, Inc. Springer Publishing Company, Inc. 536 Broadway New York, NY 10012 03 04 05 06 07 / 5 4 3 2 1
ISBN-0-8261-2444-5 ISSN-1542-412X ANNUAL REVIEW OF NURSING EDUCATION is indexed in Cumulative Index to Nursing and Allied Health Literature and Index Medicus. Printed in the United States of America by Maple Vail.
Contents Preface Contributors
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Part I: Nursing Education and the Community I
Community-Based Curricula at BSN and Graduate Levels DIANE M. WINK
2
Community-Based Curricula at the ADN Level: A Service-Learning Model M. ELAINE TAGLIARENI AND ELIZABETH SPEAKMAN
27
3
Professional- Community Partnerships: Successful Collaboration TERESA SHELLENBARGER
43
3
Part II: Mentoring and Preceptorship 4
Strategies for Promoting Nontraditional Student Retention and Success MARIANNE R. JEFFREYS
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5
Preceptorship: A Quintessential Component of Nursing Education FLORENCE MYRICK AND OLIVE YONGE
91
6
From Partners to Passionate Scholars: Preparing Nurse Educators for the New Millennium KATHLEEN T. HEINRICH WITH JUDITH A. COTE, SHEILA B. SOLERNOU, KORRINE A. ROTH, DALE K. CHIFFER, GEORGANN BONA,
109
MlCHELE McKELVEY, DEBORAH NEWELL CARPENTER,
CHRISTINE BRACKEN, M. RUTH NEESE, DOROTHY VARHOLAK, ELAINE MCCAFFREY, ALICE FACENTE, AND DORI ROGERS V
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CONTENTS
7
Rewarding Teaching Excellence Through a Master Educator's Guild CATHERINE Nuss KOTECKI
133
8
Using Care Groups to Mentor Novice Nursing Students RICHARD L. PULLEN, JR., PATRICE H. MURRAY, AND K. SUE McGEE
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Part III: Distance Education
9
Overview of Distance Education in Nursing: Where Are We Now and Where Are We Going? KAY E. HODSON CARLTON, LINDA L. SIKTBERG, JIM FLOWERS, AND PAMELA SCHEIBEL
165
10
Teaching Creativity Online PEGGY L. CHINN
191
11
Innovation and Quality in Higher Education: An RNBSN Program Goes Online JOAN E. THIELE AND ANNE M. HIRSCH
209
12
Community-Based Model of Distance Education for Nurse-Midwives and Nurse Practitioners SUSAN E. STONE
227
13
Issues in Rural Health: Model for a Web-Based Course ANGELINE BUSHY
245
14
International Distance Learning Collaboration to Prepare Nurse Educators in Malaysia DIANE M. BILLINGS, LINDA KOLANDAI, IDA CHIN MENG Li, SHEELA DEVI, GETPIN RUDIE, MARIA MAZANI, AND SHAREENA PARAMASUVARUM
267
15
Videoconferencing Innovations in Nursing Education KAY SACKETT AND SUZANNE STEFFAN DICKERSON
281
CONTENTS
16
17
Distance Technology in Nursing Education on a Taxpayer's Budget: Lessons Learned From 22 Years of Experience PAMELA E. HUGIE Ethics of Web-Based Learning ROY ANN SHERROD AND MITCH SHELTON
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309
Part IV: Innovative Strategies 18
Interdisciplinary Education: Breaking Out of the Silos DENISE G. LINK
325
19
Using Clinical Scenarios in Nursing Education CATHERINE NORED DEARMAN
341
Index
357
Topics and Authors for Volume 2
367
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Preface
nterested in the latest trends in nursing education written by the nurse educators pioneering these innovations? Then welcome to the first volume of the Annual Review of Nursing Education. This Review focuses on the practice of teaching. Sharing educational strategies that you can adapt to your own settings, the Annual Review of Nursing Education is written for educators in associate, baccalaureate, and graduate nursing programs, staff development, and continuing education. We were chosen as editors of this volume based on the articles and books we have written for nurse educators. In turn, we invited leading nurse educators from across the United States who represent associate, baccalaureate, and graduate nursing programs, and staff development, to join our Advisory Board. Some are editors of nursing journals; others serve as administrators of educational programs. As we began our work on volume 1, we asked the Advisory Board, nursing faculty, and administrators of nursing programs to identify advances nurse educators should know about and to recommend nurse experts as potential authors. Nurse educators were so enthusiastic about writing for this first volume that the overflow of names and topics completed the second volume. We are now identifying topics and authors for the third volume. The reason for this overwhelming response? Never before has there been a resource that draws on the expertise of nurse educators from all types of educational programs including academic and service settings alike. Read this overview to see if you agree that this volume describes the most compelling trends in nursing education. Over the last decade, there has been steady movement by nursing faculty to integrate community-based care into their programs. The first set of chapters, in part I, address community-based curricula in nursing and forming partnerships with the community. In chapter 1, Diane M. Wink describes community-based nursing education (CBNE) and how it is different from nursing specialties and other approaches such as service learning. She describes the implementation of CBNE for basic undergraduate, RN-BSN, and graduate students; presents several models of CBNE; and explores benefits and problems of CBNE for faculty, students, and communities. The chapter also provides helpful tools
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PREFACE
for curriculum development such as a sample curriculum design and examples of learning activities and student projects. In chapter 2, M. Elaine Tagliareni and Elizabeth Speakman call on faculty to develop partnerships with community agencies through service learning approaches. Their chapter describes a service-learning model at the Community College of Philadelphia. Partnership development focused on collaborative relationships between the Department of Nursing and local agencies to deliver health promotion and disease prevention services to residents in the local community. Partnership development also includes the emergence of colearners and collegial relationships between students and faculty to meet the needs of the local community. Professional-community partnerships provide a strategy for dealing with the rapidly changing environments in health care and higher education. These partnerships involve professionals working collaboratively in a reciprocal relationship with the community that meets the needs of all parties. Chapter 3, by Teresa Shellenbarger, provides readers with information about the benefits of professional-community partnerships, steps in partnership formation, strategies to sustain partnerships, possible partnership problems, and resources for partnerships. Part II addresses mentoring and preceptorships. More and more nontraditional students are applying to and being accepted in nursing programs. Unfortunately, the retention rates of nontraditional students are lower than traditional students. In chapter 4, Marianne R. Jeffreys describes the process of designing, implementing, and evaluating an enrichment program, which specifically targets nontraditional undergraduate nursing students. She presents the Pre-nursing Enrichment Program, which consists of free services for students: orientation, mentoring, tutoring, career advisement and guidance, workshops, networking, and transitional support services. The chapter also summarizes the research on nontraditional nursing student retention and presents the Nontraditional Undergraduate Retention and Success (NURS) conceptual model as an organizing framework. Faculty will find the Enrichment Program helpful as they struggle to retain nursing students. Preceptorships involve partnerships among students, preceptors, and faculty. In chapter 5, Florence Myrick and Olive Yonge, leading experts on preceptorships in nursing education, describe the development and outcomes of preceptorships in nursing. The chapter addresses preceptor selection, preparation for preceptorships, and preceptor stress.
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The authors describe in detail what a preceptorship program should be like and how to develop one. They also examine issues in using preceptors in today's health system and future directions. In chapter 6, Kathleen T. Heinrich and colleagues describe how faculty-student partnerships have the potential to revolutionize the way we educate nurses and prepare them as educators. The Partnership Program at the University of Hartford offers an innovative approach for preparing nurses in the master's program to become educator/scholars. As opposed to traditional learning experiences that primarily benefit either faculty or students, in partnerships faculty and students engage in mutually beneficial relationships that support both partners' scholarly work. The chapter describes how a group of graduate faculty and students are engaged in a partnering process that is fostering a community of scholarly caring. Partners' reflections are used to convey the joys and challenges of their partnering experiences and their learning from them. In chapter 7, Catherine Nuss Kotecki describes how partnerships with other disciplines were formed to promote teaching excellence across the university. In this chapter she addresses barriers to excellent teaching, ways to overcome those barriers, and the relationship of teaching excellence to tenure and promotion. She describes a Master Educator's Guild that was created to recognize teaching excellence and promote the mission of teaching at the university. The interdisciplinary partnership strengthens the individual faculty's teaching as well as the culture of education within the university. If you have ever taught beginning nursing students, you will understand why Richard L. Pullen, Jr. and his colleagues, Patrice H. Murray and K. Sue McGee, developed Care Groups to mentor novice nursing students. Care Groups promote caring relationships and help students succeed by decreasing their apprehension and anxiety when demonstrating basic nursing skills in a laboratory. This new approach guides the novice student through the development of basic nursing skills. In chapter 8, the authors describe the evolution of Care Groups, the role of faculty mentors, the Care Group Model, and student and faculty outcomes of this new approach to teaching. What's hotter than distance education (DE) in nursing? Reasons for the surging growth of DE are related to technological innovations making it easier to deliver education at a distance, the need for higher education for career advancement, the demand for flexible scheduling for students, a belief that nursing education is a lifelong endeavor, and
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PREFACE
a shift from teacher-centered education to student-centered learning. Distance education programs are purported to ease the nursing shortage. Because many nursing faculty and administrators have questions about DE, teaching online, preparing faculty, managing DE nursing programs, and related issues, part III of volume 1 focuses on DE in nursing. Chapters present the leading advances in DE with specific examples of online courses in nursing, entire programs delivered online, and how faculty are establishing relationships with their students and with other educators in an online environment. Chapter 9 is written by Kay E. Hodson Carlton, one of the leading experts on DE in nursing, and colleagues. This chapter provides the background you need to understand DE in nursing. You will read about DE technologies and what each offers to online learning and teaching in nursing. As DE grows in nursing, we need to assess the quality of our DE programs; this is addressed in chapter 9. Other content areas are faculty selection, support, and issues; use of off-campus faculty for teaching DE courses in nursing; faculty development; institutional considerations; and marketing DE courses and programs. The authors also address specific challenges to DE in nursing and provide solutions to them. Guidelines are included on implementing clinical practice courses at a distance. In chapter 10, Peggy L. Chinn addresses what she believes underlies the effective use of online approaches—creativity. She argues that creativity should be at the center of educators' concern in developing online teaching and learning materials. Effective use of the Web for creative teaching and learning requires a vision of what is possible, knowledge of Web tools available, and most important, a philosophically grounded understanding of Web-based applications that can enhance creativity. This chapter presents a philosophic grounding for creative teaching and learning using online resources, and provides examples of how creativity can be fostered in an online environment. Many educators are looking to DE as a strategy to prepare more nurses, particularly in rural areas, to ease the nursing shortage. Joan E. Thiele and Anne M. Hirsch describe the process they used to convert a traditional classroom-based RN-BSN program to a totally asynchronous, online offering. This chapter describes how the faculty reengineered their courses for DE, their plans for implementation of the program, the new role of Asynchronous Coordinator, faculty development and the workshops held to prepare faculty for teaching in an online environ-
PREFACE
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ment, and program evaluation, among other topics. Chapter 11 provides practical information for any faculty developing or expanding their online programs. Chapter 12 shifts the focus to online education in graduate programs in nursing. The Frontier School of Midwifery and Family Nursing is a leader in DE for nurse-midwives and nurse practitioners. Susan E. Stone describes the development of these programs and the process of educating students as nurse-midwives and nurse practitioners using DE. In the chapter she explains each program level and student progression; how faculty are organized and how they communicate with each other, program administrators, preceptors, and students; and the roles of course coordinators, course faculty, directors of student affairs, regional clinical coordinators, and preceptors. Many strategies are built into the programs to develop and maintain a community of learners, beginning with the orientation called Frontier Bound. The author also shares how they offer and evaluate their clinical experiences for students. In the past decade educators of health professionals have made an effort to expose students to clinical practice in rural environments. Chapter 13 by Angeline Bushy presents a Web-based rural health issues course and discusses lessons learned from that experience. The course, comprising 12 learning modules, was designed to create greater awareness of rural practice among undergraduate and graduate students in the health professions. The information provided in the chapter can be used as a model for faculty to develop similar courses, Web-based or for a traditional classroom setting. At a time when there is a need for nurses, there also is a worldwide shortage of nurse educators. Given limited resources and the need to recruit and educate nurses, international collaboration for preparing nurse educators is one solution. The increasing availability of the Internet worldwide makes DE an option for resource sharing with schools of nursing in other countries. In chapter 14, Diane M. Billings and colleagues describe a collaboration between a school of nursing in the United States and the Pantai Institute of Health Sciences and Nursing in Kuala Lumpur to offer a Web-based certificate course to prepare nurses for faculty and staff development positions in Malaysia. In chapter 15, Kay Sackett and Suzanne Steffan Dickerson describe innovations at their school of nursing where faculty initiated use of videoconferencing as a viable mechanism to reduce geographic barriers to nursing education. The authors discuss planning for videoconferenc-
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PREFACE
ing initiatives including identifying educational needs, developing partnerships, and establishing technical interfaces. They illustrate the implementation of videoconferencing through three examples: classes held remotely for RN students in the BSN program, for clinical evaluations of Family Nurse Practitioner students to effectively replace onsite faculty clinical evaluations, and a cross-cultural debate between nursing students in Buffalo, New York and students in Tortola, British Virgin Islands. In chapter 16, Pamela E. Hugie explains how the nursing program at Weber State University in Utah is using DE to prepare more qualified registered nurses statewide and increase the number of nurses prepared and willing to serve in rural areas of the state. The nursing program has multiple entry and exit options, and it uses DE to prepare licensed practical nurses and registered nurses at both the associate and baccalaureate levels. Strategies for offering clinical courses and obtaining quality clinical experiences for distance students are discussed in the chapter. "To Web or Not to Web?" is the question raised by Roy Ann Sherrod and Mitch Shelton in chapter 17. Offering courses on the Web has required educators to consider a new realm of ethical issues. This chapter describes ethical issues for faculty when making the decision to offer a course on the Web. The authors also present issues that involve students in Web-based courses in nursing. The chapter assists faculty in making more informed choices and exercising more informed options related to Web-based courses in nursing education. Part IV addresses innovative strategies for teaching in nursing. Chapter 18 by Denise G. Link describes an interdisciplinary educational program jointly sponsored by a public university and a state Area Health Education Center. She explains how the challenges that inhibit the progress of interdisciplinary education in the health professions were overcome. The chapter includes the process of developing interdisciplinary education—assembling the education team, faculty development, planning course content, setting up and evaluating the practicum component, and the significance of the project for nursing education. In chapter 19, Catherine Nored Dearman presents clinical scenarios in the form of photographs, video- and audiotapes, case studies, and simulations and provides examples. She describes the effective use of these strategies in the classroom, clinical laboratory, and online setting to foster active learning. Debriefing after a learning episode is presented as a strategy to assist students in making explicit connections between the classroom and clinical environment.
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As we said at the outset, the goal of the Review is to keep you updated on this year's innovations in nursing education across all settings. We think you will agree that this volume met that goal. Special thanks are extended to Dr. Springer for recognizing the need for an annual review in nursing education and making it happen. We also appreciate the hard work of the authors who were generous enough to share their innovations for the benefit of educators everywhere. And a heartfelt thanks to you for reading and recommending this volume to other nurse educators! MARILYN OERMANN Editor KATHLEEN T. HEINRICH Associate Editor
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Contributors
Diane M. Billings, EdD, RN, FAAN Chancellor's Professor Professor of Nursing and Associate Dean, Teaching, Learning and Information Resources Indiana University School of Nursing, Center for Teaching and Lifelong Learning Indianapolis, Indiana with Linda Kolandai, Mhc, Course Coordinator; Ida Chin Meng Li, Mhc; Sheela Devi, RN; Getpin Rudie, Diploma in Nursing; Maria Mazani, Bhs; Shareena Paramasuvarum, BSN Course Participants Pantai Institute of Health Sciences and Nursing Kuala Lumpur, Malaysia Angeline Bushy, PhD, RN, CS, FAAN Professor and Bert Fish Chair University of Central Florida School of Nursing at Daytona Beach Campus Daytona Beach, Florida
Peggy L. Chinn, PhD, RN, FAAN Professor of Nursing University of Connecticut Storrs, Connecticut Catherine Nored Dearman, PhD, RN Professor and Chair Maternal Child Health Nursing College of Nursing, Springhill Campus University of South Alabama Mobile, Alabama Suzanne Steffan Dickerson, DNS, RN Assistant Professor of Nursing University at Buffalo, SUNY Buffalo, New York Jim Flowers, PhD Professor Ball State University Muncie, Indiana
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CONTRIBUTORS
Kathleen T. Heinrich, PhD, RN Professor with Judith A. Cote, MSN; Sheila B. Solernou, MSN, CCRN; Korrine A. Roth, MSN, RNC; Dale K. Chiffer, MSN; Georg'Ann Bona, MSN; Michele McKelvey, MSN; Deborah Newell Carpenter, MSN; Christine Bracken, MSN, RNC; M. Ruth Neese, BSN; Dorothy Varholak, EdD, RN; Elaine McCaffrey, MSN, RNC; Alice Facente, MSN, RNC; Dori Rogers, MSN Participants in Partnership Program Division of Nursing University of Hartford West Hartford, Connecticut Anne M. Hirsch, DNS, ARNP Associate Dean for Academic Affairs Intercollegiate College of Nursing Washington State University Spokane, Washington Kay E. Hodson Carlton, EdD, RN, FAAN Professor and Coordinator, Educational Resources and Distance Learning School of Nursing Ball State University Muncie, Indiana Pamela E. Hugie, MSN, RN Nursing Outreach Coordinator Dumke College of Health Professions Weber State University Ogden, Utah
Marianne R. Jeffreys, EdD, RN Professor, Nursing The City University of New York, College of Staten Island Staten Island, New York Catherine Nuss Kotecki, DNSc, RN, ANP, C Director of Education and Research Our Lady of Lourdes Medical Center Camden, New Jersey Denise G. Link, DNSc, RN Clinical Associate Professor of Nursing Arizona State University Tempe, Arizona K. Sue McGee, MSN, RN Professor of Nursing Amarillo College Amarillo, Texas Patrice H. Murray, MSN, RN Professor of Nursing Amarillo College Amarillo, Texas Florence Myrick, PhD, RN Acting Dean Faculty of Nursing University of Calgary Calgary, Alberta, Canada Richard L. Pullen, Jr., EdD, RN Professor of Nursing Amarillo College Amarillo, Texas
CONTRIBUTORS
Kay Sackett, EdD, RN Assistant Professor of Nursing University at Buffalo, SUNY Buffalo, New York Pamela Scheibel, MS, RN, CPNP Clinical Associate Professor School of Nursing University of Wisconsin-Madison Teresa Shellenbarger, DNSc, RN, CS Professor of Nursing Indiana University of Pennsylvania Indiana, Pennsylvania Mitch Shelton, PhD, RN Assistant Professor of Nursing The University of Alabama Capstone College of Nursing Tuscaloosa, Alabama Roy Ann Sherrod, DSN, RN Professor of Nursing The University of Alabama Capstone College of Nursing Tuscaloosa, Alabama Linda L. Siktberg, PhD, RN Director and Associate Professor School of Nursing Ball State University Muncie, Indiana Elizabeth Speakman, EdD, RN Associate Professor Department of Nursing Community College of Philadelphia Philadelphia, Pennsylvania
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Susan E. Stone, DNSc, CNM President and Dean Frontier School of Midwifery and Family Nursing Hyden, Kentucky M. Elaine Tagliareni, EdD, RN Professor and Independence Foundation Chair Department of Nursing Community College of Philadelphia Philadelphia, Pennsylvania Joan E. Thiele, PhD, RN Professor of Nursing Intercollegiate College of Nursing Washington State University Spokane, Washington Diane M. Wink, EdD, FNP, ARNP Professor School of Nursing University of Central Florida Orlando, Florida Olive Yonge, PhD, CPsych, RN Professor Faculty of Nursing University of Alberta Edmonton, Alberta
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Part I
Nursing Education and the Community
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Chapter 1 Community-Based Curricula at BSN and Graduate Levels Diane M. Wink
ommunity-based nursing education (CBNE) uses the philosophy of community-based nursing (CBN) in the development and implementation of undergraduate and graduate nursing curriculums. This chapter presents definitions of CBN and CBNE, and describes how CBNE is different from nursing specialties and other approaches to nursing education such as service learning. The implementation of CBNE for basic undergraduate, RN-BSN, and graduate students is described, several models of CBNE are presented, and benefits and problems of CBNE for faculty, students, and communities are explored.
C
WHAT IS COMMUNITY-BASED NURSING EDUCATION? Community-based nursing is a philosophy that can guide care in all specialties and all settings (Zotti, Brown, & Stotts, 1996). The client may be the individual, family, group, aggregate, or community. Nursing care is provided wherever the client is, through a partnership with the client and with an appreciation of the client's values, culture and priorities, community, and family structure and function (Matteson, 2000; Zotti, Brown, & Stotts, 1996). Community-based nursing is not dependent on specific setting, skills, or knowledge (Hunt, 1998), and it does not occur only in nonacute settings. Community-based nursing and therefore CBNE occurs wherever and whenever nurses work in collaboration with the client and community as part of interdisciplinary and 3
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NURSING EDUCATION AND THE COMMUNITY
interdisciplinary teams to provide care across the continuum (American Association of Colleges of Nursing [AACN], 1999; Faulk, Walker, & Woods, 2000; Matteson, 2000). Beginning with the National League for Nursing and the Pew Commission reports and supported by Kellogg, Fuld, and Health Professions in Service to the Nation grants, CBN and CBNE have expanded in recent years. Initially viewed as a necessity to prepare nurses to work in community settings because of a perceived decrease in the need for nurses in acute care, CBNE is now viewed as a philosophy of nursing education that encourages the nurse to work across the continuum of care, as part of an interdisciplinary team in collaboration with the client and community (Stanley, Kiehl, Matteson, McCahon, & Schmid, 2002). Community-based nursing education requires that collaborative partnerships be formed between nursing programs and health care institutions, providers and their clients, nursing programs and communities, and organizations and their residents and clients. This model of teaching values the knowledge and expertise of all participants. Such partnerships enable participants to work collaboratively to improve the health of individuals, groups, and communities, while educating faculty and students in the realities of clients' lives as they interact with health care institutions and the neighborhoods where they live. Through their interactions with clients, the issue of compliance takes on new meaning (Shea, 1995). Benefits of CBNE to the community and students include increased access to health services and an ability to improve these services directly (Bellack, 1998; Oneha, Magnussen, & Feletti, 1998; Oneha, Sloat, & Shoultz, 1998; Shea, 1995). Thus, CBNE promotes an "engaged" nursing campus, one that is "connected" with other health care providers and recipients regardless of their setting (Stullenbarger, Kiehl, Wink, & Stanley, 2001). The goal of CBNE is a graduate who is a "change agent, critical thinker, independent learner, client advocate, and skillful practitioner able to apply theory to practice in both acute care and community settings with individuals, families and aggregates" (Kiehl & Wink, 2000, p. 293). WHAT COMMUNITY-BASED NURSING EDUCATION IS NOT Community-based nursing education has been compared with service learning, community health nursing, and nursing in the community.
COMMUNITY-BASED CURRICULA
5
These terms are not interchangeable with CBNE. Community-based nursing education also does not prepare community health specialists or consist of only a long series of observational experiences.
Service Learning A key component of service learning is the collaboration between academic and community partners to mutually define the meaning of service for the agency and of learning for the student (Peterson & Schaffer, 2000). There is a "reciprocal relationship in which both parties engage in both service and learning" (Peterson & Schaffer, 1999, p. 208). Other essential components of service learning are reflection on the experience and reciprocity in the relationship in which students, their educational institutions, and the community benefit (Callister & Hobbins-Garbett, 2000). Service learning is often associated with specific courses although some programs have service learning activities in multiple courses. Students work with a community to design and in some cases implement a project. While students rarely return to a community after the project is finished, some projects are designed to allow subsequent groups to continue a project (Bittle, Duggleby, & Ellison, 2002; Callister & Hobbins-Garbett, 2000; Kataoka-Yahiro & Cohen, 2002; Simoni & McKinney, 1998).
Community Health Nursing Community-health nursing (CRN), or public health nursing, is a process of delivering nursing care to improve the health of a community (Zotti, Brown, & Stotts, 1996, p. 212). While individuals may be the recipients of care, the overwhelming focus is on the total community, especially high-risk aggregates. The needs of the group can supersede the need or desire of the individual (Zotti, Brown, & Stotts, 1996). Community health nursing is a nursing specialty and not a philosophical approach to nursing care. A related misunderstanding is that CBNE prepares only community health nurses (Larsen, 2000). In fact, CBNE prepares nurses to work in all settings across all cultures and ages. Students complete the program as generalists with no more specialization in formal community health nursing than in the more traditional curriculum.
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Nursing in the Community Just because students are providing nursing care in the community does not mean they are engaged in CBNE (Bellack, 1998; Drevdahl, Dorcy, & Grevstadt, 2001). Nursing in the community occurs when a nurse is providing nursing care in a location not part of an acute care hospital. Examples are a nurse working with hospice clients or making home care visits to clients discharged from skilled nursing facilities. These nurses may share decision making with the client and family in light of their unique culture and needs. However, the major goal is implementing the specific plan of care dictated by the supervising provider while meeting regulatory requirements for documentation and follow up.
Observation Experiences Community-based nursing education is not simply observation after observation. Active involvement, empowerment, and accountability of the student in the design and implementation of care, in collaboration with the community, individual clients, and families, are key components (Gauthier & Matteson, 1995; Oneha, Magnussen, & Feletti, 1998; Wink, 2001). The students not only watch others complete activities, they take action. Students are expected to both meet learning objectives and take part in the problem-solving process to improve the experience for themselves and the community.
SETTING UP COMMUNITY-BASED CLINICAL EXPERIENCES Community-based clinical experiences in CBNE programs have several structures. Many are outlined in other publications (AACN, 2000; Matteson, 1995, 2000). Selected examples are given here. One structure is the development of partnerships with multiple community groups and agencies, which are then used in specific clinical courses (Fahrenwald, Fischer, Boysen, & Maurer, 1999). An example is a campus partnership with a local urban life center. Working with the community, the school of nursing and undergraduate students address the needs of the clients of the center, located in a disadvantaged
COMMUNITY-BASED CURRICULA
7
neighborhood. Projects include annual health fairs, a nursing student project to implement a public health initiative for children six and younger, establishment of a clothes closet and food pantry, a community flu vaccine project, and the development of a children's Web page for health information (Riegle, Sackett, & Seidl, 2000). In another example, a clinical group and the instructor work for a full rotation at a public school to provide care to the many aggregates at the school including students, family members, faculty, and staff (Peters, 1995). A modification of this approach is when students work in multiple communities where the school of nursing has developed partnerships (Johnson, Graham, & Workman, 2000). In one school of nursing, students are exposed to three communities over the curriculum, and they return to all communities more than once as they progress thorough their specialty coursework. The senior project takes place in one of these communities with which students are familiar because of their prior experiences (S. Johnson, personal communication, March 19, 2002). The second structure is the development of community nursing centers or "hubs," under the direction of faculty, to which students return repeatedly over the course of the curriculum (Feldman, et al., 2000; Johnson, Graham, & Workman, 2000; Matteson, 1995, 2000; Wink, 2001; Yoder, Cohen, & Gorenberg, 1998). These nursing centers may provide primary health care, a site for faculty practice, and a site for faculty and student research (Feldman, et al., 2000; Keefe, D'Meza, Laken, 2000; Kelly, 1995). More commonly, rather than provide primary care services, they are a central point of operation for a wide variety of projects with community partners. Students interact with the community, community residents, and multiple agencies and institutions, using activities and projects as a means of entry to the community. One of the most important outcomes of these experiences is that the students interact with clients "on the clients' own turf." These clients do not always act like patients, they act like consumers. The problems they present are diverse and complicated, and the inadequacies of the established health and social support systems to solve them are made clear (Meservey, 1999). The students get to know the community well, as the community gets to know the students. Community nursing centers often start small with only a few partnerships and projects and then grow as requests for assistance from the community are received and new areas for partnerships are identified. Fourteen steps to accomplish this goal are presented in Table 1.1.
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TABLE 1.1
Setting Up and Maintaining a Community Nursing Center
1. All you need to start is a place to hang your cap. You need a place where you are "housed" both to store supplies, have a central meeting place, and sustain visibility. 2. Involve students as you develop partnerships and learning experiences. Students must take an active role and should be encouraged to identify, modify and implement projects that meet community needs and their own learning goals. 3. Focus on the priorities of the community. That is why you are there. Students learn to determine priorities with the community as they work to mesh programs to achieve their learning goals and the goals of the community. Community assessment and reassessment are essential. 4. Trust takes time. Community members are not familiar with academic programs, which are sustained over time and which are truly collaborative in nature. 5. Advertise and be visible. Community members need to know who you are, what you do, where you are, and when you will be there. 6. Set limits but remain flexible. No is an important word. Clearly identify what you can do and then do it well, but keep an open mind about new projects that may benefit students and the community. With new sites, start slow and let them grow. 7. Go with the flow. Unlike a clinical experience in a formal agency, things do not always go as planned. 8. Encourage problem-based learning. Self-directed learning and learning to problem solve are essential skills. 9. Clarify curriculum goals and then revisit objectives periodically. A lot of what students are invited to work on will not be nursing. Although other learning is valuable, it should not take over the experience to the detriment of clinical learning objectives. 10. Expect students to interact with the larger community. Students will ask questions, suggest new approaches, and meet key contacts. 11. Maintain contact with partners to sustain relationships. Treat each partnership as a precious gift. Let them know when you will be back, write thank you letters, and go to planning meetings.
COMMUNITY-BASED CURRICULA
TABLE 1.1
9
(continued)
12. For projects with an agency that overlaps the community nursing center, assign a single faculty liaison for communication and planning. Even the most interested community group or agency will not welcome dealing with multiple faculty on the same project. 13. Identify one faculty member to coordinate the community-based clinical component of the curriculum. This person can offer leadership and support to the community-based faculty group, help develop new sites, resolve problems, and do initial consultation with new partners. 14. Support faculty and students working in community-based clinical sites. This is a total school of nursing responsibility and can range from moral support to release time to understanding that teaching in community-based clinical sites is not the same teaching in acute care settings. Adapted from Wink, D. M. (2001). Developing a community nursing center. Nurse Educator, 26, 70-74 and Yoder, M., Cohen, J., & Gorenberg, B. (1998). Transforming the curriculum while serving the community: Strategies for developing community-based sites. Journal of Nursing Education, 37, 118-121.
STUDENT ACTIVITIES IN COMMUNITY-BASED NURSING EDUCATION Active learning, accountability, empowerment, and creativity are the four characteristics of student work in CBNE. Students are actively engaged in assessment, planning, implementation, and evaluation of nursing care with community partners. They also are directly accountable for the care they provide, empowered to act as change agents, and expected to use the knowledge they bring from their nursing education program (Gauthier & Matteson, 1995). Once students are encouraged to be creative, active learners, most will be. Students must be empowered to take action and act "outside the box." Such action will sometimes be independent. Students will demonstrate a level of independence that would be impossible in formal health care settings where students have little power or ability to act as change agents (Kiehl & Wink, 2000). Three approaches are found in CBNE that promote these characteristics in students: the total group, the team project, and the aggregate team. In the group approach, the entire student group participates in an activity. Working together, the group identifies components of the
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activity, divides responsibility among group members, and then implements, evaluates, and improves the project. An example is a communitywide disaster preparedness project in which students worked with a local hospital coordinator on all stages of the project. Law enforcement agencies, electric and gas companies, county fire, EMS, and flight services, and an observer from the Federal Emergency Management Association (FEMA) participated on site (P. Faulk, personal communication, March 22, 2002). In the team project approach, small (2-3 person) teams take responsibility for development of projects with specific community partners. For example, two students work with a local elementary school to set up yearly screening and referral programs, two others coordinate the health education classes at the literacy program, and two students set up and implement a community-wide education initiative as part of the school of nursing's "Still Back to Sleep" SIDS prevention program. Using this approach the student directors for the health classes at the literacy program met with the director of the program to identify potential topics. They then sent the list to the women in the class who chose the final set of presentations, coordinated sign-up of their peers for specific classes, distributed the schedule to their peers and the program director, and developed the bilingual evaluation form. In the aggregate team approach, students again work in teams but focus on aggregates in the community. For example, teams explore services for children, senior citizens, and the homeless. After assessing needs for their aggregate group, students identify specific services and develop with their community partners projects to meet identified needs. Another outcome of this approach is that students observe the impact of a problem, such as poor nutrition, across the continuum as teams working with different aggregates identify similar problems. For example, students, focusing on children, worked extensively with the faculty of a new charter school that was developing a program to evaluate the students for obesity. Students used a family centered approach to address the problem. They assessed height and weight, calculated Body Mass Index, identified children needing intervention, and then worked with the school and parent group to implement a program for weight control. While the student team focusing on the children did most of the planning, all students in the group had an opportunity to work on the project. This team also worked with children in other settings and was able to transfer their knowledge to the care of other groups with similar problems.
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11
EXAMPLE OF COMMUNITY-BASED NURSING EDUCATION At the University of Central Florida, the curriculum is designed to prepare students for increasing complexity and levels of responsibility as they progress through the two-year upper division program. This curriculum has been in place since 1997 (Kiehl, 2000). Table 1.2 presents the curriculum design for the basic undergraduate program. Clinical experiences are divided with approximately 40% in community sites and 60% in acute care and skilled nursing sites. Students are assigned to one community nursing center for all of the community focused courses. Students not only become familiar with the community, its people, government, geography, strengths, problems, and resources, but the community members also get to know the students. Because students return to the same community each semester, they can complete assessments or initiate projects in one semester and then return to implement, expand, or evaluate the project, or develop a new program in a subsequent semester.
First Semester First semester classroom and clinical work focuses on assessment and care for healthy communities and families. The didactic component includes courses in health assessment, therapeutic interventions (basic nursing skills), and the role of the professional nurse (Table 1.2). The course "Promoting Healthy Communities" introduces concepts of community health, health promotion, and nursing intervention across the continuum of care in a multicultural society. This course contains much of the content found in a classic community health course. The "Promoting Healthy Families" course introduces the concepts of community and family nursing as they relate to health and health promotion and contains much of the content typically found in courses on care of the childbearing family and well child. In the clinical course in the first semester, "Clinical Practice in Promoting Healthy Families Across the Lifespan," students are immersed in the community with which they will work over the next two years. They take a bus to the community, walk around neighborhoods, meet
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TABLE 1.2 Basic Undergraduate Program for Community-Based Nursing Education Fall Semester: Year-One (15 credits) Focus: Healthy Communities and Families 3 credits (30 hrs lecture/ Health Assessment 30 hrs lab) Therapeutic Interventions for Health 1 credit (30 hrs on-campus lab) Professionals Promoting Healthy Communities 3 credits (45 hrs lecture) Role of the Professional Nurse 2 credit (30 hrs lecture) Promoting Healthy Families Across the 3 credits (45 hrs lecture) Life Span Clinical Practice in Promoting Healthy 3 credits (135 hrs clinical) Families Across the Lifespan Spring Semester: Year-One (14 credits) Focus: Promoting Physical and Mental Health Pathophysiology/Pharmacology 5 credits (75 hrs lecture) Promoting Physical and Mental Health 5 credits (75 hrs lecture) Clinical Practice in Promoting Physical 4 credits (180 hrs clinical) and Mental Health in the Community Summer Semester: Year-One (9 credits) Focus: Critical Examination of Nursing Practice Critical Inquiry 3 credits (45 hrs lecture) Elective 3 credits (45 hrs lecture) Health Care Issues, Policy, & 3 credits (45 hrs lecture) Economics Fall Semester: Year-Two (14 credits) Focus: Nursing Care of Clients with Acute and Life-Threatening Illness Across Lifespan Clinical Practice in Caring for Clients with Acute Illness Leadership and Management Nursing Intervention in Mental Illness Clinical Practice With Mentally 111 Clients
Acute Illness 4 credits (60 hrs lecture)
4 credits
(180 hrs clinical)
3 credits 2 credits 1 credits
(45 hrs lecture) (30 hrs lecture) (45 hrs clinical)
Spring Semester: Year-Two (11 credits) Focus: Community as Continuum of Care Community as the Continuum of Care 3 credits (45 hrs lecture) Clinical Practice in Community 2 credits (90 hrs clinical) Selected Nursing Practicum 4 credits (180 hrs clinical) Role Transition 2 credits (30 hrs lecture) From University of Central Florida School of Nursing, Orlando, Florida. Reprinted by permission.
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13
with and interview key informants, participate in projects already established with community agencies, work in local health clinics and providers' offices, and implement teaching programs. The students explore the culture of the community, its diverse populations, and the legal and geographic characteristics of the area. Opportunities for basic assessments, for example, height, weight, and health history; health screening and education; and skilled intervention, such as immunizations, occur in nursing clinics and health fairs. Students complete a comprehensive community assessment and the first installment of a multisemester family case study. Families for the case study are primarily from the community in which the student is working, but some are drawn from the student's experiences during an observational rotation (two 12-hour shifts) on the labor and delivery and mother-baby units of the hospital that serves their community. Students write a weekly journal in which they set personal goals, describe activities in which they participate, evaluate how they met prior goals, and ask (and answer) questions raised during the clinical rotation. They also maintain a clinical log, documenting the number of hours spent in the community nursing center each week, the ages, gender, and ethnic group of clients, and types of activities. Faculty are present in the community with the students, making rounds between student sites and holding conferences daily or weekly so the whole group can share, learn from, and teach each other.
Second Semester In the second semester, the course "Promoting Physical and Mental Health" introduces students to the care of clients and families with chronic diseases and acute problems that have implications for long term health (Table 1.2). In-depth examination of therapeutic communication; common mental health problems such as depression, anxiety, substance abuse, and family violence; and nursing interventions to help clients, families, and communities address these problems are major components of the course. Half of the accompanying clinical course occurs in a skilled nursing facility and the other half in the community. During the skilled nursing facility rotation, students increase competence in psychomotor skills essential to client care and develop holistic multidisciplinary care plans
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addressing the client's and family's acute and long-term health needs. Journal and clinical logs are not required during this portion of the clinical. In the community, the students continue work on projects and with agencies and community members with whom they developed relationships in the first semester. Students spend approximately 80% of their clinical practice time in a single agency that provides care for clients with mental health problems. Where possible, the agencies are located in the community of the student's nursing center. Faculty continue to make regular rounds and hold conferences with the students. Because of the specialized nature of many of the mental health placements, a psychiatric clinical nurse specialist visits each group to offer additional support and answer questions. Students continue to submit a weekly journal and clinical log. They also complete the second part of their family case study and submit a series of interpersonal recordings based on therapeutic conversations with clients in the mental health sites. Table 1.3 presents examples of community-based activities in the first and second semesters.
Third Semester In the third semester, held during the summer term, the focus is a critical examination of nursing practice. The courses are "Critical Inquiry" (nursing research) and "Health Care Issues, Policy, & Economics" (Table 1.2). There are no community-based activities in this semester. Students are invited to participate voluntarily in health-related community events in their community, and the community experiences of prior semesters are used as exemplars in both courses. Students often bring real world practice issues to their course projects. For example, when they write letters to government officials, they write about real problems faced by the communities and community residents with whom they have worked over the past year.
Fourth Semester The focus of the fourth semester is the nursing care of individuals and families experiencing acute, unstable, and life-threatening health
COMMUNITY-BASED CURRICULA
TABLE 1.3
15
Sample Community-Based Activities
First Semester • Head Start: Screenings (height, weight, blood pressure, development, and vision) • Walk-in screenings (blood pressure, glucose, hemoglobin, and lipids), education, and referral at the community nursing center • Medication reviews with senior citizens and clients at nursing centers • Participation in maternity and pediatric clinics • Development, presentation, and evaluation of an educational program to community residents • Assistance with school health projects (screenings, immunization review, and education) • Assistance with community health fairs • Work with clients of Meals-on-Wheels • Immunization activities (childhood and influenza) Second Semester • Work in county domestic abuse shelters, take crisis calls (after the class), and interact with clients • Work in residential and day treatment programs for adults recovering from addiction, conduct health intake interviews, and participate in group therapy sessions • Visit homeless shelters to provide health education and counseling while learning from residents about what it means to be homeless • Participate in day programs for clients with developmental and physical disabilities, conduct small group health education sessions, and accompany clients to their group homes and on outings with staff • Work at nurseries with children who are victims of abuse and those removed from their homes because of inability of parents to care for them
problems (Table 1.2). In "Nursing Care of Clients with Acute and LifeThreatening Illness Across the Lifespan," students study the care of both children and adults, and the corresponding clinical rotations are on pediatric and acute adult care units in a hospital. Two of the rotations are set up so students can make home visits to clients seen in the acute care area. The clinical practice experiences emphasize the holistic nature of client and family needs as they deal with acute illnesses. Students also complete a course, "Nursing Intervention in Mental Illness," that addresses the more complex psychiatric illnesses that often require high intensity and ongoing care. The corresponding clinical
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rotation is in a facility that provides inpatient care for clients with complex and acute mental health problems. The leadership and management course presents scientific theories and principles of leadership and management applied to health care settings with an emphasis on the role of the nurse. There is no formal community-based experience in this semester. However, students return to their case study family to complete the third part of their paper. In addition, they participate in at least one event in their community and begin planning for their spring semester project. Journals are not required during this term, but students submit a clinical log for any community activities.
Fifth Semester The final semester in the nursing curriculum integrates content from prior semesters (Table 1.2). The course "Community as the Continuum of Care" presents community-based practice models, from a global perspective, that effect changes in the health status, health risk, and selfcare capacity of target populations. The nurse is viewed as a change agent and case manager. The final segment of the family case study is completed during this course and includes a multidisciplinary action plan that examines the needs of the family, and individuals in the family, over the next five years. In the clinical component for this course, students return to their communities where they base their activities on community assessment data, use case management strategies, act as a change agent, incorporate principles of ethical decision making in care, use technology in care planning and implementation, and formulate a method to evaluate outcomes. The projects students complete must demonstrate their competencies beyond those mastered in earlier clinical courses. Each project has an overall goal, specific objectives, clearly outlined steps for completion, and outcome measures to determine the effectiveness of the process itself and outcomes for the client group served. Students meet regularly with faculty, usually in the community while working on their projects, to review accomplishments and gain feedback and assistance from peers and the faculty member. Table 1.4 provides examples of these projects.
COMMUNITY-BASED CURRICULA
TABLE 1.4
17
Sample Community-Based Projects in Final Semester
• Implementation of grief counseling program for children in multiple schools. Nursing students complete local hospice's grief education program and then lead group sessions under guidance of faculty and hospice nurse • Implementation of health screening and education program at a homeless shelter. Students make referrals to free or low cost health care and work with day care director to improve nutrition for children • Peer counseling at teen residential facility with focus on life skills, communication, and goal setting • Work in local OB/GYN office to teach breast self-examination, nutrition, and prenatal care • Outreach to senior citizens including medication checks, blood pressure and blood glucose monitoring, and health fair that is student organized and implemented • Case management and education (breast self-examination, osteoporosis prevention, diet, exercise, and other topics) to residents of shelter for homeless youth and young women recovering from alcohol and substance abuse. • Case management to address health problems for clients receiving Meals on Wheels • Follow up on ongoing school wellness projects started earlier in year. Data used by school district to document need for physical education programs. • Work with county health department to gather data on prevalence of tuberculosis in homeless population and implementation of plan for intervention and surveillance • Implementation of teen pregnancy prevention program, including group and individual education classes, assistance in clinics, and follow up, in collaboration with family planning NP. • Coordination and presentation of series of group sessions focusing on self esteem, health, and personal growth for women in residential substance abuse treatment program. Included individual sessions with clients, participation in case management meetings at center, and identification of sources of assistance for women who were pregnant and had no supplies for infant care.
The culminating "Role Transition" course covers issues related to entry into professional practice and professional growth as students begin their nursing careers. Students also complete a clinical practicum with preceptors in an area of their own choice, generally an acute care area. In this course, students meet personal as well as course objectives with emphasis on fostering independence. A faculty member serves as
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a resource to the preceptor, makes rounds, meets weekly with the students, and responds to a weekly student journal.
COMMUNITY-BASED NURSING EDUCATION FOR RNS AND GRADUATE STUDENTS RN-BSN and MSN Students Registered nurses (RN) completing their baccalaureate nursing degrees and those in the RN-MSN program have community-based concepts introduced in their first "Transitional Concepts" course. Traditional community health content is included in a subsequent course in which students complete a community assessment and family case study. If possible, this assessment is on the community where they will practice in the "Community as the Continuum of Care" course. That course is the only one in which the RNs have regular contact with a faculty member in the clinical setting. Other clinical courses for RNs are with preceptors. The RN students participate in ongoing projects of the community nursing center. Projects of the RNs take advantage of their existing nursing knowledge and the fact that they are already licensed. For example, they may independently offer home visits to residents of a low income apartment complex or hold a nursing clinic at a homeless shelter. Because many RNs have little experience outside of the acute care area, they also increase their knowledge of community-based resources and how to work with clients on their own turf. It is not uncommon for even seasoned RNs to express feelings of inadequacy as they start this course, particularly when they recognize their knowledge deficits about community-based care. The RNs complete weekly journals with goals and reflection on their activities as well as develop a full plan for their individual project as described earlier for the basic students.
Graduate Students All graduate students examine the meaning of health and illness across the continuum of care in three, one-credit role courses. Students in the
COMMUNITY-BASED CURRICULA
19
nurse practitioner (NP) tracks, in pediatrics, adult, and family, examine community-based concepts in all of their clinical courses. The NP students also design, implement, and evaluate a community program through multisemester projects based in the community nursing center. In the first semester they gather community assessment data, often in conjunction with the undergraduate students in the community nursing center. They then design and implement a program to address one of the needs identified in the assessment. The final component is an evaluation of the outcomes of the project and presentation at our annual "Community Nursing Center Day." Many of the projects have had products, such as client education materials, educational aides, and programs, which were extended or used again in subsequent semesters. It is not unusual for students from all levels of our program to work collaboratively on a graduate student project. Table 1.5 provides examples of graduate student community projects.
CHALLENGES Community-based nursing education has numerous challenges. The first and most important is the need for a high degree of flexibility on the
TABLE 1.5 Sample Graduate Student Community-Based Projects • Development and implementation of sex and health education program for 5th graders. Follow up by undergraduate students • Implementation of seminars "No STD for Me!" at shelter for women and children • Falls prevention education program for seniors in community environment • Evaluation of impact of dietary approaches to stop hypertension education (DASH diet) on dietary compliance and blood pressure • Implementation of "Heart Power" program for children in Head Start • Implementation of diabetes nutrition education as part of health promotion and disease prevention program for clients at senior citizens apartment complex. Undergraduate nursing students continued program • Cholesterol screening in community, including screening and focused education by graduate and undergraduate students • Adolescent nutritional education at middle school, including development of instructional materials and presentation of classes
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part of the faculty, students, school of nursing, and community (Bellack, 1998). Presence of the faculty member in the community on the clinical days is essential (Oneha, Magnussen, & Feletti, 1998; Peters, 1995). Faculty cannot expect to "stop by school for a meeting" and then "drop in" to see the student in the clinical setting. Faculty presence also supports community members and agency preceptors who work directly with the students. However, community-academic partnership activities do not occur only at the times and places of the student assigned clinical "days." The more students and faculty can work at alternative times, the richer the experience will be. Board of Nursing rules help dictate how this can occur. Some experiences such as an immunization clinic usually mandate the presence of a faculty member or a formal preceptor arrangement. Other experiences, for example, assisting with a class for high school students on HIV given by community health educators, generally do not require the presence of the instructor. Some learning activities can be done with the faculty on beeper call if the students have already demonstrated competence in the activity. Non health care providers also can serve as preceptors, for example, as evaluators for educational presentations by students. Flexibility on the part of the school of nursing is needed. Faculty working in communities have obligations that are more complex than those associated with a single agency placement. In one semester, faculty and students in a single community may work with multiple agencies. Membership on community and local agency boards is common for community focused faculty as is attendance at multiple community planning meetings. Work over semester breaks is often needed to maintain partnerships. If other students, for example, RNs and master's students, work in the community, additional communication and coordination are required although these students may not be on the faculty's official class roster. Some schools use small grant money, for example from the local Area Health Education Consortium, to remunerate faculty for these additional responsibilities. Faculty whose prime education was in a highly specialized area of acute care need to learn community health concepts and develop collaboration skills. Faculty can be energized by moving to this new setting (Shea, 1995), but bringing students to a community where they work in several locations with multiple partners in one day is very different from going to an acute care unit in a single agency.
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21
Unfamiliarity with the structure of CBNE can be a problem for a state board of nursing when program approval is given and when accreditation is sought. Education of the board members about the implementation of such programs is essential as is active work on changes in state board rules regarding the clinical supervision of students in community settings (Larsen, 2000; Oneha, Magnussen, & Feletti, 1998). Carefully crafted accreditation reports also will result in successful evaluation by these outside agencies (Van Ort & Townsend, 2000). A review of CBNE by the American Association of Colleges of Nursing found that it clearly reflects all components of their Essentials of Baccalaureate Education for Professional Nursing Practice (Stanley, Kiehl, Matteson, McCahon, & Schmid, 2002). Issues of student and faculty safely are sometimes raised (Larsen, 2000). Student education about safe conduct in the community as well as prudent selection of clinical sites, similar to other community courses, is essential. Student safety is further enhanced by the fact that students often become an integral part of the community and are viewed as a group there to help (Carroll, Morin, Hayes, & Carter, 1999). Another concern is that students will miss out on essential specialty clinical practice because they are spending less time on inpatient acute care units. Again, this is rarely true. Because the students have exposure to all clinical specialties in the community, they can focus on the acute care aspects of the specialty when in the inpatient agencies. For example, through their work at senior citizens centers and health fairs, students bring to an acute care course extensive experience in interviewing and educating elderly people and an understanding of common medication regimes. Students begin their acute psychiatric nursing experience after working with clients in community-based programs in which they participated in the therapeutic regimen and developed their own therapeutic communication skills. Fiscal implications of CBNE also are challenges since there is an additional cost of travel and communication tools such as beepers and cell phones. Outside funding to support individual projects is a major way to help defer expenses (Hall-Long, 2000). Communication between faculty and students and with the community is a major challenge. A clinical log to both document clinical hours and confirm the scope and breadth of the clinical activities is essential. Logs can be paper and pencil or kept on a spreadsheet and sent electronically. Use of new technology, such as PDAs and the Nightingale tracker,
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NURSING EDUCATION AND THE COMMUNITY
facilitate both speed and completeness of essential information exchange (Connolly, Huynh, & Gornery, 1999; Thomas, Coppola, & Feldman, 2001). Faculty need both phone mail and a beeper to ensure contact can be made with students and community partners. The use of a cell phone, dedicated to community-based work, helps community members find faculty and students in addition to allowing easy communication by faculty and students among themselves and with the community. Sporadic, but real, student resistance to clinical experiences in the community is another challenge (Shea, 1995; Wink, Gichia, & Ramey, 2000). Most students respond favorably to the opportunity to use their growing nursing knowledge to make an impact on the health of the community and clients served by their nursing center. This is particularly noticeable in the final semester when they apply their knowledge and experience to design projects that make a difference. However, other students actively resist the ideas that anything done outside of the acute care setting has meaning and that they have a role in helping clients who lack health care resources. This problem can be addressed by designing a community-based experience that challenges the students and draws on their knowledge base.
CONCLUSIONS Community-based nursing education is an approach to nursing education that promotes academic, student, and community partnerships. Through these partnerships, students learn to develop, implement, and evaluate interventions that reflect the needs of the clients. Students are empowered to be change agents and creative in their care, regardless of the setting in which they work.
REFERENCES American Association of Colleges of Nursing (AACN). (1999). Position statement: Nursing education's agenda for the 21st century. Washington, DC: Author. American Association of Colleges of Nursing. (2000). Implementing community-based education in the undergraduate nursing curriculum. Washington, DC: Author. Bellack, J. (1998). Community-based nursing practice: Necessary but not sufficient. Journal of Nursing Education, 37, 99-100.
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Bittle, M., Duggleby, W., & Ellison, P. (2002). Implementation of the essential elements of service learning in three nursing courses. Journal of Nursing Education, 41, 129-132. Callister, L., & Hobbins-Garbett, D. (2000). "Enter to learn, go forth to serve": Service learning in nursing education. Journal of Professional Nursing, 16, 177-183. Carroll, M., Morin, K., Hayes, E., & Carter, S. (1999). Assessing students' perceived threats to safety in the community: Instrument refinement. Nurse Educator, 24(1), 31-35. Connolly, P., Huynh, M., & Gornery, M. (Winter, 1999). On the cutting edge or over the edge? Implementing the Nightingale Tracker. On-Line Journal of Nursing Informatics, 3(1). Drevdahl, D., Dorcy, K., & Grevstad, L. (2001). Integrating principles of communitycentered practice in a community health nursing practicum. Nurse Educator, 26, 234-239. Fahrenwald, N., Fischer, C, Boysen, R., & Maurer, R. (1999). Population-based clinical projects: Bridging community-based and public health concepts. Nurse Educator, 24(6), 28-32. Faulk, P., Walker, C., & Woods, D. (2000). Community-based nursing education at Tarleton State University. In Implementing community-based education in the undergraduate nursing curriculum (pp. 107-114). Washington, DC: American Association of Colleges of Nursing. Feldman, H., Colombraro, G., Lewenson, S., Landa, J., Kelleher, C., Greenberg, M., et al. (2000). The power of partnerships. Changing people and systems. Nursing and Health Care Perspectives, 21, 280-286. Gauthier, M., & Matteson, P. (1995). The role of empowerment in neighborhoodbased nursing education. Journal of Nursing Education, 34, 390-395. Hall-Long, B. (2000). Reaching outside the box. An academic-community model to prepare nurses for the future. Nursing and Health Care Perspectives, 21,116-121. Hunt, R. (1998). Community-based nursing: Philosophy or setting? American Journal of Nursing, 98(10), 44-48. Johnson, S., Graham, M., & Workman, D. (2000). Caring moments WITH communities: Implementation of community-based nursing education at the College of Mount St. Joseph. In Implementing community-based education in the undergraduate nursing curriculum (pp. 91-96). Washington, DC: American Association of Colleges of Nursing. Kataoka-Yahiro, M., & Cohen, J. (2002). Marketing principles for a learning-service community partnership model. Journal of Nursing Education, 41, 136-138. Keefe, M., D'Meza, J., & Laken, M. (2000). Integrating research, practice and education. Nursing and Health Care Perspectives, 21, 287-292. Kelly, B. (1995). Community based research: A tool for community empowerment and student learning. Journal of Nursing Education, 34, 385-387. Kiehl, E. (2000). In the shadow of the mouse all is not a magic kingdom: The experience of the University of Central Florida. In P. Matteson (Ed.), Community based nursing education: The experiences of eight schools of nursing. New York: Springer Publishing Co.
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Kiehl, E., & Wink, D. M. (2000). Nursing students as change agents and problem solvers in the community. Nursing and Health Care Perspectives, 21, 293-297. Larsen, P. (2000). Community-based curricula: New issues to address. Journal of Nursing Education, 39, 140-142. Matteson, P. (Ed.). (1995). Teaching nursing in the neighborhoods. The Northeastern University model. New York: Springer Publishing Co. Matteson, P. (Ed.). (2000). Community based nursing education: The experiences of eight schools of nursing. New York: Springer Publishing Co. Meservey, P. (1999). Learning in the city: What is the value added? Holistic Nursing Practice, 14(1), 77-83. Oneha, M., Magnussen, L., & Feletti, G. (1998). Ensuring quality nursing education in community-based settings. Nurse Educator, 23(1), 26-31. Oneha, M., Sloat, A., & Shoultz, J. (1998). Community partnerships: Redirecting the education of undergraduate nursing students. Journal of Nursing Education, 37, 129-135. Peters, R. (1995). Teaching population-focused practice to baccalaureate nursing students: A clinical model. Journal of Nursing Education, 34, 378-383. Peterson, S., & Schaffer, M. (1999). Service learning: A strategy to develop group collaboration and research skills. Journal of Nursing Education, 38, 208-214. Peterson, S., & Schaffer, M. (2000). Service learning: Isn't that what nursing education has always been? A strategy to develop group collaboration and research skills. Journal of Nursing Education, 40, 51-52. Riegle, E., Sackett, K., & Seidle, A. (2000). Community connections: Partners in health. University urban neighborhood partnerships. In Implementing community-based education in the undergraduate nursing curriculum (pp. 119-123). Washington, DC: American Association of Colleges of Nursing. Shea, C. (1995). Laying the groundwork for curriculum change. In P. Matteson (Ed.), Teaching nursing in the neighborhoods: The Northeastern University model (pp. 31-53). New York: Springer Publishing Co. Simoni, P., & McKinney, J. (1998). Evaluation of service learning in a school of nursing: Primary care in a community setting. Journal of Nursing Education, 37, 122-128. Stanley, J., Kiehl, E., Matteson, P., McCahon, C., & Schmid, E. (2002). Moving forward with community-based nursing education. Washington, DC: American Association of Colleges of Nursing. Stullenbarger, E., Kiehl, E., Wink, D., & Stanley, J. (2001). The discipline of nursing and the engaged campus: Collaborative partnerships. Paper presented at 1st Annual AAHE Disciplinary Meeting, Washington, DC. Thomas, B., Coppola,]., & Feldman, H. (2001). Adopting handheld computers for community-based curriculum: Case study. Journal of the New York State Nurses Association, 32(1), 4-6. Van Ort, S., & Townsend, J. (2000). Community-based nursing education and nursing accreditation by the Commission on Collegiate Nursing Education. Journal of Professional Nursing, 16, 330-335. Wink, D. M. (2001). Developing a community nursing center. Nurse Educator, 26, 70-74.
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Wink, D., Gichia, J., & Ramey, E. (2000). AACN report on implementation of community based nursing education. In Implementing community-based education in the undergraduate nursing curriculum (pp. 125-128). Washington, DC: American Association of Colleges of Nursing. Yoder, M., Cohen, J., & Gorenberg, B. (1998). Transforming the curriculum while serving the community: Strategies for developing community-based sites. Journal of Nursing Education, 37, 118-121. Zotti, M., Brown, P., & Stotts, R. (1996). Community-based nursing versus community health nursing: What does it all mean? Nursing Outlook, 44, 211-217.
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Chapter 2 Community-Based Curricula at the ADN Level: A Service-Learning Model M. Elaine Tagliareni and Elizabeth Speakman
uring the past decade, as the health care arena shifted emphasis from acute care to community-based care, nursing faculty in Associate Degree Nursing (ADN) programs responded to these changes in order to prepare graduates for emerging roles. Similarly, faculty in both associate degree and baccalaureate nursing programs have been challenged to create complementary paths to meet emergent health care needs (Tagliareni & Mengel, 2000). Yet the task to develop interactive and contemporary curriculum models has been complicated by the lack of clear indicators to provide direction. Nursing faculty look for guidance from national organizations and publications (which provide a focus but do not furnish clear prescriptions for action), for example: Healthy People 2010 (U.S. Department of Health and Human Services, 2000); Nursing's Agenda for Health Care Reform (American Nurses Association, 1991); A Vision for Nursing Education (National League for Nursing [NLN], 1993); the Pew Health Professions Commission (Shugars, O'Neil, & Bader, 1991); and the National League for Nursing Accrediting Commission (1999). Despite this lack of clear focus, there has been consistent and steady movement by undergraduate nursing faculty to integrate communitybased care into programs of learning. Yet progress needs to quicken and include partnerships with community agencies through service learning approaches. The ultimate goal of this partnership is to find a common ground in nursing education and practice that reveals a shared purpose
D
27
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NURSING EDUCATION AND THE COMMUNITY
for nursing—working together to improve the health status of Americans. This chapter describes a service-learning model at the Community College of Philadelphia designed to build that common ground. Partnership development focused on collaborative relationships between the Department of Nursing and local agencies to deliver health promotion and disease prevention services to residents in the local community. Partnership development also included the emergence of colearners and collegial relationships between students and faculty to meet the needs of the local community. Additionally, linkages with baccalaureate programs in Philadelphia including the National Nursing Centers Consortium (NNCC) enhanced the ability of faculty to prepare nursing students for interactive and collaborative practice in today's health care environment.
INNOVATION AT COMMUNITY COLLEGE OF PHILADELPHIA: THE 19130 ZIP CODE PROJECT In the mid-1990s, nursing faculty at the Community College of Philadelphia realized that, even with their deep commitment to students and to the health of Philadelphians, the nursing department did not know and fully understand the health care needs of the neighborhood around the college. In January 1996, the nursing faculty began an initial assessment of the college's neighborhood, the 19130 zip code in lower North Philadelphia. It quickly became apparent that a wide variety of health care services, previously unknown to faculty, existed within the immediate college neighborhood. Based on this assessment, faculty designed a service-learning project to provide health promotion and disease prevention services in the local community around the college. The Independence Foundation of Philadelphia funded the project. In January 1999, the Independence Foundation funded an evaluation project to develop and implement measures to assess the impact of health promotion and disease prevention activities carried out by the nursing faculty and students in partnership agencies. This project focused on a description of the health promotion and disease prevention services provided to clients in the 19130 zip code. Currently, project faculty are refining measures to describe the impact of these services to vulnerable populations in the college's neighborhood.
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29
Both projects were designed to foster collaborative relationships with neighborhood agencies to meet local nursing needs and to provide health promotion and disease prevention services to targeted groups in partner agencies. These services are characterized by on-going assessment of the needs of individuals and families, collaboration with agency staff, sensitivity to the needs of culturally diverse populations and a strong emphasis on health education. At present, activities undertaken by the Department of Nursing in the local neighborhood have focused primarily on target groups served by partner agencies and on expansion of health promotion and disease prevention services determined to be essential to the mission of these agencies. Currently, students and faculty provide these services during more than 5,500 encounters each semester.
A CONSIDERATION OF CURRENT LITERATURE Traditionally, literature about innovation in community-based curricula in undergraduate nursing education has emerged from baccalaureate programs. Matteson (1995, 2000) and Nehls, Owen, Tipple, and Vandermause (2001) described a number of community-based education projects in baccalaureate education, which highlight service learning through interdisciplinary education and partnership development between educational institutions and the community. Recent literature also includes descriptions of community-based experiences in associate degree education, which stress the importance of partnership development, community assessment activities, and use of non-traditional agencies for delivery of health promotion and disease prevention services (Lusk & Decker, 2001; Tagliareni & Marckx, 1999; Tagliareni & Murray, 1995). Interestingly, the approaches suggested by both associate degree and baccalaureate degree nurse educators are more similar than dissimilar. Both sources present a vision of community-based nursing education in which nursing as service is taught and learned, educational goals and objectives flow from the needs of the community, and partnership development is integral to achievement of successful outcomes. In some ways, debate about whether an associate or baccalaureate degree is the right educational preparation for nursing's mission to serve the public is an artifact of the late twentieth century (Mengel & Donnelly, 1999). The literature is replete with references to the new health care system that demands nurses at all levels who can prove effectiveness of
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both cost and quality through evidence-based practice and who understand community-based approaches to delivery of nursing care in a wide variety of clinical situations. Practice today requires a new skill set that includes community assessment, interdisciplinary management competencies, collaborative skills to foster partnership development, documentation for evidenced-based practice, utilization of research for care planning, and evaluation of health impact and cultural sensitivity in nontraditional community settings (American Association of Colleges of Nursing, 1999; Heller, Oros, & Durley-Crowley, 2000; NLN Accrediting Commission, 1999; O'Neil & Coffman, 1998; Tagliareni & Mengel, 1999). The move to population-based systems of care has reinforced the belief that nursing curricula derive from practice, and practice demands a workforce that is competent in population-based approaches to nursing care. To exclude one level of nursing from attainment of these basic skills is to ignore the mandate to move toward population-based approaches to delivery of essential nursing services. Past models of conflict and competition between the levels of nursing education will not address this demand. Essential to development of this new skill set is a curriculum that teaches the knowledge and ability to work in a world of change and ambiguity (Lindemann, 2000; Tagliareni & Sherman, 1999). Current literature links socialization into the profession, defined as teaching methods to foster a student's self-confidence, leadership ability, and sense of empowerment (Nehls, Owen, Tipple, & Vandermause, 2001), with development of faculty-student relationships. Relationships are encouraged and nurtured within the context of a curriculum that is solidly based in concepts consistent with integration of populationbased care. Students and faculty, in partnership, engage in clinical education that promotes service, and educational goals and objectives emerge from the needs of individuals and families in the local community (Hurst & Osban, 2000; Matteson, 2000; Tagliareni & Coleman, 1999).
SERVICE LEARNING AND COMMUNITY-BASED EDUCATION Service learning coupled with community-based nursing education is a definitive strategy to assist educators to prepare nurses for the 21st century (Poirrier, 2001). To accomplish this goal, nursing faculty at the
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31
Community College of Philadelphia have developed teaching/learning methodologies to address the needs of the local community and have expanded clinical learning experiences beyond the experiential mode. Increasing services to vulnerable populations by extending existing services is less costly than creating new models of care. As part of their learning, nursing students, in collaboration with zip code agency partners, design and offer health promotion and disease prevention programs that meet the needs of individuals and families in the local neighborhood. Assessment of the neighborhood's needs has indicated that health promotion and disease prevention strategies are often neglected in local agencies because of more pressing health and safety needs. School nurses, for example, often find their health promotion goals and program displaced by the immediate needs of children who come to school sick or in crisis. By making the delivery of primary health care programs a part of every nursing student's education, service to clients in the zip code is expanded at minimal cost. At the center of service learning initiatives is an emerging understanding, by nursing faculty and students, that strengthening social networks and enhancing the exchange of ideas and strategies with zip code agency partners result in improved access for residents to neighborhood primary care services. Coordination of collaborative planning with neighborhood organizations based on shared purpose has emerged as an important and exciting role for the Department of Nursing. Expanded social network linkages between the Department of Nursing and neighborhood agencies have the potential to enhance health promotion and disease prevention services for neighborhood residents and families. The 19130 Zip Code Project is fully integrated into the college's associate degree nursing curriculum. Concepts of community-based care, issues of cultural competence, and principles of collaborative, interdisciplinary care delivery of health promotion and disease prevention services are introduced in the first year of the curriculum and are expanded in subsequent semesters. In the second year of the nursing program, all nursing students spend three weeks per semester engaged in delivery of health promotion and disease prevention services in the 19130 Zip Code Project. Table 2.1 describes a profile of their experiences. From 1996 to the present, nursing students and nursing faculty provide health promotion and disease prevention services in over twenty partner agencies in the lower North Philadelphia community. Four types
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TABLE 2.1
Profile of Student Experiences3
Percentage of students rotating through the health promotion/disease prevention nursing center:
100% of second year associate degree nursing students
Number of students engaged in nurse-managed clinic activities:
Spring 2001 = 87 Fall 2001 =91
Number of hours spent in nursing center per student:
Each student spends six 6-hour days per semester for two semesters Total hours per student = 72 hours
Total number of hours spent by students in neighborhood partner agencies:
Spring 2001 = 3132 hours Fall 2001 = 3276 hours
"From January-December 2001.
of partner agencies are currently being used to provide primary health care services: public schools, preschool programs, primary care clinics, and residential independent living apartments. Most of these agencies serve preschool and school-age children and/or vulnerable older adults. Although the largest population in lower North Philadelphia is people aged 15 to 34 years, faculty in the Department of Nursing made a deliberate choice to focus on vulnerable older adults and children based on community assessment activities. Most services are provided during the academic year; during the summer months, faculty and student volunteers respond to agency needs. Table 2.2 lists client profile data for calendar year 2001. Nursing students and faculty develop and implement health promotion and disease prevention programs in all partner agencies in collaboration with agency staff. Students conduct classes and one-on-one counseling for individuals and families. Sample classes offered by students include asthma care for parents and teachers; diet, exercise, and insulin control for residents diagnosed with diabetes; and diet and exercise for individuals at risk for cardiac problems. Health education programs implemented in partner agencies are specifically directed toward those diseases with the highest incidence in lower North Philadelphia. Preventive services including health screening, immunization, and strategies to decrease the incidence of chronic disabling conditions such as heart disease, stroke, sexually transmitted diseases, and diabetes are
COMMUNITY-BASED CURRICULA AT THE ADN LEVEL
TABLE 2.2
19130 Zip Code Project Client Profile3
Characteristics of Clients Gender Male Female Race Black/African American White Latino Asian/Pacific Islander Age 3-9 10-19 20-44 > 44 a
33
%
48 52 70 16 12 2 38 36 12 14
From January-December 2001.
conducted according to a schedule determined in collaboration with agency staff. Referrals are made to appropriate health care services as needed. Tracking and follow-up of immunization records with referral to primary care providers are part of case management services. Additionally, screenings for height and weight, hearing, vision, growth and development, scoliosis, and lead levels at all agencies serving children are routinely carried out by nursing students throughout the academic year.
FOCUS ON DATA COLLECTION Nursing faculty, in collaboration with nursing students and agency partners, have refined and enhanced a needs assessment document that describes services in the local community. This document discusses an organizing framework of health promotion and disease prevention activities based on national guidelines for resource allocation of health care services (U.S. Department of Health and Human Services, 2000) and the Omaha Classification System (Martin & Scheet, 1992). Both sets of guidelines provide useful schemata to categorize nursing needs and describe delivery of services.
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NURSING EDUCATION AND THE COMMUNITY
The Omaha framework comprises four intervention categories to address health needs of individuals and families: (1) case management; (2) health teaching, guidance, and counseling; (3) surveillance; and (4) treatments and procedures, and provides a mechanism to collect descriptive data and facilitates incorporation of a strong health education component. Students and faculty collect simple descriptive data, such as the number of client encounters and types of health teaching and screening activities provided in partner agencies, using these four intervention categories. The Department of Nursing has developed a Webbased tool to facilitate data collection on health promotion. Table 2.3 reports the number of health promotion and disease prevention programs offered during the 2001 calendar year using Omaha nursing intervention categories to describe services. More encounters were recorded in the spring semester than in the fall semester because in the fall students spent a portion of their time conducting a neighborhood "walk-around" assessment and a needs assessment in collaboration with agency staff in preparation for service-learning activities. Students provided some health promotion and disease prevention services during the fall semester. In the spring semester, students returned to the same agency and provided services to greater numbers of community residents. Table 2.4 lists types of surveillance services provided in spring 2001, and exemplifies the comprehensive nature and variety of screening and
TABLE 2.3 Programs Offered in 19130 Zip Code Project Type of service
Health teaching, guidance and counseling Surveillance Case management (referral) Treatments and procedures Total number
Number of client encounters (Spring 2001)
Number of client encounters (Fall 2001)
2326
1760
4944 332
2947 126
509
143
8111
4976
COMMUNITY-BASED CURRICULA AT THE ADN LEVEL
TABLE 2.4
35
19130 Zip Code Surveillance Interventions11
Type of surveillance Back examination (scoliosis) Blood pressure Cholesterol Functional assessment General health assessment Growth and development Head lice Hearing Height and weight Hemoglobin Urine Vision Tracking for immunizations and health records
Number of client encounters
243 949 14 43 165 64 29 532 945 10 53 910 987
Spring 2001.
health promotion and disease prevention services delivered to neighborhood residents in partner agencies. Currently, nursing faculty are working collaboratively with the National Nursing Center Consortium (NNCC) in Philadelphia to develop a data collection tool based on identification of uniform data elements and national targets from Healthy People 2010 goals for the nation (Anderko & Kinion, 2001). The 19130 Zip Code Project is a member of the NNCC, and nursing faculty serve on its governing board and work groups. The mission of the NNCC is consistent with that of the 19130 Zip Code Project, that is, to enhance the health and wellbeing of the constituencies served by nursing centers and to improve community health through neighborhood-based comprehensive primary health care services (Hansen-Turton & Kinsey, 2001). Additionally, the educational goals of the 19130 Zip Code Project, to provide community based, service-learning experiences for associate degree-nursing students and to afford opportunities for nursing students to provide culturally competent care to vulnerable populations, are enhanced by data collection activities. Consideration of Healthy People 2010 objectives to determine outcome measures for collection of health promotion and disease prevention data has been useful in making recommendations for the development of the data collection tool.
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LESSONS LEARNED Experience of Being Co-learners with Faculty Students immersed in these new service-learning experiences are asked to explore the unknown and to challenge assumptions about how individuals and families access care and attend to current health needs (Poirrier, 2001). The experience of being co-learners with faculty is essential to this process. When students join faculty to co-experiment in the learning process, students begin to feel attached to the learning process and enter into a learning contract that helps them to mature and feel effective (Speakman, 2000). When relationships with faculty are linked with opportunities for autonomy and collaborative care planning, students begin to perceive themselves as effective providers of care, and their self-confidence deepens. In her daily log, a fourth-semester nursing student described her metamorphosis: Although clinical experience in the hospital is crucial to learning assessments, basic nursing skills, and communication skills, it was not until I stepped outside of the structured environment of the hospital that another facet of learning took place for me. The 19130 Zip Code Project has helped to foster my independence while at the same time has helped me to learn the importance of teamwork. When I went out into the community, it was just myself and another student. Individually we had to do assessments, do one-on-one teaching, and keep a daily journal. As a team we had to conduct interviews, collect data, and write and carry out a teaching plan. We talked with our instructor about our plans and received feedback, but there wasn't an instructor watching over us in the community, telling us what to do. We had to tap into our own resources. The experience for me was like driving a car for the first time without my parents, totally empowering!
Students: Members of Community Nursing students at the college typically live, work, and complete their education within the Philadelphia community. Eighty percent of the college's nursing graduates remain in Philadelphia to serve their neighbors as RNs, contributing to the health and economy of the region. They are rooted deeply into the community. This is not unlike the
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37
national profile of nurses who graduate from community college nursing programs. In the United States, the majority of all new RNs graduate from associate degree programs (O'Neil & Coffman, 1998). The majority of these individuals, who traditionally represent diversity in age, gender, race, academic ability, and socioeconomic status, stay to work in their local community, providing health care services across the life span in a wide variety of settings—acute care, long-term care, ambulatory care, and community-based centers. Projects like the 19130 Zip Code Project provide these students with a foundation to plan nursing care that is responsive to communitybased nursing needs. Their frame of reference for the provision of health care to diverse groups is firmly grounded in an understanding of the need for a continuum of care, with the local neighborhood as the common ground for delivery of essential services. Another student describes her new outlook: The Zip Code Project is important to me because I live near the neighborhood where many of the sites are located. When I first heard about the Zip Code Project, I thought that it had little significance to me. After we started our community rotation, I found out exactly how significant it was, not only to me but also to many people who live in the surrounding communities. The Zip Code Project is important to me as well as other residents because of the way it serves the population. We go out to the schools, daycare centers, and rest homes and assess each individual situation. We listen to what residents perceive as their needs instead of deciding for them what we think their needs are. The Zip Code Project has shown us how to identify the needs of individuals as well as large groups. The work that is completed by each group of students doesn't end when the rotation is over but is passed on as building blocks for the next rotation. This is important so that new students know that they have a responsibility to live up to not only their own expectations but also those of the previous students, residents, and teachers.
Racial and Ethnic Diversity of Students One of the most crucial issues currently facing nursing practice and nursing education today is the underrepresentation of nurses from minority backgrounds (Griffiths & Tagliareni, 1999; Mengel & Sherman, 1997; O'Neil & Coffman, 1998). Though individuals from minority populations represent 25 to 35% of the United States population, individuals from minority backgrounds comprise only 12.3% of the approximately two and one-half million nurses currently licensed to practice,
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NURSING EDUCATION AND THE COMMUNITY
and a significantly lower percentage of those professionals prepared in higher degree programs (U.S. Department of Health and Human Services, 2001). The 19130 Zip Code Project has the potential to change that reality. The majority of minority students in Pennsylvania begin their college education at the Community College of Philadelphia. Currently, racial and ethnic minorities comprise about 47 percent of the nursing students at the college. During their experiences in the 19130 community, minority students interact as nurses in environments where their cultural group is dominant. They often realize, for the first time, that a career in nursing is not necessarily acute care-based and that meeting the health care needs of vulnerable populations in local neighborhoods is important and relevant work. Based on their experiences in a wide variety of community care settings, students from minority backgrounds become confident in their ability to pursue advanced degrees in nursing, a route that is supported by strong articulation agreements with local universities. One graduate commented, "I never saw myself as a person who was capable of attaining a master's degree. But now I feel a commitment to being with clients in the community and to finding a way to facilitate their ability to be healthy and productive."
View of Baccalaureate Degree as Extension of the ADN Program As a result of the 19130 Zip Code Project, nursing faculty at the Community College of Philadelphia encourage students to regard the baccalaureate degree as an extension of their current learning, rather than as a distinct and perhaps intimidating course of study. Faculty have introduced students to concepts of population-based health care, beginning research skills, and problem-based critical thinking methodologies to prepare students for the university learning environment. With the new focus on community-based care in the curriculum, students from the Community College of Philadelphia have the opportunity to earn credits for knowledge and skills acquired in the associate degree program in both community health nursing and leadership and management courses in baccalaureate programs. Competency in community-based care has become the common ground for articulation as associate degree nursing students seek to further their education to
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provide health care that is based solidly on an understanding of neighborhood health care needs. A new graduate describes her view of the community: Many people, including myself, think of a nurse only in an acute care setting and patients as people who are sick in a hospital. The 19130 Zip Code Project opened my eyes to the world of nursing beyond the hospital door, enabling me to see people not as patients but as individuals with a purpose and important roles in their community. This concept is best understood through the 19130 Zip Code Project experience. Here is a small synopsis of what I tell others: The community is a circle of nurturing. It's where nursing begins, teaching clients about their own health with prevention as a focus, and where nursing goals are ultimately achieved, returning the person to his or her home as a viable functioning member of that neighborhood. Since the client is in the community setting for the majority of his or her life, focusing my efforts in that area allows me to take a more proactive role in my own community. In the future, 1 hope to incorporate what I have learned from my community rotation in dealing with my own clients. 1 plan to remember that the most essential outcome of nursing is to keep people as a healthy part of their community.
FINDING THE COMMON GROUND The 19130 Zip Code Project represents the nursing department's commitment to a community-based approach to curriculum design. By extending the primary health care services currently available in zip code partnership agencies, nursing faculty and students at the Community College of Philadelphia believe that involvement in the 19130 Zip Code Project through a service-learning project will make a positive, lasting difference in the lives of our students and our community. Finally, there is no magic formula for curriculum reform; no one design will fit all nursing programs uniformly. The challenges of an ambiguous, uncertain health care future cannot be addressed with rigidity. Nor can these challenges be addressed with traditional approaches to undergraduate nursing education that fail to include partnerships with students, with community agencies, with all levels of nursing education, and with national nursing organizations to meet the common goal of service to the public. Common sense tells us that we need to build on each other's skills and strengths (Fitzpatrick, 2001). Faculty who are creative, innovative, and willing to accept community-based care as the common ground will lead the way.
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ACKNOWLEDGMENT The authors gratefully acknowledge the support of the Independence Foundation of Philadelphia for its assistance in extending health care services to residents of lower North Philadelphia. REFERENCES American Association of Colleges of Nursing. (1999). Essential clinical resources for nursing's academic mission. Washington, DC: Author. American Nurses Association. (1991). Nursing's agenda for health care reform. Kansas City, MO: Author. Anderko, L., & Kinion, E. (2001). Speaking with a unified voice: Recommendations for the collection of aggregated outcome data in nurse-managed centers. Policy, Politics, &• Nursing Practice, 2, 295-303. Fitzpatrick, J. J. (2001). The learning academy. Nursing and Health Care Perspectives, 22, 169. Griffiths, M., & Tagliareni, M. E. (1999). Challenging traditional assumptions about minority students in nursing education. Nursing and Health Care Perspectives, 20, 290-295. Hansen-Turton, T., & Kinsey, K. (2001). The quest for self-sustainability: Nursemanaged health centers meeting the policy challenge. Policy, Politics, &> Nursing Practice, 2, 304-309. Heller, V. R., Oros, M. T., & Durney-Crowley. (2000). The future of nursing education. Ten trends to watch. Nursing and Health Care Perspectives, 21, 7-15. Hurst, C, & Osban, L. (2000). Service learning on wheels: The Nightingale mobile clinic. Nursing and Health Care Perspectives, 21, 184-187. Lindeman, C. (2000). Nursing's socialization of nurses. Creative Nursing, 6(4), 3. Lusk, M., & Decker, I. (2001). Moving toward a model for nursing education and practice. Nursing and Health Care Perspectives, 22, 81-84. Martin, K. S., &Scheet, N.J. (1992). The Omaha System: A pocket guide for community health nursing. Philadelphia: W. B. Saunders. Matteson, P. S. (Ed.). (1995). Teaching in the neighborhoods. New York: Springer Publishing Co. Matteson, P. S. (Ed.). (2000). Community-based nursing education: The experience of eight schools of nursing. New York: Springer Publishing Co. Mengel, A., & Donnelly, G. (1999). Associate degree and baccalaureate degree nursing education: Finding complementary paths in a population-focused health care system. In M. E. Tagliareni & B. Marckx (Eds.), Teaching in the community: Preparing nurses for the 21st century (pp. 95-101). Boston: Jones and Bartlett. Mengel, A., & Sherman, S. (1997). Access to higher education for all Americans—the role of associate degree nursing. In V. Ferguson (Ed.), Educating the 21st century nurse (pp. 109-118). New York: NLN Press.
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National League for Nursing. (1993). A vision for nursing education. New York: Author. National League for Nursing Accrediting Commission. (1999). Interpretive guidelines for standards and criteria. New York: Author. Nehls, N., Owen, B., Tipple, S., & Vandermause, R. (2001). Lessons learned from developing, implementing, and evaluating a model of community-driven nursing. Nursing and Health Care Perspectives, 22, 304-307. O'Neil, E., & Coffman, J. (Eds.). (1998). Strategies for the future of nursing. San Francisco: Jossey-Bass. Poirrier, G. (2001). Service learning: Curricular applications in nursing. Boston: Jones and Bartlett. Shugars, D., O'Neil, E., & Bader, J. (1991). Healthy America: Practitioners for 2005, An agenda for U.S. Health Professional Schools. Durham, NC: Pew Health Professions Commission. Speakman, E. (2000). The phenomenon of attachment between faculty and students and its effect on self-empowerment at an urban community college. Unpublished doctoral dissertation, Teachers College, Columbia University. Tagliareni, M. E., & Coleman, 1. (1999). Associate degree nursing students assess neighborhood health care. In M. E. Tagliareni & B. B. Marckx (Eds.), Teaching in the community: Preparing nurses for the 21st century (pp. 210-223). Boston: Jones and Bartlett. Tagliareni, M. E., 6s Marckx, B. B. (Eds.). (1999). Teaching in the community: Preparing nurses for the 21st century. Boston: Jones and Bartlett. Tagliareni, M. E., & Mengel, A. (1999). Nursing competencies in community settings: Results of a community-based DACUM activity. In M. E. Tagliareni & B. B. Marckx (Eds.), Teaching in the community: Preparing nurses for the 21st century (pp. 51-64). Boston: Jones and Bartlett. Tagliareni, M. E., & Mengel, A. (2000). Broadening clinical education in basic nursing education. In J. M. Dochterman & H. K. Grace (Eds.), Current issues in nursing (pp. 112-117). St. Louis, MO: Mosby. Tagliareni, E., & Murray, J. (1995). Community focused experiences in the ADN curriculum. Journal of Nursing Education, 43, 366-371. Tagliareni, M. E., & Sherman, S. (1999). When ambiguity replaces certainty, new faculty roles in community settings. In M. E. Tagliareni & B. B. Marckx (Eds.), Teaching in the community: Preparing nurses for the 21st century (pp. 20-34). Boston: Jones and Bartlett. U.S. Department of Health and Human Services. (2000). Healthy people 2010: National health promotion and disease prevention objectives. Washington, DC: Author. U.S. Department of Health and Human Services. (2001). The registered nurse population, findings from the National Sample Survey of Registered Nurses. Washington, DC: Author.
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Chapter 3 Professional-Community Partnerships: Successful Collaboration
Teresa Shellenbarger
rofessional-community partnerships provide a strategy for dealing with the rapidly changing environments in health care and higher education. The purpose of this chapter is to provide readers with information about the benefits of professional-community partnerships, steps in partnership formation, strategies to sustain partnerships, possible partnership problems, and resources for partnerships.
P
BACKGROUND In 1993, the American Association of Colleges of Nursing (AACN) published a position statement, "Education and Practice Collaboration: Mandate for Quality Education, Practice, and Research for Health Care Reform." In this statement the AACN suggested that "excellence in practice, education, and research can best be attained when those in education and practice settings combine their talents in productive exchanges. In addition, systems for delivery of high-quality care can be improved by the use of a collaborative process. Therefore, AACN recommends that all schools of nursing establish, maintain, and evaluate collaborative relationships with practice settings" (p. 1). During these changing times for businesses, educational institutions, and health care, it is an opportune moment to think about expanding the AACN statement that all health care professionals establish, maintain, and evaluate collaborative relationships with the community, 43
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NURSING EDUCATION AND THE COMMUNITY
to include "working together to address areas of interest and concern." Collaborative relationships are the substantive interchange of human and material resources for the purpose of advancing common goals in practice, education, and research (AACN, 1993, p. 1). AACN further asserts that nursing leaders in practice and education have the responsibility of directing the future of nursing's role in health care reform through a sharing of values and principles. Professional-community partnerships can be defined as professionals working collaboratively in a reciprocal relationship with the community that builds on strengths and meets the needs of all parties. This partnership may involve professionals in health care organizations such as hospitals, health care agencies, skilled nursing facilities, rehabilitation facilities, and other health care delivery sites. Professionals in educational settings may also be involved in these partnerships. The community may include service organizations such as the American Heart Association or the Red Cross, civic organizations such as the Rotary Club or Lions Club, faith-based organizations such as health ministries, special interest groups, and other community members. Table 3.1 provides a listing of potential partners.
WHY PARTNER? The time is right to consider partnership activities for health care institutions, educational facilities, and the community. Many changes in the delivery of health care have necessitated a new way of looking at how business is conducted.
Importance for Health Care Institutions The state of the changing health care system characterized by fragmented delivery, limited reimbursement for nursing care, decreasing federal spending on social issues, accountability for attainment of outcomes, and the increased need for services makes today an ideal time to look at partnerships. Additionally, changing national demographics including the increasing elderly population with multiple chronic illnesses, the impact of the environment on community health, and the need to manage complex health problems at home necessitates a re-examination
PROFESSIONAL-COMMUNITY PARTNERSHIPS
TABLE 3.1
45
Potential Partners
Educational facilities Partnerships with preschools, elementary and secondary schools (public and private), Head Start, parent-teacher organizations, local libraries, and other educational organizations Faith communities Partnerships with church groups, church leaders, and YMCA/YWCA Local citizens and civic organizations Partnerships with youth groups such as Girl and Boy Scouts, 4H, Rotary, Lions, Veterans, Kiwanis, American Association of Retired Persons, and other community organizations Governmental supported organizations Partnerships with Social Security Administration, Cooperative Extensions, Job Centers, Public Welfare, Department of Health, law enforcement, and elected governmental officials Health and human service organizations Partnerships with Women, Infants, and Children programs, homeless shelters, food banks, local chapters of national organizations such as the American Cancer Society, American Heart Association, and American Red Cross Community-based health care delivery sites Partnerships with adult day care, continuing care communities, hospices, rehabilitation services, and nursing homes Businesses Partnerships with drug stores, pharmacies, health clubs, medical equipment and supply firms, insurance companies, and the Chamber of Commerce Media Partnerships with newspapers and radio and television stations Philanthropy Partnerships with foundations and granting organizations, including the United Way
of health care practices. It is difficult to have an impact on the community and provide care to those in need without considering the contribution that others can make. Probably the most pressing reason for considering partnerships is the existing national nursing shortage. Health care facilities are now struggling to fill and keep qualified nursing staff in crucial positions. A
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collaborative relationship with others in the community may be the ideal tool to help recruit and retain qualified nursing personnel.
Importance for Educational Institution Partnerships are not only important for health care facilities to consider but also for nursing faculty. As the shift to a community-based curriculum has occurred, faculty have had to consider how partnerships with community members can help provide quality learning experiences for students. These partnerships provide students with a variety of useful experiences to develop skills in communication, assessment, collaboration and team building, leadership, and adaptation to change. Working intensely with community members provides students with first hand knowledge of the actual needs and issues facing community members. Community partnerships enable students to see care delivery prior to admission to tertiary care facilities, as well as follow-up after hospital discharge. Students also have the opportunity to apply what is learned in the classroom to a broad range of recipients. Collaborative partnerships with the community may help faculty to adequately prepare a nursing workforce to meet the needs and demands for the future health care environment. Objective 1-7 of the Healthy People 2010 Objectives suggests that there should be an increase in the proportion of schools of medicine, nursing, and other health professions whose basic curriculum for health care providers includes core competencies in health promotion and disease prevention (U.S. Department of Health and Human Services, 2000). With the emphasis on health promotion and disease prevention, students have exposure to those skills through the delivery of primary prevention activities. An added advantage of partnerships with the community is the fostering of civic duty and community responsibility. Students have the opportunity to build a lasting connection with the community and may feel a commitment to care for the community and its needs while developing leadership skills for effective citizenship. The benefits to faculty also are a consideration when asking why partnerships are important. Faculty struggle to meet the demands of academia by attempting to provide outstanding performance in areas typically evaluated including teaching, scholarship, service, and practice. In the past, faculty may have been forced to conduct activities in various
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sites leading to a scattered approach. Community partnerships can provide faculty with a streamlined way to integrate these areas into a common focus. A faculty member may use the partnership as a clinical teaching site for students, as a practice site for care delivery, to conduct research, and to provide service to the community through committee membership or other activities. As faculty work intimately with community members, they may become aware of community needs and issues that can be incorporated into a program of work, leading to collaborative grant activities, further practice and teaching opportunities, and other scholarly opportunities such as presentations and publications resulting from partnership work. Finally, many universities and professional groups seek to serve the local community. Partnerships with community members may help to fulfill the mission of some of these institutions. A collaborative relationship may help to advance the health status, economic, political, and cultural strength of the community.
Importance for the Community Partnerships sound like a good idea for educational and professional groups, but why would communities want to get involved? The community and organizations within it also may seek to achieve goals of improved health, elimination of disparities, and civic involvement, yet they may lack the knowledge and resources to achieve these goals. A partnership approach allows the community to collaborate on issues of importance and encourages all partners to participate in the process. It also emphasizes listening to the voices of those directly affected by problems and issues. By working with the partnered community, members directly associated with issues may be able to suggest more effective ways to achieve goals and accomplish tasks. Community members can help to identify problems and concerns and can participate in suggesting ways to resolve the issues based on their knowledge of the community. People living and working within the community know how to get things done, know what will work and will not work in that setting, and may have creative ideas for accomplishing goals. This insider information is valuable in program planning. A collaborative approach may make it easier to get services to those who truly need the care, not those whom "experts" perceive need the care.
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The typical model of care delivery emphasizes competition for scarce financial dollars. Partnerships force those involved to see care in a different way. Partners seek to collaborate in working together rather than working against each other. The goal with partnerships is cooperation rather than competition. Through this collaborative model, members seek to identify duplication of services and to develop ways to meet needs that work for all parties. If less effort is spent on competitive projects, more effort can be focused on enhancing services that are provided. This approach may help to address economic and performance pressures that many are feeling in today's market of accountability. Some partnerships are forming in health care. Many hospitals are joining health care networks, and physician groups are banding together as well, but these partnerships are forged primarily out of a financial need. In addition, there is limited community input and collaboration occurring in these types of partnerships. Therefore, the drive to develop other professional-community partnerships must come from some other sources. FORMING A PARTNERSHIP Partnership formation may evolve in various ways. There are no strict rules that must be followed, and no definitive steps required for all partnerships. Table 3.2 provides a listing of Internet resources that might be helpful in partnership development. Sometimes partnerships emerge from already established relationships, and at other times efforts are directed at partnership development among previously uninvolved parties. The nature of the institutions, community profile, and context may lead to partnership development. There are some general steps that can be followed when establishing a partnership. These steps include: topic identification, awareness of issues, development of the partnership, community action, and evaluation. Keep in mind that partnership is an ongoing process. Once the partnership is formed, it may continue to evolve over time as new issues are addressed, new members join, or evaluation data suggest new directions.
Topic Identification A common first step in the development of a partnership is the identification of a topic or concern. The Healthy People 2010 Objectives may be
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Resources for Partnership Development
Coalition for Healthier Cities and Communities http://www.hospitalconnect.com/healthycommunities/usa/index.html Community Campus Partnerships for Health http://futurehealth.ucsf.edu/ccph.html Community Tool Box http://ctb.lsi.ukans.edu/ Health Profession Schools in Service to the Nation Program http://futurehealth.ucsf.edu/hpsisn.html Health Resources and Service Administration Academic/Community Partnership Initiatives http://bhpr. hrsa. gov/hrsaacpi. htm Healthy People 2010 Toolkit http://www.health.gov/healthypeople/state/toolkit Healthy People in Healthy Communities http ://odphp. osophs. dhhs. gov/pubs/healthycommunities/hcomm2 .html The National Association of Community Health Centers http://www.nachc.com/ The Pew Charitable Trusts http://www.pewtrusts.com
used as a guide for identification of possible issues to address. Table 3.3 provides a listing of some common health concerns that would lend themselves to partnership development. Potential members need to ask what are the shared experiences or concerns? Faculty, community members, and other professionals may feel that a need or desired goal is not being achieved, that the current methods of care do not adequately address the issues, or that new questions and concerns need to be raised. For example, a nurse working in a community hospital identifies that there is limited information and support to assist family caregivers once a patient is discharged from the hospital. As the nurse begins to explore available resources, she contacts a local home nursing agency, where a staff member confirms the problem and indicates that families are still in need of information and support after the patient is discharged from home care. Further exploration with others involved in care delivery such as Aging Services leads to the identification of a community-wide problem. There is duplication of some support services and a lack of support for other needs of caregivers in the community. A number of community members decide to address the problem collaboratively and a partnership is formed.
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TABLE 3.3
Potential Health Problems for Partnership Development
Substance abuse Tobacco use Violence prevention HIV/STD prevention Safe sex Obesity Low infant birth weights Asthma management Cardiovascular risk reduction Cancer prevention and screening Teenage pregnancy Environmental health Crime prevention
Awareness of Issues The next stage, developing awareness of issues, requires partners to ask some crucial questions. These questions may include: • • • • • • • • •
What is the issue or concern to be addressed? Who cares about this problem? Who should be involved? What do we want to do? Why is this important at this time? What resources do we have, and what resources do we need? What are our strengths and how can we contribute? What are our weaknesses, and how can we get past them? Who has the power to influence change?
For a partnership to be effective, it is important for potential partners to discuss these questions during the early stages of partnerships (Cauley, 2000). As partners are selected, it is helpful to brainstorm a list of possible members who are interested in the topic. The group should consider potential partners that can add diversity or can bring a different perspective to the group, and those directly involved with or affected by the issue. Although it is important for partners to represent a wide range of
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stakeholders in the community, it is critical to include a key community leader. This is someone who has connections, knows community issues and members, gets things done, and is respected in the community. The addition of a community leader to a partnership increases the likelihood that the community will support it. During this awareness stage, potential partners may come and go as people and agencies explore the partnership and assess their fit with the group. Some potential partners will determine that a partnership is not for them. Now is the time for people to "test the waters," knowing that the final partnership will not be complete until a later stage.
Development of Partnership Once the crucial assessment questions have been answered and potential partners have inventoried their strengths and weaknesses, a partnership can begin to develop. During this next stage, partnership development, planning activities can take place. Members can collaboratively arrive at a shared vision or purpose, write a mission statement, set goals for the group, plan projects, and seek support. It is helpful if the purpose of the group can be stated simply so that it is easy to remember, thereby keeping everyone focused on the issue. For example, a partnership developed to address cardiovascular health issues might focus on improving heart-healthy lifestyles. Next in the partnership development stage, the partners should write a specific mission statement that supports the vision and provides a clear outcome-oriented approach to the problem. Through collaborative efforts the Healthy Hearts partnership may focus on decreasing the incidence of hypertension for African Americans by 15%. A specific, yet descriptive, mission statement will provide clearer direction for the partnership work than global mission statements like "improve community health for African Americans." The mission statement should lead to an action plan. This plan, developed in cooperation with the partners and community, specifies what actions will be taken, who will carry out the actions, when and where the activities will take place, how the projects will get done, a timeline for actions, and the evaluation strategies. While planning, the partners may identify other people or resources to include in the various activities, thus the partner composition may continue to change.
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Seifer and Maurana (2000) suggested use of a formal partnership agreement to formalize the partnership and action plans. They recommended that the agreement include a statement of goals, roles, responsibilities, and key tasks and expectations for members. It also should include details about how work gets done and who "owns" the work generated through the partnership. During this planning stage, it is important to establish a forum for open communication that respects other members' knowledge and opinions, and builds trust. Team building strategies developed at this point may contribute to the ultimate success or failure of the partnership over time.
Community Action The next step is the community action stage. During this stage, partners conduct the activities as outlined in the earlier planning process. Programs, projects, and research are completed during this stage. It is important to remember that the activities undertaken should be developed specifically for the community and its situation. A "one size fits all" program will probably not be successful because it will not address the particular needs of the community and partners.
Evaluation The final stage in partnership is evaluation. There should be ongoing evaluation of the partnership and collaborative activities. Members need to continually reassess the goals, projects, and effectiveness of the work and their partnership. It is helpful to keep records of activities and projects so that partners can monitor progress over time. Additionally, this documentation might be of use in future project planning and grant seeking. Members need to know what is occurring and the effectiveness of activities so they can decide to keep what works and revise what is ineffective. Partners need to continually evaluate their attainment of outcomes and measure their progress in an effort to improve. Evaluation feedback allows partners to assess their continued involvement with group activities and identify future projects and other possible partners.
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SUSTAINING PARTNERSHIPS Sustaining a partnership can be difficult. There are a variety of strategies that can be used to help maintain the partnerships that have developed. Building the working environment for partnership sustainability is crucial for ongoing success. Partners need to have an open forum for discussion and disagreement. Providing opportunities to discuss issues is critical. Members need to feel comfortable stating opinions and sharing ideas without being criticized if they express divergent views or opinions. A trusting relationship develops through mutual respect for others. Members need to value and respect the knowledge and expertise of other members. All members can make valuable contributions to the group. Even though some members may not have formal education or training, they have expertise that should be shared with and valued by the members of the partnership (Wolff & Maurana, 2001). Another key aspect to sustainability of the partnership is the inclusion of key community members. A common mistake in partnership formation is including only professionals in the partnership. To be effective, those individuals directly affected by the concern or issue should be included. The partners should find out from community experts what is important to community members and how partner activities can help reach community goals. For example, if poverty were identified as the community issue to be addressed, it would be important to have residents of low-income neighborhoods included as partners. Another potential problem in sustainability is the selection of concerns or issues of individual members rather than community issues. For example, a nursing faculty member may have a research focus on smoking cessation and may want to initiate smoking cessation programs. The community, however, sees violence prevention as its most pressing need. Without community support and buy-in, a program or project will probably not generate widespread use. Knowing the history and past experiences of the community also will help ensure sustainability. Perhaps community members have had negative experiences with professionals in the past. Having an understanding of past problems can help to prevent partners from making the same mistakes and undermining progress. Partnerships require members to rethink the traditional models of leadership and group dynamics. For effective partnerships the group
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interactions should encourage a sharing of responsibilities and resources. One member should not dictate the work or conduct all the partnership activities. There should be collaboration and sharing. Members need to contribute their knowledge, resources, and expertise, and in cooperation with each other, work to accomplish the group goals. Members bring unique and diverse talents to the group. Those talents need to be utilized to further the group work. For example, one member may be an expert grant writer. While that person may prepare a grant application to support partner activities, other partners need to contribute to the development of the project. Ideally, the grant writer could help develop the skills of the other partners, thereby empowering them for future success. Sustainability of the group also requires attention to the group meetings and work time. Having regular contact with partners is important. That contact can be through group meetings, phone conversations, or e-mail communication, with consideration given to the scheduling of meetings and locations that are convenient to the partners. There are times when some partners will not be able to meet, but it is still important to update those partners missing from the meetings on progress and work of the group. Part of the regular communication that goes on should be updates on progress. Members need to be involved not only in planning activities but also in the evaluation feedback loop. It is necessary for partners to know the data gathered during evaluation. This knowledge will help partners be aware of group progress and assist in ongoing partner activities and future planning. Another key aspect of sustaining a partnership is to celebrate and reward success. Letting others know of the efforts and successes of the partnership is critical. Sharing news about the partnership can take a variety of forms including newsletters, community publications, media announcements, and personal communications. The dissemination of news about partnership activities can build community support and help the partnership gain recognition.
PREPARATION OF STUDENTS FOR PARTICIPATION IN PARTNERSHIP Faculty and students can be critical to the success or failure of the partnership. Students who will be working with community members
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need to be adequately prepared for the experience. Providing sufficient orientation, communicating clear expectations, and preparing for safety and emergencies are critical. Students also need to understand the community standards, norms, culture, and structure, and to be sensitive to those issues. From a learning perspective, the community activities in which students participate should be linked to course objectives. These experiences should not be "added on" or a replacement for other learning activities, but instead should be integrated within the course. Finally, a critical component to enhance student learning is an opportunity for reflection. Students need to reflect on their experiences, for example, through group discussions and learning journals. These activities encourage students to develop critical thinking and evaluation skills and also provide feedback to the faculty member.
POSSIBLE CONCERNS FOR PARTNERS Like any union of people, partnerships are not without their problems. At the initial developmental stages, there can be potential problems that set the partnership up for failure. The selection of partners may be a problem, whether it is individual personalities or the dynamics of the group. In establishing a partnership, members should consider the social, racial, religious, ethnic, economic, and educational differences among the partners and how these differences could create problems. Another possible problem can be the vision, mission, or goals of the partnership. Unwritten, unclear, or unrealistic expectations can lead to poor planning by the partners and ultimately lead to failure. The very nature of academic institutions can create problems for partnerships. For example, the academic schedule can create gaps in a calendar of community offerings. If partnership activities involve student participants, partners need to prepare and plan for what happens when students are away over spring break, summers, and semester breaks. If partnerships involve delivery of services, how will care delivery continue with students and faculty gone? Differences between the community and academia also can create problems. The typical mode of thinking for those in academic institutions is to "do for" the community rather than to "do with" the community. Traditionally, those in clinical nursing education arrive at a clinical
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site and complete the tasks that were identified for the course without much regard for the recipients. Many possible community partners may be afraid of being used in such a way (Maurana & Goldenberg, 1996). A second problem is that professionals may not have all the answers even though they may think they do. Community experts may know more about community issues, but may not feel empowered to question professionals. Partnerships require that members view situations in new and creative ways, which can create problems for those comfortable with traditional thinking. Members may need to think beyond "the way we have always done this" and think about innovative approaches. This requires a new way of conducting business. Partners need to deal with issues of power, control, and accountability. Group progress and process may be different from what is typically encountered in traditional work situations. Members may not be accustomed to sharing resources and power. The partnership model forces faculty and other partners to participate in the decision-making process in an unaccustomed way. Decisions need to be arrived at by the group rather than by individuals. Additionally, members may experience reduced independence since decisionmaking is not a solo effort. Group members may not be accustomed to trusting others, sharing knowledge and information, and valuing differences. Group leaders may not have the skills needed to ensure collaboration rather than competition. This lack of trust and lack of leadership can undermine the partnership. Leaders need to be comfortable sharing power and ideas and helping to enable collaboration and empowerment of members. Time also becomes an issue for partners to consider. Having group meetings, arriving at group decisions, and collaborating on partner projects can be time intensive. It may take longer to accomplish a specific task by working as a group than by completing the task independently. Members need to consider this time element and include careful planning to allow for these potentially increased time demands. A major problem for many professional-community partnerships involves funding. Do the agencies have the financial resources to carry out the projects proposed? If not, are grant funds available to support the project? It is difficult to document the effectiveness of partnerships in improving health since there are multiple factors that could influence these outcomes, yet funding sources expect documentation of these outcomes (Lasker, Weiss, & Miller, 2001). If a grant is written, who
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claims credit, how is the disbursement of funds managed, and who gets the funds? If funds are sought through grants, what happens after the funding period is over? Community members may come to depend on the services developed through the partnership, so partners need to have a clear plan for sustainability of projects after a funding period ends. Other concerns include the reward for participation. Many systems do not reward members for participation in partnership activities. Faculty needs to consider how these activities will be viewed in light of tenure and promotion requirements. Do other partners acknowledge the value and benefits of the partnership, and are members given incentives for participation? Another consideration dealing with rewards is the funding system. Do funding agencies value collaborative partnership activities? Many grant sources are now recognizing the value of interdisciplinary work and encouraging grant applications with partnership initiatives.
SUMMARY Although possible problems exist, partners should consider the overwhelming benefits of working together. This reciprocal relationship allows partners to share knowledge and resources and build on each other's strengths to provide an environment that meets the needs of all stakeholders. Before embarking on a partnership, potential members need to consider the possible problems and use strategies to ensure success and sustain the partnership.
REFERENCES American Association of Colleges of Nursing. (1993). Education and practice collaboration: Mandate for quality education, practice, and research for health care reform. Washington, DC: Author. Cauley, K. (2000). Partners have agreed upon mission, values, goals and measurable outcomes for the partnership. In K. Connors & S. D. Seifer (Eds.), Partnership perspectives (pp. 13-18). San Francisco: Community-Campus Partnerships for Health. Lasker, R. D., Weiss, E. S., & Miller, R. (2001). Promoting collaborations that improve health. Education for Health, 14, 163-172. Maurana, C. A., & Goldenberg, K. (1996). A successful academic-community partnership to improve the public's health. Academic Medicine, 71, 425-431.
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Seifer, S. D., & Maurana, C. A. (2000). Developing and sustaining communitycampus partnerships: Putting principles into practice. In K. Connors & S. D. Seifer (Eds.), Partnership perspectives (pp. 7-12). San Francisco: CommunityCampus Partnerships for Health. U.S. Department of Health and Human Services. (2000). Healthy People 2010 [CDROM]. Washington, DC: Author. Wolff, M., & Maurana, C. A. (2001). Building effective community-academic partnerships to improve health: A qualitative study of perspectives from communities. Academic Medicine, 76, 166-172.
Part II
Mentoring and Preceptorship
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Chapter 4 Strategies for Promoting Nontraditional Student Retention and Success
Marianne R. Jeffreys
he nursing profession must be ready to embrace a new age of realism with regard to the changing student population. Currently, the dramatic shift in demographics, the restructured workforce, and a less academically prepared college applicant pool have created a more diverse nursing applicant pool (Kelly, 1997; Tayebi, Moore-Jazayeri, & Maynard, 1998). The projected increases in immigration, globalization, and minority population growth have the potential to enrich the diversity of the nursing profession and to help meet the needs of an expanding culturally diverse society (Bessent, 1997; Griffiths & Tagliareni, 1999; Tucker-Allen & Long, 1999; Yoder, 2001). Thus, the untapped potential of the nontraditional student population demands a focused attention on promoting nontraditional nursing student success. Unfortunately, the retention rates of nontraditional students are substantially lower than for "traditional" students (Bean & Metzner, 1985; Bessent, 1997; Levin & Levin, 1991; Tucker-Allen & Long, 1999). Although attrition is financially costly to students, educational institutions, and society, the severest impact can be the adverse psychological costs to the student (Nora, Cabrera, Hagedorn, & Pascarella, 1996; Rowser, 1997; Tinto, 1993). Enrollment trends, retention rates, professional goals, societal needs, and ethical considerations all declare the need to prioritize the retention of nontraditional students. Nurse educators are in a key position to positively influence retention. As active partners in the complex
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process of nontraditional nursing student retention, nurse educators can design theoretically and empirically supported retention strategies specifically targeting the nontraditional student population. Design of a diagnostic-specific strategy first requires an understanding of the dynamic and multidimensional phenomenon of nontraditional student retention, the complex interaction of influencing variables, and insight into the student's perspective (Harvey & McMurray, 1994; Jeffreys, 2001). An extensive search in the nursing and higher education literature revealed several conceptual models to explain undergraduate student attrition (Bean & Metzner, 1985; Metzner & Bean, 1987; Nora, 1987; Pascarella & Chapman, 1983; Spady, 1970; Tinto, 1975). However, only one model specifically targeted the nontraditional student. Subsequently, the Bean and Metzner (1985) model of nontraditional undergraduate student attrition provided the underlying conceptual framework for several studies on nontraditional undergraduate nursing student retention Qeffreys, 1993, 1998, 2001, 2002). Results from these studies supported the theory that nontraditional students often juggle multiple roles such as student, parent, financial provider, and/or employee and, therefore, were more influenced by environmental variables than academic variables. Additionally, students perceived family, faculty, friends, tutoring, and an enrichment program as greatly supportive Qeffreys, 2001, 2002). The main purpose of this chapter is to describe the process of designing, implementing, and evaluating an enrichment program (EP), specifically targeting nontraditional undergraduate nursing students. An illustrative case exemplar, using the Prenursing Enrichment Program (PEP), will complement each step of the process. The PEP consisted of free services for students: orientation, mentoring, tutoring, career advisement and guidance, workshops, networking, and transitional support services facilitated through a collaborative partnership in learning and professional development. The chapter will first provide an overview of the multidimensional process of nontraditional undergraduate nursing student retention, will present the Nontraditional Undergraduate Retention and Success (NURS) conceptual model as an organizing framework, and will define key terms. Evaluation of EP components, including academic outcomes, psychological outcomes, and variables influencing retention, will conclude the chapter.
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NONTRADITIONAL UNDERGRADUATE NURSING STUDENT RETENTION AND SUCCESS Retention has been examined and discussed extensively in both the higher education and nursing literature (Courage & Godbey, 1992; Tinto, 1998). Empirical studies, however, have been more limited and have targeted predominantly traditional students in baccalaureate programs. Many studies have focused on attrition through use of autopsy studies after the student has already withdrawn, rather than on retention. Although similar study variables have been examined, inconsistencies between operational definitions varied extensively, making comparison difficult (Garcia, 1987). Additionally, voluntary attrition, due to personal reasons, and involuntary attrition, due to academic failure, is often undifferentiated (Tucker-Allen, 1989). Diverse sample size, enrollment status, and methodology further compound this interpretive difficulty (Jeffreys, 1993). Among the studies guided by a conceptual framework, many used frameworks originally designed for the traditional student (Eaton & Bean, 1995; Metzner & Bean, 1987). Although many of the factors influencing nontraditional students across various disciplines are also relevant to nursing students, there are some distinguishing characteristics of the nontraditional undergraduate nursing student. As a profession, nursing also is different from liberal arts and science disciplines. Consequently, the NURS model (Figure 4.1) is proposed specifically for examining nontraditional undergraduate nursing student retention and success. Although it is beyond the scope of this chapter to discuss the NURS model in detail, the main features will be highlighted in an attempt to succinctly summarize the literature and enhance understanding of the multidimensional phenomenon of nontraditional undergraduate nursing student retention and success.
Purposes and Goal of the NURS Model The purpose of the NURS model is to present an organizing framework for examining the multidimensional factors that affect nontraditional undergraduate nursing student retention and success in order to identify at-risk students, develop diagnostic-prescriptive strategies to facilitate success, guide innovations in teaching and educational research, and
FIGURE 4.1
Model of Nontraditional Undergraduate Retention and Success (NURS).
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evaluate strategy effectiveness. While several models have been proposed to examine college student attrition, this model specifically focuses on the aspect of retention (rather than attrition) and targets a specific student population. The main goal of the model is to promote nontraditional undergraduate nursing student retention and success. The model is tentative and will require modification when new data become available.
Definitions To develop a common knowledge base and avoid discrepancies in definitions, Table 4.1 defines terms important in understanding nontraditional undergraduate nursing student retention and success.
Assumptions/Premises of Model Based on a review of the literature and previous studies of nontraditional undergraduate nursing student retention, several assumptions underlie the NURS model. Although it is beyond the scope of this chapter to discuss the assumptions in detail, the assumptions are listed below: • Nontraditional undergraduate nursing student retention is a priority concern for nurse educators. • Student retention is a dynamic and multidimensional phenomenon that is influenced by the interaction of multiple variables. • For the nontraditional nursing student, environmental variables and professional integration variables greatly influence retention. • All students, regardless of prior academic performance, can benefit from enrichment strategies throughout preprofessional and professional education. • Psychological outcomes and academic outcomes may interact and influence persistence (Bean & Metzner, 1985; Metzner & Bean, 1987).
Overview of Model The NURS model is presented in Figure 4.1. Briefly, the model indicates that retention decisions will be based on the interaction of student profile
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TABLE 4.1
Definition of Terms
Nontraditional undergraduate nursing student refers to a nursing student who is enrolled in an entry level undergraduate nursing program (diploma, associate degree, or generic baccalaureate) and who meets one or more of the following criteria: (1) age 25 years or older; (2) commuter; (3) enrolled part time; (4) male; (5) member of an ethnic and/or racial minority group; (6) speaks English as a second (other) language; (7) has dependent children; (8) has a general equivalency diploma (GED); and (9) requires remedial classes. (Note: The definition of "nontraditional" in nursing expands on Bean and Metzner's (1985) definition, the first three criteria above, to include groups traditionally underrepresented in nursing and to recognize the prevalence of decreased academic preparedness for college). Course retention is the continuous enrollment in a nursing course without withdrawal. Course success refers to passing the nursing course. Program retention is the continuous enrollment in a nursing program (part or full time) by taking the required courses sequentially until meeting the program's graduation requirements, possibly including courses repeated for previous withdrawal and/or failure. In ideal program retention, the student successfully completes the required courses sequentially, in the specified time period, and without evidence of withdrawal or failure. Interim program retention is the intermittent enrollment in a nursing program (part or full time) by taking the required courses sequentially until meeting the program's graduation requirements, possibly including courses repeated for previous withdrawal and/or failure. Program success refers to a student's (1) successful completing the program's graduation requirements, (2) passing the NCLEX, and (3) obtaining a part- or full-time job as a RN and/or enrolling in a baccalaureate or master's degree nursing program. In ideal program success, the student successfully completes the program's graduation requirements within the specified time period and without withdrawing or failing, passes the NCLEX on the first attempt, and obtains a job as a RN and/or enrolls in a baccalaureate or master's degree nursing program. Withdrawal is when students officially withdraw from a college course or courses due to personal and/or academic reasons. Stopout refers to a break in continuous enrollment for one or more semesters (excluding summer sessions and intercessions).
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TABLE 4.1
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(continued)
Attrition refers to students "dropping out" of the nursing program. Voluntary attrition is when a student drops out due to personal (nonacademic) reasons compared with involuntary attrition because of academic reasons (failure or dismissal). Student profile variables describe student characteristics prior to beginning a nursing course and include age, ethnicity and race, gender, first language, prior educational experience, the family's educational background, prior work experience, and enrollment status. Student affective variables are students' attitudes, values, and beliefs about learning and their ability to learn and perform the necessary tasks required for course and program success, including cultural values and beliefs, self-efficacy, and motivation. Academic variables include personal study skills, study hours, attendance, class schedule (Metzner, 1989), and general academic services (e.g., college library services, college counseling services, and computer laboratory services). Environmental variables are factors external to the academic process that may influence students' academic performance and retention (Metzner, 1989) and include financial status, family responsibilities, child care arrangements, family emotional support, family financial support, employment hours, employment responsibilities, encouragement by outside friends, and transportation. Professional integration variables are variables that enhance students' interaction with the social system of the college environment within the context of professional socialization and career development. These include nursing faculty advisement and helpfulness, enrichment programs, professional events, encouragement by friends in class, memberships in professional organizations, and peer mentoring-tutoring. Outside surrounding variables are factors existing outside of the academic setting and the student's personal environment that can influence retention such as world, national, and local events; politics and economics; health care system and nursing professional issues; and job certainty.
variables, student affective variables, academic variables, environmental variables, professional integration variables, academic outcomes, psychological outcomes, and outside surrounding variables. Outside surrounding variables have the power to affect student persistence and retention either positively or negatively despite positive academic and psychological outcomes for nursing. At the beginning of each nursing course, student profile variables provide information on the composition
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of the student group. Individual variables may interact with each other to increase or decrease persistence or risk of attrition. Similar to the Bean and Metzner (1985) model, it is presumed that environmental variables are more important for nontraditional undergraduate nursing students than academic variables. Also consistent with the model, academic outcomes interact with psychological outcomes. Good academic performance only results in retention when accompanied by positive psychological outcomes for the nursing program and profession. The voluntary and/or involuntary decision to remain in a course, persist in the nursing program, graduate, take the NCLEX, and enter the nursing workforce and/or begin a RN-BS nursing program occurs during and at the conclusion of each nursing course. Many models explaining attrition among traditional college students have emphasized the importance of social integration in college in student adjustment, persistence, and success (Nora, 1987; Pascarella & Chapman, 1983; Spady, 1970; Tinto, 1975). For nontraditional undergraduate nursing students, a new perspective of social integration is proposed. In the NURS model, professional integration variables represent variables that enhance students' interaction with the social system of the college environment within the context of professional socialization and career development. Results from recent studies (Jeffreys, 2001, 2002) have consistently identified professional integration variables, such as nursing faculty advisement and helpfulness, an EP, and peer mentor-tutoring, as instrumental in assisting with retention. Professional integration variables are at the center of the model because they are at the crossroads of the decision to persist, drop out, or stop out.
ENRICHMENT PROGRAM DESIGN, IMPLEMENTATION, AND EVALUATION Enrichment program design, implementation, and evaluation should be a systematic and well-planned process. This involves time, energy, money, commitment, collaborative partnerships, and a systematic plan. Figure 4.2 presents the eleven-step process that can guide EP development. Each step will be described followed by a case exemplar. The Prenursing Enrichment Program (PEP) case exemplar illustrates how this process can be adapted by other nurse educators interested in developing diagnostic-prescriptive enrichment programs for nontraditional undergraduate nursing students.
FIGURE 4.2 Enrichment program design, implementation, and evaluation process.
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Although the first phase of the process might appear to be "design," there is really a pre-design phase. This involves five steps: assessing the current situation, reviewing the literature, searching for grants, drafting a plan, and soliciting support. Each step will be described individually and within the context of the PEP case exemplar.
Step 1—Assess Current Situation A retention strategy or enrichment program should be designed for a specific situation and have empirical support (National League for Nursing Accrediting Commission, 1999). The first step is to systematically assess the current situation, including student profile variables, retention rates, success rates, departmental support, administrative support, and the existing college resources. A systematic assessment of the targeted student population can be initiated using the NURS model. The realization that there are multidimensional variables influencing retention and success is often overwhelming, yet it is essential to evaluate before designing the EP. The assessment of student profile variables can give a general description of the student population or can help the nurse educator target a specific student group. For example, a nursing program with many Englishas-second-language (ESL) students may need to incorporate language enhancement strategies into an EP. In the PEP case example, student perceptions had been assessed in a previously funded study. Descriptive results from the study of first semester nontraditional associate degree nursing students found that environmental variables were perceived as more influential for academic achievement and retention than academic variables (Jeffreys, 1993,1995, 1998). Students felt that family, faculty, and friends greatly influenced retention; however family responsibilities were thought to be severely restrictive. Overly confident students who rated their academic factors as greatly supportive had significantly lower nursing course grades. Students with a more conservative self-appraisal of academic and environmental factors had higher nursing course grades. This suggested that some students did not have realistic self-appraisals of strengths and weaknesses, or accurate comprehension of the skills needed for professional nursing education (Jeffreys, 1993, 1995, 1998). Because inaccurate perceptions could be detrimental to student retention and success, it
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was believed that an EP consisting of proactive, ongoing, and transitional interventions would be most effective (Jeffreys, 1993, 1995, 1998, 2001, 2002). Assessment of current retention rates should differentiate between course retention, ideal program retention, program retention, and interim program retention. Course retention is the easiest to assess. Comparison of course retention rates across various semesters and between courses can help identify trends within the overall program. However, tracking nontraditional students throughout the program is difficult for a variety of reasons. First, nontraditional students often attend college part time, and therefore a cohort group for analysis is difficult to identify. Second, nontraditional students often must "stop out" for nonacademic reasons such as pregnancy, childcare, care of a sick family member, financial strain, employment constraints, and other endless examples. Third, the institution's computer capability for tracking such nontraditional students who frequently attend college part time and stop out one or more times may be limited. Fourth, the individual tracking of students who stop out and attend part time is labor intensive, costly, at increased risk for human error, and results in a small number of students in many different cohorts. A small sample cohort becomes problematic when trying to use inferential statistical analyses. One recommendation would be to calculate three different program retention rates: ideal program retention, program retention, and interim program retention. After several semesters, a trend and student profile would emerge. This assessment could guide EP design to specific groups. For the purposes of the PEP, course retention rates across various semesters and for each of the clinical nursing courses was the primary focus. Assessment of current success rates should differentiate between program success and ideal program success. Additionally, the various components of "success" should be operationalized, measured, and compared for several semesters to look for common trends and/or gross disparities in trends. This means measuring graduation rates, NCLEX pass rates, employment rates, and baccalaureate enrollment rates. A problem in one area could have an impact on other areas. For example, failing the NCLEX will affect employment and enrollment in a baccalaureate program because an RN license is usually conditional for both options. Inclusion of program success was beyond the scope of the PEP; however, with future expansion of student support strategies and
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ongoing measurement strategies, it could be possible to evaluate the entire process of retention and success. Determining departmental support should address both conceptual and instrumental support. Conceptual support refers to the support of the idea of an EP and can range from passive support (listening without offering opinions and suggestions) to active support (advocacy, suggestions, and verbal commitment). It is valuable to have conceptual support from the chairperson, deputy chairperson, faculty, and staff. Instrumental support refers to allocation of resources such as expertise, money, released time, secretarial services, supplies, space, and teaching load distribution. After appraising departmental support, administrative support should be assessed. Determining administrative support first requires a comprehensive understanding of the institution's administrative structure, organizational culture, politics, policy, and procedures. Formally arranged meetings with key administrators can provide a valuable guide for EP development. Careful review of current and proposed college resources available to all college students and the adequacy or inadequacy of such services for nontraditional undergraduate nursing students is important to avoid duplication of existing services, substantiate the need for absent or insufficient services, and explore partnership possibilities and pooling of resources. After assessing each of these areas individually, the overall strengths and weaknesses in the already existing college resources can be surmised. This overall assessment should reveal areas that would need development and provide some basis to determine costs and feasibility. Without the conceptual support of the department and administration, there are too many obstacles that would impair feasibility and implementation. Conceptual support without some commitment to instrumental support also would pose obstacles, although with generous grant funding this could be overcome. Before designing the PEP, collaboration with the department chairperson resulted in both conceptual and instrumental support. The chairperson readily gave active support by offering encouragement for the idea and advocating the pursuit of the project. Instrumental support ranged from the chairperson sharing her expertise to acknowledging the future access to secretarial services and supplies. Administrative support was assessed during formally arranged meetings with the divisional dean and vice president of the college. College resource assess-
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ment revealed the absence of college tutoring services for nursing courses and the presence of several support services for student referral (such as personal counseling). College resources for the project director such as services via the institution's office of grants and research were identified. Collaborative partnerships with measurement experts and the director of institutional research were discussed in anticipation of the evaluation phase of the PEP. Conclusively, the overall assessment revealed that the institutional climate was favorable toward PEP development.
Step 2—Review Literature Next, a review of the nursing and higher education literature should be conducted. Materials should be reviewed for gathering background information about student retention, nontraditional students, retention strategies, evaluation methods, and funding sources. Choice of a relevant conceptual framework can be instrumental to the organization. When reviewing literature concerning other student support strategies, determining strategy strengths, limitations, and appropriateness of fit to the targeted population can help sort through various possibilities. One must be aware, however, that there is no panacea that enrichment programs will solve all problems and help every student succeed. Realistically weighing the possible benefits against the risk of doing nothing can help in the decision-making process. In the PEP, a previous compilation of literature on retention necessitated an updated review of the nursing and higher education literature. Published journal articles and books were reviewed and organized into specific categories, expanding the current literature files and making future retrieval and updates easy.
Step 3—Search for Grants Grant resources can be identified via a computerized search done by the nurse educator or by requesting assistance from the institution's office of grants and research. For the PEP, one specific funding source was selected. The funding was specifically allocated for public institutions, associate degree programs, and vocational education. Additionally,
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specific populations of students were targeted. Prior assessment of student variables in Step 1 supported the assumption that many students fell into the targeted categories, therefore it was appropriate to pursue this grant opportunity.
Step 4—Draft Plan Next, a written draft must be developed. Familiarity with the grant's terminology, goals, format, funding capabilities, and guidelines is important prior to drafting a plan. Grant specifications must guide the draft development. Relevant issues reported in the literature and assessment findings (Step 1) also should be incorporated throughout the plan. Clear identification of the need and justification based on the literature and assessment findings is a necessary precursor to establishing goals. At this point, goals should be broad and relate directly to the identified need. The draft should include an "idea" list, leaving details for later consideration. In the case example, data from the preliminary study of nontraditional associate degree nursing students strongly supported the need for the PEP. The use of a conceptual model as a proposed organizing framework for designing a retention strategy was an added strength. This suggested that the strategy would not haphazardly use a "trial and error" approach but based on available conceptual and empirical literature would use a systematic and detailed approach. The broad goal was to improve student retention. Brainstorming resulted in a list of possible retention strategy components. Reviewing the list for feasibility eliminated some strategies. Finally, prioritizing the remaining components provided an outline of ideas that could be a starting point for soliciting support.
Step 5—Solicit Support Although soliciting support can seem time consuming, the benefits of having conceptual and instrumental support commitments are invaluable and help build alliances and partnerships. Although both are important here, soliciting a significant amount of instrumental support commitments is an essential precursor to preparing a proposal. Although this step may seem similar to the assessment of support in Step 1, it has many important differences. First, this step builds on
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the collaborative relationship initiated in Step 1 that should then evolve (or be nurtured) into a collaborative partnership. A collaborative partnership can have varying degrees of direct or indirect supportive involvement but all could be potentially critical to the funding of an EP and ultimately its success. At this point of more formalized commitment to specific tasks, the anticipated time line for the tasks should be mentioned. This gives more structure and organization. For instance, if the timeline is not realistic, it can be adjusted before writing it into the proposal and setting up for failure later in a written progress report or final project report. Before preparing a proposal, it is important to tease out what strategies are feasible and realistic and what would be more problematic. In this way, the presence or absence of support will result in a modified list of possible strategy components. Instrumental support cannot occur without conceptual support, however conceptual support without instrumental support greatly limits the possibilities of EP success. Evaluating student support for various components is crucial before entering the design phase (proposal preparation and approval). The following examples were applicable to the PEP: • Students agree to actively use PEP services and/or encourage their use • Faculty members agree to make announcements in class to encourage students to use PEP services • Chairperson agrees to reserve an empty adjunct office to be used for possible peer mentor-tutoring • Administrators commit to support release time for project director • Director of Institutional Research agrees to actively assist with transcript data retrieval and data analysis • A colleague with psychometric expertise agrees to review questionnaire drafts • Two colleagues with relevant expertise agree to serve as expert reviewers for content validity.
Step 6—Prepare Proposal In the PEP, the broad goals listed in the draft plan (Step 4) needed to be rewritten to fit with the terminology used in the grant proposal guidelines. The initial draft was decreased to pilot several of the strategy
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components first, followed by an evaluation. This was done for three main reasons. First, there would not be enough time for the project director to carry out all interventions along with teaching and other faculty responsibilities even with released time. Second, students would be overwhelmed with so many choices that it would be confusing and would encourage fragmented use of many services rather than promote a concentrated effort and consistency in one or two services. Third, financial constraints limited what could be done. PEP strategy components were organized to include proactive, ongoing, and transitional interventions. Theoretical and empirical support for this approach and its components were documented in the proposal. Using grant specific guidelines and terminology, the evaluation plan included formative and summative evaluation measures. Although the grant's guidelines focused primarily on quantitative results documenting improved academic outcomes, the measurement of students' psychological outcomes (satisfaction) and perceived variables influencing retention were written into the evaluation plan. The justification for their inclusion was based on prior research and the underlying conceptual model. Instrument development and evaluation (reliability and validity studies) were accordingly incorporated into the proposal. Several revisions finally resulted in a final proposal that was submitted on time according to the procedure at the educational institution.
Step 7—Get Approval When a project or grant proposal is approved, it is important to review the budgetary allocations for specific categories and check if there are any restrictions or added guidelines. Budgetary constraints may require some modifications from the original proposal plan. These modifications should be finalized before entering the next phase of pre-implementation. The pre-implementation phase acknowledges that there are two essential steps that need to be done before program implementation: communication and preparation. For the PEP, no major changes from the original proposal were noted.
Step 8—Communicate Once grant funding is awarded and the budgetary plan modifications are finalized, the project director should communicate that funding has
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been received. The important questions to consider are with whom to communicate, what needs to be communicated, and how to communicate. Essentially, what must be communicated is that a grant was received and how this will involve the other collaborative partner(s). Collaborative partners or those individuals who committed time, expertise, service, or some other instrumental support toward the proposed project should be contacted personally. A telephone contact followed by a written memo or copy of the grant award and proposal may be indicated depending on the type of partnership required and level of involvement. Memos that communicate the necessary details serve as reinforcement to the verbal communication. A copy of the grant award may be forwarded to the administration as part of the grant notification process. If not, a copy should be forwarded to all administrators. Announcements made at faculty, curriculum, and other pertinent meetings can be made both verbally and in the form of a written memo or information sheet. Students can be notified about the upcoming services via classroom announcements, memos, and student club meetings. In the PEP, announcement of the grant award was automatically forwarded to administrators by the institution's office of grants and research. A scheduled meeting with the department chairperson endeavored to build on the communication, commitments, and partnerships established previously in Steps 1 and 5. Because the grant was awarded after classes had ended, chairperson support for communicating with students via a mailed letter was greatly welcomed. A letter outlining the main features of the PEP was mailed to all students listed as prenursing or associate degree nursing students along with an application for an orientation session and study group sessions. A letter explaining the funded project also was mailed to all full-time nursing faculty members. Students already enrolled in the associate degree or RN to BS program also received an invitation to apply for a peer mentor-tutor position. Job qualifications and responsibilities were included along with a blank application form. Peer mentor-tutor qualifications included (a) current enrollment in an upper level associate degree nursing course or in the baccalaureate program after completion of the college's associate degree program; (b) above average grades in prenursing and nursing courses and in clinical evaluations; and (c) excellent communication skills. Responsibilities included assistance with orientation sessions, tutoring for prenursing and/or nursing courses, individual and small
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group mentoring sessions, and collaborating with the project director. Hours were advertised as flexible and negotiable with wages set at a rate competitive with other college assistant, work-study, and unlicensed hospital personnel wages. Copies of all letters were posted on bulletin boards. The two individuals who had agreed to serve as content experts for the instrument validation process were notified by telephone contact. An estimated date for instrument completion and mailing was reconfirmed; a mutual timeline was reestablished for instrument review, return, and possible second review after revisions. Likewise, the psychometric expert was contacted personally to reaffirm a mutually agreeable timeline. These professional services were offered in-kind, therefore gratitude was conveyed personally and by follow-up letters. Timelines and proposed tasks also were discussed with the two prospective project assistants. Project assistant wages were nonnegotiable since they were predetermined by the grant guidelines; this was communicated to the prospective project assistants. The director of institutional research also was informed that the grant had been awarded and that end-of-semester transcript data would be needed in sufficient time for data analysis by the project director and writing of the final report, as previously agreed.
Step 9—Prepare for Program Allocating a sufficient amount of time for program preparation is important. Making a list of what needs to be done, by whom, and the needed date of completion can help prioritize program preparation components. Preparation may include creating or obtaining educational materials and documentation forms, selection and orientation of personnel, questionnaire development and evaluation, and arranging the physical setting. In the PEP, a timeline was originally submitted with the project proposal so this served as a valuable guide. Two tasks that had the highest priority because they involved a series of steps, were time consuming, and involved several people, were questionnaire development and the selection and orientation of personnel (project assistants and peer mentor-tutors). Questionnaire Development Several instruments were developed as proposed in the grant proposal. A cover letter explaining some background information and purpose of
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the instruments, requested due date, a self-addressed stamped envelope, and an instruction sheet for rating content validity accompanied the instruments. The ratings and comments of the content reviewers provided the basis for minor revisions. Review by a psychometric expert supported that the instruments were in a format that could easily be scanned, interpreted, and analyzed using the SPSS statistical program. The instrument drafts were then given to a second project assistant who had computer expertise in creating optical scanning instruments, scanning, and conversion into SPSS. Several drafts required review by the project director due to spelling errors, spacing between response bubbles to enhance item response accuracy, font, and other cosmetic as well as psychometric considerations. All instruments needed a trial run for scanning to assure ease with future data processing. The psychometric expert assisted again by reviewing the final drafts.
Selection and Orientation of Peer Mentor-Tutors The selection of peer mentor-tutors (PMT) first involved a review of completed applications by the requested due date. The next step involved review of student transcripts and clinical evaluations for each course completed so far. The review of clinical evaluations was quite time consuming but provided insightful information such as a record of the student's verbal communication and interaction with others, attendance, tardiness, and other important qualities and skills. The highest ranking applicants were then invited for an interview. Scheduling and arranging interviews as well as conducting the interviews were time consuming yet essential to the selection process. During the interview it was emphasized that a collaborative partnership among PMTs, students, and the project director was an important goal. The next priority was to organize and prepare the educational and documentation materials needed for the PMT orientation. A 90-minute orientation session was held with the PMTs. The overall purposes and goals of the enrichment program, particularly detailing the significance of mentoring in nursing and the role of PMT and student as partners in learning, was described (Figure 4.3). The expected benefits of specific PMT roles and interventions were discussed. This discussion clarified the scope of the PMT role and emphasized the importance of conveying this information during the first contact meeting with students.
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FIGURE 4.3 Peer mentor-tutor and student as partners in learning and professional development.
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Documentation forms for recording the study group's activities and for recording anticipated plans for the next meeting were reviewed with PMTs. The documentation forms would serve as a weekly communication between the PMT and project director. Strategies for enhancing student survival skills addressed such issues as academic support strategies, time management, stress reduction techniques, assisting students throughout the educational process, promoting professional growth, and balancing multiple role responsibilities. Handouts and lists of referral resources within the college complemented this discussion. Next, the simulated situations and group discussion provided an opportunity for PMTs to use problem-solving strategies for academic and nonacademic problems that could potentially arise. Decision-making dilemmas and varying opinions identified areas that required further clarification and guidance. It was emphasized that the PMT would have an ongoing collaborative relationship with the project director throughout the semester. Finally, PMT study group schedules were confirmed. Since several study groups would occur at the same time, finding sufficient space necessitated organizing room arrangements and reservations via the college's protocol. A written evaluation of the PMT orientation concluded the meeting.
Step 10—Implement the Program A well-developed and detailed proposal accompanied by an itemized timeline can serve as the guide for program implementation. To facilitate smooth implementation, the program should be divided into various intervention categories: proactive, ongoing, and transitional. Each category of interventions should complement the other and easily flow into the next category. There may be some eventual overlap in categories as students participate in an enrichment program throughout several semesters. Proactive interventions are interventions implemented before the beginning of the semester that aim to prepare students academically, psychologically, and practically for the new semester and to enhance performance, satisfaction, and success. Preparation may allow for opportunities to review previously learned skills, ask questions, review pertinent information, assist with time management strategies specific to the
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new nursing course, interact with students who previously completed the course, and informally meet the new course instructors. Ongoing interventions aim to maximize student success by the early identification of student strengths and weaknesses before academic difficulties, role conflicts, or stress arise. Early identification of the at-risk student can prevent failure or withdrawal. Often students do not seek help until difficulty arises, and then it is often too late to improve an academically precarious situation. Another benefit of ongoing interventions is that collaborative and productive partnerships can flourish. For example, the PMT-student partnership cannot truly develop without consistent and frequent contacts. Students also can feel more at ease with study group peers, offering both emotional and academic support strategies. This peer interaction helps develop professional socialization, integration, and acculturation into the nursing student role and future RN role (Alvarez & AbriamYago, 1993; Baldwin & Wold, 1993; Bessent, 1997; Chrisman, 1997; Perry, 1997; Schwitzer & Thomas, 1998; Tucker-Allen & Long, 1999; Vance & Olson, 1998). The opportunity to share experiences and watch role models and peers struggle with similar academic and nonacademic challenges can help increase self-efficacy and motivation to persist (Bandura, 1986; Zimmerman, 1995). As students move from one phase of the educational process to the next, transitional interventions should be implemented (Schon, 1987). Transition from preprofessional to professional education (first nursing course), and from one nursing course to the next level nursing course, challenges students to embark on new, unknown paths in their journey toward becoming a registered nurse. Guidance at these transitional stages is crucial to encourage retention, enhance achievement, promote satisfaction, and minimize stress. The PEP encompassed the various stages of the educational process and included proactive, ongoing, and transitional interventions. Activities will be described in the sections that follow.
Orientation The piloted program included a 2.5-hour orientation program before the start of the semester. Although the orientation targeted prenursing students, not yet enrolled in a clinical nursing course, several students already in the first nursing course attended. All students were invited to bring a family member, friend, or support person. Each student was
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personally greeted by a PMT. Everyone received an orientation folder, calendar, and study skills handouts. Several of the participants had just enrolled at the college for the first time; other prenursing students had completed all prenursing required courses. The agenda included: (a) purposes and goals of the PEP; (b) nursing program requirements; (c) student information; (d) family, friend, and faculty support network; (e) time management strategies; (f) enhancing textbook reading comprehension; (g) enhancing learning skills in the classroom including taking notes effectively; and (h) collaborating with the PMT. Prenursing students then met with their PMT. Following a brief introduction, a follow-up meeting date or phone call was set up based on the individual needs of the student. Next, students completed a satisfaction questionnaire. All students found the orientation session to be "very helpful and informative." Written and verbal comments by students provided additional information. For example, one student commented that the mentor encouraged her to keep trying. Many students commented that it was helpful to have someone to talk to who had already been through the nursing courses. A few students realized the need to resolve personal and/or family issues before trying to take a full-time course schedule. Most students commented that the handouts and orientation session provided them with new study skills and time management strategies. One student commented that she would share the handouts on family-studentfaculty partnerships with her family so that her requests for assistance with household responsibilities would be respected and honored. Newsletter The newsletter was created to enrich the prenursing and nursing program experience by broadening information access to students. The biannual newsletter addressed relevant issues such as requirements of the nursing program, student responsibilities, strategies for enhancing academic success, career advisement and guidance, management of work and family responsibilities, and services available to assist students. Announcements concerning workshops, tutoring, and nursing application dates, and notices about the enrichment program were included. Feature article sections were presented. Questions frequently asked by students or questions submitted by students were selected for answers in the featured section "What Enquiring Students Want to Know." The "Stories from the Field" feature provided some clinical case scenarios
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and attempted to showcase how nursing students can make a positive difference in the clinical setting. Tear-off application forms for PMT study groups comprised the last two pages of the newsletter.
Study Groups The study groups, led by PMTs, were in great demand. Application forms submitted by the deadline exceeded available openings. Registration was done on a first-come, first-serve basis on the assigned registration date and time before the beginning of the semester. Students who submitted applications by the deadline had first choice in selecting study group sessions and must commit to regularly scheduled group meetings (usually weekly) starting at the beginning of the semester. The study group registration session also allowed for informal meetings between peers, PMTs, and the project director. Students in the study groups developed a working partnership with the PMT and other group members. Study groups usually consisted of five students per one PMT. Additional in-person meetings, telephone meetings, and/or referrals were individualized as needed. Frequently, the project director met with referred students about academic and nonacademic problems. The project director was informed about group activities weekly either through personal visits and/or weekly written study group documentation forms. The documentation forms focused the group on the day's specific tasks or topics, identified specific areas for next week's session, and documented attendance. Additionally, a PMT comment section informed the project director about individual and group concerns, strengths, weaknesses, and other pertinent academic and nonacademic issues. The documentation forms also helped maintain consistency and structure between groups and within groups on a regular basis while keeping the project director informed.
Transitional Workshop All nursing students were invited to attend a brief transitional workshop prior to the beginning of the next semester. Although there was some overlap between proactive and transitional interventions, the main difference was that transitional interventions targeted students who had already participated in the PEP. The agenda included the purposes and goals of the PEP, nursing student transitional process, strategies for successful transition, collaborating with a PMT, and study group selec-
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tion. The workshop addressed the transitional process and issues that nursing students are often faced with when moving from one phase of their professional nursing education to another. Each phase offered different challenges and required students to modify previous successful study strategies to accommodate these new challenges. For example, study time allocation for a six-credit, 15-week course would have to be adjusted to meet the demands of a nine-credit course or a five-credit, half-semester course. Sometimes students needed assistance in changing the focus from an adult client with medical or surgical problems to pregnant clients, children, or mentally ill clients. Although many of the essential underlying professional skills had been learned previously, guidance through the transition from one phase (course) to another could be eased by first acknowledging that a transitional process existed and second by learning effective strategies to meet transitional challenges. Nursing students stated that working with a PMT has assisted them through this transitional process. Other transitional support measures included the PEP Nursing Skills Lab Practice Sessions prior to the beginning of the new semester. Nursing students were encouraged to practice any previously learned and evaluated technical skills during the supervised PEP practice session in preparation for clinical practice. New students accepted into the first clinical course were invited to participate in a Nursing Skills Lab and Educational Resources Tour led by a PMT guide. The tour familiarized students with their new environment and showed students what resources were available to assist them throughout their educational experience.
Step 11—Evaluation A carefully orchestrated evaluation should be tied explicitly to the proposal's measurement plan and should include both formative and summative components. Formative evaluations assess the process of a program rather than outcomes. Formative evaluations can be monitored as the program is implemented and can document specific activities, identify difficulties, and allow for diagnostic-prescriptive modifications based on participants' feedback, using both quantitative and qualitative data. Summative evaluations should be monitored every semester and compared globally at the completion of the program to assess the
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achievement of desired program outcomes. Since student retention is a dynamic and multidimensional phenomenon, the success of any teaching, support, or enrichment strategy requires a multidimensional evaluation strategy. The NURS model may be used to identify desired program outcomes such as academic, psychological, and affective. Desired academic outcomes may include course retention, course success, course withdrawal, program retention, interim program retention, ideal program retention, program success, and ideal program success. Psychological outcomes may include measures of satisfaction or stress; affective outcomes may include self-efficacy (confidence) perceptions. Consistently and rigorously following the preestablished plan for data collection and data analysis will help make the evaluation results more valid and reliable. This includes working diligently with previously established partners in the evaluation process such as the data collectors, director of institutional research, project assistant, and psychometric expert. Once the results are obtained and reviewed for statistical and practical significance, inferences from the data can guide future enrichment program activities, outcome measures, and desired outcomes. The process of evaluation naturally leads into the beginning of the enrichment design process (Step 1) again in which the nurse educator would assess the new current situation and compare it with the EP evaluation just completed. Assessment would include the appropriateness of generalizing findings to the "new" current situation. The ultimate goal of the EP design, implementation, and evaluation process is that empirical and conceptual based enrichment programs will address the holistic needs of nontraditional students. In the PEP, a study was undertaken to evaluate select aspects of the PEP among students who participated in PMT led study groups throughout the semester (intervention group). The evaluation addressed academic outcomes, psychological outcomes (satisfaction), and perceived variables influencing retention. Academic outcomes targeted course retention by measuring course success rates (pass rates), course failure rates, and course withdrawal rates for the intervention group and a control group. Comparisons were done between the clinical nursing courses, within courses, and throughout several semesters. Overall, the intervention (PEP) group had lower failure rates, lower withdrawal rates, higher course success rates, and positive psychological outcomes (satisfaction). Students also perceived that environmental vari-
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ables were more influential than academic variables in influencing retention. Social integration variables such as faculty advisement and helpfulness, tutoring, and the EP were perceived as highly supportive. Details concerning the PEP evaluation, including instrumentation, are described in two recently published articles (Jeffreys, 2001, 2002). High student satisfaction with the PEP and perceptions that the PEP supported retention emphasize the continued need for strategies that enrich the nursing student experience. Formative evaluations of EP interventions and comments on the Satisfaction Questionnaire also provided valuable information to guide future enrichment strategies. For example, students' written requests for extended study group hours, especially in the beginning nursing courses, substantiated the need for greater allocation of resources to the beginning students. Additionally, requests for longer study group sessions increased the sessions from an average of 45 to 90 minutes. SUMMARY Enrollment trends, retention rates, professional goals, societal needs, and ethical considerations necessitate a strategic plan to facilitate the retention and success of nontraditional undergraduate nursing students. Nurse educators are ultimately challenged to develop theoretically and empirically based retention strategies tailored to students' strengths, weaknesses, and holistic needs. The NURS model provides an organizing framework for examining the multidimensional factors that affect nontraditional undergraduate nursing student retention and success in order to identify at-risk students, develop diagnostic-prescriptive strategies to facilitate success, guide innovations in teaching and educational research, and evaluate strategy effectiveness. Collaborative partnerships are integrated within the eleven-step EP design, implementation, and evaluation process and can guide future EP development. The PEP case exemplar illustrates each step individually, describes PEP activity components, and highlights the main benefits of peer mentor-tutor partnerships and other essential partnerships. Nurse educators must thoroughly comprehend the multidimensional factors that influence nontraditional undergraduate student retention, expand the teaching role into a mentor role, develop and nurture strategic partnerships, and create innovative strategies to enhance nontraditional nursing student success.
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ACKNOWLEDGMENTS The enrichment program and its evaluation was partially funded by the New York State Education Department Vocational and Technical Education Act (VATEA) and by the Research Foundation of the City University of New York, PSC-CUNY Grant Number 61576-00-30.
REFERENCES Alvarez, A., & Abriam-Yago, K. (1993). Mentoring undergraduate ethnic-minority students: A strategy for retention. Journal of Nursing Education, 32, 230-232. Baldwin, D., & Wold,J. (1993). Students from disadvantaged backgrounds: Satisfaction with a mentor-protege relationship. Journal of Nursing Education, 32, 225-226. Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory. Englewood Cliffs, NJ: Prentice-Hall. Bean, J. P., & Metzner, B. (1985). A conceptual model of nontraditional undergraduate student attrition. Review of Educational Research, 55, 485-540. Bessent, H. (Ed.). (1997). Strategies for recruitment, retention, and graduation of minority nurses in colleges of nursing. Washington, DC: American Nurses Publishing. Chfisman, L. (1997). Socialization to professional nursing roles. In B. Kozier, G. Erb, & K. Blais (Eds.), Professional nursing practice: Concepts and perspectives (p. 127). New York: Addison-Wesley. Courage, M. M., & Godbey, K. L. (1992). Student retention: Policies and services to enhance persistence to graduation. Nurse Educator, 17(2), 29-32. Eaton, S. B., & Bean, J. P. (1995). An approach/avoidance behavioral model of college student attrition. Research in Higher Education, 36, 617-645. Garcia, M. (1987). Community college persistence: A field application of the Tinto model. Unpublished doctoral dissertation, New York: Teachers College, Columbia University. Griffiths, M. J., & Tagliareni, M. E. (1999). Challenging traditional assumptions about minority students in nursing education. Nursing & Health Care Perspectives, 20, 290-295. Harvey, V., & McMurray, N. (1994). Self-efficacy: A means of identifying problems in nursing education and career progress. International Journal of Nursing Studies, 31, 471-485. Jeffreys, M. R. (1993). The relationship of self-efficacy and select academic and environmental variables on academic achievement and retention. Unpublished doctoral dissertation, New York: Teachers College, Columbia University. Jeffreys, M. R. (1995). Joining together family, faculty, and friends: New ideas for enhancing nontraditional student success. Nurse Educator, 20(3), 11.
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Jeffreys, M. R. (1998). Predicting nontraditional student retention and academic achievement. Nurse Educator, 23(1), 42-48. Jeffreys, M. R. (2001). Evaluating enrichment program study groups: Academic outcomes, psychological outcomes, and variables influencing retention. Nurse Educator, 26(3), 142-149. Jeffreys, M. R. (2002). Students' perceptions of variables influencing retention: A pretest and post-test approach. Nurse Educator, 27(1), 16-19. (Erratum, 2002, 27(2), 64). Kelly, E. (1997). Development of strategies to identify the learning needs of baccalaureate nursing students. Journal of Nursing Education, 36, 156-162. Levin, M. E., & Levin, J. R. (1991). A critical examination of academic retention programs for at-risk minority college students. Journal of College Student Development, 32, 322-334. Metzner, B. J. (1989). Perceived quality of academic advising: The effect on freshman attrition. American Educational Research Journal, 26, 422-442. Metzner, B., & Bean, J. P. (1987). The estimation of a conceptual model of nontraditional undergraduate student attrition. Research in Higher Education, 27, 15-38. National League for Nursing Accrediting Commission. (1999). Criteria and guidelines for the evaluation of associate degree programs in nursing 1999. New York: National League for Nursing. Nora, A. (1987). Determinants of retention among Chicano college students: A structural model. Research in Higher Education, 26, 31-60. Nora, A., Cabrera, A., Hagedorn, L., & Pascarella, E. (1996). Differential impacts of academic and social experiences on college-related behavioral outcomes across different ethnic and gender groups at four-year institutions. Research in Higher Education, 37, 427-451. Pascarella, E. T., & Chapman, D. W. (1983). Validation of a theoretical model of college withdrawal: Interaction effects in a multi-institutional sample. Research in Higher Education, 19, 25-47. Perry, L. (1997). The bridge program: An overview. Association of Black Nursing Faculty Journal, 8(1), 4-7. Rowser, J. (1997). Do African American students' perceptions of their needs have implications for retention? Journal of Black Studies, 27, 718-726. Schon, D. (1987). Educating the reflective practitioner. San Francisco: Jossey-Bass. Schwitzer, A., & Thomas, C. (1998). Implementation, utilization, and outcomes of a minority freshman peer mentor program at a predominantly white university. Journal of the Freshman Year Experience, 10, 31-50. Spady, W. (1970). Dropouts from higher education: Toward an empirical model. Interchange, 2, 38-62. Tayebi, K., Moore-Jazayeri, M., & Maynard, T. (1998). From the borders: Reforming the curriculum for the at-risk student. Journal of Cultural Diversity, 5, 101-109. Tinto, V. (1975). Dropout from higher education: A theoretical synthesis of recent research. Review oj Educational Research, 10, 259-271. Tinto, V. (1993). Leaving college: Rethinking the causes and cures oj student attrition. Chicago: University of Chicago Press.
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Tinto, V. (1998). College as communities: Taking research on student persistence seriously. Review of Higher Education, 21, 167-177. Tucker-Allen, S. (1989). Losses incurred through minority student nurse attrition. Nursing & Health Care, 10, 395-397. Tucker-Allen, S., & Long, E. (1999). Recruitment and retention of minority nursing students: Stories of success. Lisle, IL: Tucker Publications. Vance, C, & Olson, R. (1998). The mentor connection in nursing. New York: Springer Publishing Co. Yoder, M. K. (2001). The bridging approach: Effective strategies for teaching ethnically diverse nursing students. Journal of Transcultural Nursing, 12, 319-325. Zimmerman, B. J. (1995). Self-efficacy and educational development. In A. Bandura (Ed.), Self-efficacy in changing societies (pp. 202-231). New York: Cambridge University Press.
Chapter 5 Preceptorship: A Quintessential Component of Nursing Education Florence Myrick and Olive Yonge
n old adage suggests that in order to know where we are going, we have to know first from where we came. This implies that if we do not know our origins and development, it is unlikely that we will have a strong sense of direction or a clear vision of what we intend or are likely to achieve. The same can be said for preceptorship. We need to understand how it began and developed, what its original goals were, and how it evolved over time to understand how it looks today and precisely where we intend to go with it. Over the last several decades, preceptorship has become the leading approach to the clinical teaching of undergraduate nursing students and the leading method of choice for orienting new nurses and reorienting more seasoned nurses. In fact, preceptorship is now reported to be a major factor in nursing education in numerous countries, including Australia, Canada, Great Britain, and the United States (Letizia & Jennrich, 1998; McGregor, 1999; Myrick & Yonge, 2001; Usher, Nolan, Reser, Owens, & Tollefson, 1999). How has this instructional phenomenon gained such momentum? How has it become what it is today? To answer these questions, we must begin by examining preceptorship's historical roots and exploring its development within the context of nursing education.
A
CONTEXTUAL OVERVIEW Although preceptorship is often perceived as a relatively recent development within the realm of clinical teaching, historically this is not the 91
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case (Backenstose, 1983). In fact, preceptorship has been an important aspect of the nursing profession since its genesis. During Florence Nightingale's time it was expected that the first-year practical training for nurses would occur in the hospital setting under the direct guidance of those nurses who had been "trained to train" (Myrick, 1988a; Palmer, 1983). Subsequently, nursing students continued to be taught by practicing nurses for many years. Schools of nursing were guided by the principles of the first Nightingale school when initially established in Canada and the United States, and for a considerable time following their implementation (Duncanson, 1970; Myrick, 1988b). From the beginning, however, it was clear that the goals of hospitals clashed with those of schools of nursing. Teaching was marginalized. The educational needs of the students were secondary to the nursing care needs of patients. For years, nursing leaders in both countries strove to overcome this hurdle. Following World War II, the transfer of nursing education into the general education system became the primary focus of nurse educators. In the 1950s, a break between nursing education and nursing service began, and by the 1960s nursing students were being taught in colleges, universities, and technical institutions. The transfer of nursing education from hospital schools to colleges and universities, however, resulted in the forfeit of some of the former benefits of closer student association with the clinical environment (Limon, Spencer, & Walters, 1981). Nursing students were "in the clinical environment but not of it" (p. 267). Graduates entered into the work world as virtual strangers at the mercy of the clinical environment. Throughout the 1960s, new graduates of 2-year diploma and 4-year baccalaureate programs began to express concerns about their clinical preparation. In the 1970s, the term "reality shock" was coined to describe the relative inability of new nurse graduates to assume full patient care responsibilities in accordance with employer expectations (Kramer, 1974). Concerns abounded in the practice and academic worlds as to how the competence of new nurses could be assured on graduation. As a result, considerable effort and initiative were directed to exploring ways in which the clinical competence of nursing students could be fostered and even ensured (McGrath & Koewing, 1978; Myrick, 1988b; Willis, 1981). Faculties of nursing initiated clinical programs to facilitate the transition of student nurse to graduate nurse by teaming future graduates with staff nurses in the practice setting (Estey & Fergu-
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son, 1985; Myrick, 1988a). Thus the preceptorship model of clinical instruction emerged as a response to a need for better clinically prepared graduate nurses (Shamian & Inhaber, 1985). It was intended to enhance student learning in the practice setting and to facilitate the socialization of nursing students into the role of nurse.
FOCUS OF PRECEPTORSHIP EXPERIENCE The transition from student to professional nurse is recognized as a "tumultuous experience fraught with anxiety and problems of adjustment" (Allanach & Jennings, 1990, p. 22). Students faced with this transition express considerable self-doubt and apprehension. Often they are quite daunted by the prospect of encountering and caring for vulnerable individuals suffering illness or requiring guidance in health promotion. Preceptorship, however, offered a vehicle that would prove to be invaluable in facilitating this transitory phase by socializing nursing students into their professional roles and bridging the critical juncture between the classroom and the practice setting. Studies indicate that pairing nursing students with practicing nurses in the practice setting enhances the transition from student to staff nurse and contributes positively to the socialization process (Allanach & Jennings, 1990; Clayton, Broome, & Ellis, 1989; Goldenberg & Iwasiw, 1993; Myrick & Yonge, 2001). As preceptorship gained more momentum as an approach to clinical teaching in nursing education, it focused increasingly on socializing nursing students into the professional nurse role and facilitating their clinical competence. Professional socialization is a complex, interactive process by which neophytes acquire the knowledge, skills and behavior of the professional role and assume values, attitudes, goals and identities intrinsic to the profession (Goldenberg & Iwasiw, 1993). The primary responsibility for this process, a monumental responsibility in anyone's estimation, generally lies directly with staff nurse preceptors, who thus play a pivotal role in that socialization process and in the ultimate shaping of the nursing profession. This requires nurse educators to be acutely sensitive to the considerable onus that is placed on preceptors both within this context and in the present climate of the health care system. Current nursing shortages and policies of attrition escalate the workload of those nurses remaining
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in the system, often exponentially, so it is only reasonable to assume that nurses who also serve as preceptors could become most susceptible to fatigue and disillusionment from the impact of the ongoing changes. Nurse educators thus need to determine how they can facilitate the preceptorship experience to support both preceptors and students so that the teaching/learning process is not jeopardized by extraneous factors. Over the years, preceptorship has proven to be an appropriate way to address concerns about inadequate preparation of nursing students to meet employer expectations immediately upon graduation. Pairing nursing students with staff nurse preceptors on a one-to-one basis in the practice setting affords students opportunities to work side by side with experts who serve as an immediate resource. Students have opportunities to observe and be supervised by practicing nurses in planning, implementing, and evaluating nursing care. What better way is there to develop clinical competence? Studies have found that the preceptoring of students does indeed make a difference in the development of clinical competence of nursing students (Laschinger & McMaster, 1992; Ridley, Laschinger & Goldenberg, 1995; Scheetz, 1989). In today's health care milieu, considerable emphasis is placed on developing and promoting critical thinking. Professionals who persevere and prosper in the future will be those who have the intellectual and emotional ability to effectively and critically assess and deal with complex changing situations. In other words, critical thinking is fundamental in adapting to the ongoing professional demands of the future. Graduate nurses must be able to cope with the generation of new nursing knowledge, progressive changes in science and technology, and the economic constraints that continue to precipitate massive health care changes (Jacobs, Ott, Sullivan, Ulrich, & Short, 1997; Laschinger & McMaster, 1992; Myrick, 1998). Recently, the impact of the learning climate on the student's ability to think critically has been found to be paramount (Myrick, 1998). Indeed, the success of students in developing their critical thinking skills depends quite heavily on the tone that is set by preceptors and other staff in the practice setting (Myrick & Yonge, 2001). Because of its success as a teaching-learning approach, preceptorship today is often used for the complete clinical teaching component or senior practicum of undergraduate nursing education and usually acts as a conduit for graduate level students in the practice setting. Learning objectives are designed by course professors and imparted to preceptors, who are then expected to work closely with the student in
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the process of ensuring that these objectives are achieved within a designated time frame. This arrangement can work to the advantage of both the student and the preceptor. The faculty involvement in this process is equally important but unfortunately is often perceived to be peripheral to the preceptorship experience. The ideal representation of the preceptorship model is a triad, with students and preceptors working one on one on a day-to-day basis in the practice setting, and with faculty acting as a teaching-learning resource for all. It is only through such collaboration among students, preceptors, and faculty that the preceptorship experience can be guaranteed to succeed.
RELEVANT ISSUES IN TODAY'S CONTEXT Warm Body Syndrome While speaking with a Patient Care Manager (PCM) some years ago, one of the authors, who was curious about the process for selecting preceptors, asked how the PCM assigned her staff nurses to preceptor roles. The PCM replied "whoever is available at the time." This process has given rise to the notion of the warm body syndrome (Myrick & Barrett, 1994). The authors have noted from their own experiences as nurse educators that preceptors are indeed frequently selected for availability rather than for their qualifications for the role. Baccalaureate nursing students in particular are often preceptored by staff nurses with minimal or no preparation for the preceptor role (Myrick & Barrett, 1994). Such arrangements have an impact on students. "By its very nature, the one-to-one relationship between neophyte and expert is fraught with potential difficulty" (Myrick & Barrett, 1994, p. 195). It is not unusual for students assigned to preceptors with considerable experience, expertise, and clinical competence to report that the experience was disappointing. Subsequent to the discussion with the PCM, the author decided to investigate exactly what preceptor selection criteria, if any, were used in various nursing programs. Findings indicated that although most of the 20 baccalaureate schools of nursing surveyed reported having preceptor selection criteria, only a small percentage actually defined or indeed used the criteria for selecting preceptors (Myrick & Barrett, 1992).
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Preceptor Selection and Screening The preceptorship experience is both interesting and complex from a variety of perspectives. First, perceptorship pairs two virtual strangers to work together one on one for extended periods of time, usually in difficult situations. Second, preceptorship requires immediate adaptation by these two individuals, one a neophyte and the other experienced, to each other's learning, personality, and work styles. That adaptation, a complex phenomenon itself, must succeed within a limited time frame. Finally, and paradoxically, preceptorship is intrinsically hierarchical. While ostensibly intended to be facilitative, supportive, and egalitarian, preceptorship inherently involves a power differential. Preceptors evaluate and students are constantly being evaluated and thus quite vulnerable. Ironically, students often refer to their preceptors as friends or being like friends (Myrick, 1998). It is precisely because of the complexities of the preceptorship experience that a formalized preceptor selection and screening process needs to be in place. From a nurse educator's perspective, such a process affords students the best possible opportunities for learning under the guidance of individuals who are suited to the preceptor role. The ideal preceptor acts as a guide, facilitator, teacher, evaluator, and role model (Myrick, 2002). Appropriate individuals, however, can be chosen only through a formalized selection and screening process. Ideally, the preceptorship relationship would involve a staff nurse preceptor chosen on the basis of specific criteria and a variety of factors. Potential preceptors would have a genuine commitment to the preceptor role, be effective communicators, and possess the ability to be good role models. Such individuals also would demonstrate interest in the research process and display ongoing participation in professional development. Finally, they would have at minimum a baccalaureate nursing degree (Myrick & Barrett, 1994). The selection process also would entail a collaborative endeavor between the Nurse Unit Manager (NUM) and the faculty directly involved in the organization of the clinical practicum. Such collaboration would involve ongoing communication that would ensure the explication of the learning objectives and address and clarify both preceptor and student expectations prior to the actual commencement of the experience. While such a process may seem obvious to some, in practice many preceptorships are much less structured, often to the detriment
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of the learning experience and to the satisfaction of students, preceptors, and faculty alike.
PREPARATION FOR PRECEPTORSHIP Preceptorship programs have been instituted with relative ease and success in educational programs, and the literature explicitly indicates a need to prepare and orient faculty, preceptors, and students to their roles. Currently the manner of preceptor orientation and preparation varies widely (Stevenson, Doorley, Moddeman, & Benson-Landau, 1995). For preceptorship experiences to be successful, creation and maintenance of the program by educational institutions and clinical agencies are imperative (Usher, Nolan, Reser, Owens, & Tollefson, 1999). The few authors who address the role of faculty indicate consistently that faculty, as well as preceptors, need preparation for their role in the preceptorship experience (Dibert & Goldenberg, 1995; Ferguson, 1996; Yonge, Krahn, Trojan, Reid, & Haase, 2002b). Without such preparation they are not committed to the experience. Generally, faculty become oriented to their role through the writing of manuals, planning of educational sessions or workshops, and arranging for student placements. Faculty work diligently to facilitate the ongoing relationship between preceptors and students (Letizia & Jennrich, 1998). Rittman (1992) noted that faculty are generally responsible for orienting preceptors to their role. Faculty also are responsible for supporting preceptors and practicum students in their roles. Ideally, faculty should develop guidelines demarcating the roles and functions of the preceptor in collaboration with assigned and potential preceptors (Letizia & Jennrich, 1998). Oddly, there is little in the literature, however, about the preparation of faculty themselves. Preceptors are chosen for their (1) expert clinical and theoretical knowledge (McGregor, 1999; Yonge, Krahn, Trojan, & Reid, 1997); (2) expressed desire to teach (Young, Theriaut, & Collins, 1989); (3) capability to be role models (Young, Theriaut, & Collins, 1989); and (4) willingness to assume the responsibility (Ferguson, 1996; Myrick & Barrett, 1994). The orientation of preceptors often includes many dimensions: the process of assessing student learning needs, characteristics of a helping relationship, principles of adult learning theory, strategies for
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giving feedback, mechanisms for goal setting (LeGris & Cote, 1997), and how to orient and socialize students to the practice setting (Burke, 1994). Recently, a phenomenological study identified three themes that reflect the preceptor's roles: learning alongside a practicing nurse, teaching caring practices, and teaching as nursing (Nehls, Rather, & Guyette, 1997). The researchers suggested that "teaching nursing thinking" is a caring practice that should be included in all curricula. To ensure a successful experience, all preceptors should be given adequate orientation to student expectations and course objectives (Ferguson, 1996). In a 1999 study of preceptors, Laforet-Fliesser, Ward-Griffith, and Beynon emphasized that preceptors should receive continuous support and guidance along with written information outlining the course objectives. Indeed, inadequate preceptor orientation can be linked to lack of consistent preceptors and preceptor burnout (Letizia & Jennrich, 1998). Vital also to preceptorship is preceptor awareness that faculty are available to offer support and guidance. Dibert and Goldenberg (1995) suggested that the role of the preceptor must be examined in more depth. Insufficient preceptor preparation about written and verbal evaluation of students can be stressful for preceptors (Yonge, Krahn, Trojan, Reid, & Haase, 2002a). The preceptor role is often a difficult one which some nurses may not be educationally equipped to assume (Ferguson, 1996). Without faculty support, therefore, preceptors may feel overburdened and withdraw from their responsibilities. A sound understanding of the students' levels of preparation will prevent unrealistic expectations on the part of preceptors (Hill, Wolf, Bossetti, & Saddam, 1999). A pivotal factor relevant to the success of the preceptorship experience is that students be screened prior to being placed in preceptorship situations. Those with deficiencies in knowledge, motivation, or language skills should not be placed until the deficits are addressed (Yonge, Krahn, Trojan, Reid, & Haase, 2002b). On the other hand, sometimes students are placed with preceptors based solely on preceptor availability, which can frequently lead to unsuccessful matches (Bittner & Anderson, 1998). Some educators call for students to be individually matched to their preceptors (Letizia & Jennrich, 1998). In one survey of 430 subjects, it was suggested that students entering a preceptorship experience be adept in both technical and communication skills (Hill, Wolf, Bossetti, & Saddam, 1999). This study also stressed the need for further preparation of students prior to entering their clinical experiences. Some educators note that there is a certain
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amount of confusion that continues to surround preceptor and faculty roles throughout the entire preceptorship experience (Laforet-Fliesser, Ward-Griffin, & Beynon, 1999). The proven success of preceptorship experiences to date, however, suggests that such experiences will become even more pervasive in the future. Since faculty, preceptors, and students have to work together, it is necessary to define the orientation and preparation of each to their distinct roles in the experience. Currently, students and preceptors often tend to be given the same orientation packages (LeGris & Cote, 1997). Is this process appropriate given the uniqueness of the individual roles? Indeed, it is important that faculty, preceptors, and students be aware of the different roles each plays and be prepared for their distinct demands.
PRECEPTOR STRESS Some preceptors view perceptorship as a burden (Atkins & Williams, 1995; Grealish & Carroll, 1998). This is true particularly if preceptors are repeatedly asked to serve as preceptors, multiple programs use the same clinical site, students are ill-prepared for the clinical experience, or preceptors are assigned students in short and varied preceptorship placements. Repeatedly being asked to act as a preceptor for students can result in fatigue, stress, and burnout (Letizia & Jennrich, 1998). The complex demands of preceptorship also can precipitate a variety of stressors. It has been found, more often than not, that preceptors feel responsible for their students and find it difficult to balance close supervision with necessary independence (Robinson, Mclnerney, & Sherring, 1999). If students have marginal clinical skills, the preceptor has to provide more intensive supervision. Ironically, preceptors are frequently concerned about being marginally competent themselves, fearing that their knowledge base is weak and that they may not be able to do a good job (Hayes, 1994). At times, the goals of students differ from those of their preceptors. Students sometimes view the preceptorship experience as an opportunity to tie together all the loose ends of their education (Lunday, Winer, & Batchelor, 1999). They may ask endless questions, often focusing on small details that their preceptors take for granted. Preceptors usually work in contexts characterized by heavy workloads and multiple responsibilities (Coates & Gormley, 1997; Hallett, 1997; LeGris & Cote, 1997;
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Stevenson, Doorley, Moddeman, & Benson-Landau, 1995). If responsibilities conflict, patient care rather than student needs are afforded the preceptors' top priority (Grealish & Carroll, 1998). Such situations often leave the preceptors feeling guilty and overly pressured. Other nursing personnel in the clinical area also may unwittingly contribute to preceptor stress. For example, they may not give the preceptors relief from their usual workloads and may assume that being assigned to a student justifies increasing the number and complexity of the preceptor's patient assignment (Alspach, 1989). Frequently, preceptors find that the lack of relief from their usual workloads is the most stressful aspect of their role. In fact, preceptors sometimes describe the resulting preceptorship experience to be exhausting, stressful, and at times overwhelming (Alspach, 1989). A recent survey that involved 295 preceptors provides some interesting revelations. The researchers indicated that one of the most common sources of preceptor stress was the sense of having added responsibilities and the need for additional time to fulfill those responsibilities (Yonge, Krahn, Trojan, Reid, & Haase, 2002a). Preceptors feel responsible for their students' work habits, nursing care, and mistakes. Their stress is increased if students are not suited to the clinical area, lack confidence, have unrealistic expectations, or possess marginal interpersonal or clinical skills. Such students are viewed as a burden in terms of time and as a cause of preceptor overwork. Even highly motivated and prepared students are a cause of "preceptor overwork" at the beginning of placements because, in addition to their learning needs, students also require considerable orientation and preparation time. Such findings suggest that placements should be arranged based on the premise that preceptors are entitled to support as a means of decreasing their stress. Usually they are volunteering their time and energy to help educate and socialize students out of a sense of commitment to the nursing profession. The extra work of preceptorship, therefore, should be shared with others—nurse educators, managers, and peers (McGregor, 1999). Nurse educators need to identify and employ strategies such as consultation and conflict resolution to minimize preceptor stress. Nurse managers as well need to guard against "overwork" when assigning patients by being cognizant of the fact that the supervision of students constitutes a teaching assignment. Finally, the preceptors' peers can arrange "breaks" from teaching responsibilities and provide opportunities for debriefing (Yonge, Krahn, Trojan, Reid, &
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Haase, 2002b). Just as students need to be assessed for preceptorship readiness, so do preceptors.
WHAT A PRECEPTORSHIP PROGRAM SHOULD BE The review of the literature and the emerging research with regard to preceptorship make it clear that there are a variety of issues associated with this type of teaching. The history of nursing and the professional orientation of nurses to "volunteer" their time allowed early preceptorship programs to flourish without critical examination. Over time nurse educators and administrators became acutely aware that preceptors were a finite source and that the entire process of preceptorship required reexamination when preceptors started to complain of stress and refuse student placements (Yonge, Myrick, & Haase, 2002). Preceptorship programs should begin with the realization that preceptorship involves a program, rather than merely finding a warm body for the teaching of nursing students. The successful creation of such a program requires leadership not only from nurse educators but also collaboration with all stakeholders (students, preceptors, and nursing administrators) and a critical review and application of the preceptorship research literature. The program must be coordinated and sustainable, and have continuity and relevance. The issues discussed in this chapter (selection criteria for preceptors; preparation and orientation of faculty, students, and preceptors; and preceptorship stress) can be managed successfully only at the program level. Successful preceptorship programming also requires commitment of resources. Faculty may be assigned as many as 24 preceptored students at any one time, in which case they would really have 48 people to teach and with whom to interact if each student has only one preceptor. Many students, however, have more than one preceptor. As well, students are often dispersed between various agencies and over great distances from their educational institutions, thus requiring considerable travelling time on the part of the faculty to meet with students and their preceptors. Between site visits, faculty also may spend many hours responding to students and preceptors by e-mail. Not only faculty, however, need resource commitment. Preceptors also need resources ranging from release time to teaching materials. Release time from their usual duties often is difficult to obtain owing
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to the attitude that the preceptor "has an extra pair of hands." While preceptors in fact do have extra pairs of hands, depending on the competencies of the students, those hands require extra direction and supervision. This takes additional attention, time, and effort. It also means that other personnel need to be educated as to the expectations placed on both the preceptor and student. Although nurse educators have easy access to teaching materials such as CD ROMs, videotapes, and journal articles, preceptors are usually limited to oral presentation of their knowledge, which in turn requires additional time, energy, and organization. Finally, programs only improve if they are critically evaluated. Typically courses in which preceptorship is used often have preceptors evaluate students and students evaluate their experiences. In-depth or formal evaluations are rarely conducted at the program level to measure the effectiveness of preceptors or learning opportunities at the sites, quality of teaching of assigned faculty, abilities of clinical coordinators, and overall satisfaction with the entire preceptorship program. Unlike the preceptor and student self-evaluations, these other areas tend to be evaluated via observation or informal assessment.
FUTURE DIRECTIONS Preceptorship programs provide students with opportunities to access specialized areas; observe and participate in practice in remote, rural, and international areas; and assess employment possibilities in supervised settings. Preceptors also have benefited from their experiences with preceptorship by being exposed to current nursing issues through the lens of the students to whom they are assigned. Faculty too have benefited. As a result of their involvement with the preceptorship experience, faculty acquire knowledge about the current practices in specialized sites and are afforded opportunities that promote linkages between education and service. As shifting trends in society affect the focus of nursing education, they also affect preceptorship programming. One significant advance has been the development of multi- and interdisciplinary education in response to the demand of health care consumers for more coordination of services (Zwarenstein et al., 2002). On the clinical level, use of preceptorship can enhance multi- and interdisciplinary education. While
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large numbers of students from health professions can be brought together fairly easily in the classroom setting, in the clinical setting, it is difficult to accommodate more than one medical student, one pharmacy student, one rehabilitation student, and perhaps two nursing students. This is likely to lead to increasing use of multi- and interdisciplinary preceptorship teaching resources and evaluation methods. A wider trend that affects nursing education is the notion of globalization (Scherubel, 2001). In many nursing programs today, students at some point are encouraged to learn about nursing in international settings. Students have long been taught by professors in international settings (Yonge & Profetto-McGrath, 1990), but now many more are seeking preceptored international experiences. These placements require a new level of preparation and faculty commitment (Yonge, 1990, 1997), as well as understanding of risk assessment. Most students do not understand how vulnerable they are to illnesses, transgressing cultural norms, becoming involved in risky relationships, and experiencing the effects of cultural shock. Various international student exchange models exist. The strategy of twinning students in reciprocating host relationships minimizes risks but cannot be used for entirely clinically based course exchanges. This area needs more research and thought about how to prevent harm to nursing students. Other disciplines, such as teacher education, law, engineering, and dentistry, facilitate the preceptorship process through financial rewards by paying honorariums to preceptors or paying students directly for their services. Union initiatives have also led nursing to begin to pay preceptors. This trend will have a direct effect on preceptorship programming. If staff nurses are paid for preceptoring, in many respects more will be expected of them. Aside from having a certain level of education, preceptors in the future may have to be certified to obtain a preceptorship position.
SUMMARY Preceptorship has become pivotal to nursing education at the undergraduate and graduate levels. Although it has been used with relative ease, a variety of issues continue to emerge that affect preceptors, students, programs, and faculty alike, issues such as preceptor selection, student and preceptor preparation for their roles in the experience, preceptor
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stress, and faculty involvement. As health care dynamics change, so too will the nature of the preceptorship experience. More new questions and issues will be raised, innovative solutions sought, and changes implemented. The potential for preceptorship within the context of nursing education continues to be a promising one. Through a process of careful and thoughtful collaboration, nurse educators can, in conjunction with their counterparts in clinical practice, propel the preceptorship model into a bright and flourishing future.
REFERENCES Allanach, B. C, & Jennings, B. M. (1990). Evaluating the effects of a nurse preceptorship programme. Journal of Advanced Nursing, 15, 22-28. Alspach, J. G. (1989). Preceptor survey report: Part II. Critical Care Nurse, 9, 214. Atkins, S., & Williams, A. (1995). Registered nurses' experiences of mentoring undergraduate nursing students. Journal of Advanced Nursing, 21, 1006-1015. Backenstose, A. G. (1983). The use of clinical preceptors. In S. Stuart-Siddall & J. M. Haberlin (Eds.), Preceptorship in nursing education (pp. 9-20). Rockville, MD: Aspen Systems. Bittner, N. P., & Anderson, A. (1998). The preceptoring map for RN-to-BScN students. Journal of Nursing Education, 37, 367-372. Burke, L. (1994). Preceptorship and post-registration nurse education. Nurse Education Today, 14, 60-66. Clayton, G. M., Broome, M. E., & Ellis, L. A. (1989). Relationship between a preceptorship experience and role socialization of graduate nurses. Journal oj Nursing Education, 28, 72-75. Coates, V. E., & Gormley, E. (1997). Learning the practice of nursing: Views about preceptorship. Nurse Education Today, 17, 91-98. Dibert, C., & Goldenberg, D. (1995). Preceptors' perceptions of benefits, rewards, supports, and commitment to the preceptor role. Journal of Advanced Nursing, 21, 1144-1151. Duncanson, B. (1970). Development of nursing education at the diploma level. In M. Q. Innis (Ed.), Nursing education in a changing society (pp. 109-129). Toronto: University of Toronto Press. Estey, H., & Ferguson, F. (1985). A process of role transition: Nursing students in a clinical preceptorship. RNABC News, 17(4), 25-28. Ferguson, L. M. (1996). Preceptors' needs for faculty support. Journal of Nursing Staff Development, 12, 73-80. Goldenberg, D., & Iwasiw, C. (1993). Professional socialization of nursing students as an outcome of a senior clinical preceptorship experience. Nurse Education Today, 15, 3-15.
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Grealish, L., & Carroll, G. (1998). Beyond preceptorship and supervision: A third clinical teaching model emerges for Australian nursing education. Australian Journal of Advanced Nursing, 15(2), 3-11. Hallett, C. (1997). Managing change in nurse education: The introduction of Project 2000 in the community. Journal of Advanced Nursing, 25, 836-843. Hayes, E. (1994). Helping preceptors mentor the next generation of nurse practitioners. Nurse Practitioner, 19(6), 62-66. Hill, N., Wolf, K. N., Bossetti, B., & Saddam, A. (1999). Preceptor appraisals of rewards and student preparedness in the clinical setting. Journal of Allied Health, 28, 86-90. Jacobs, P. M., Ott, B., Sullivan, B., Ulrich, Y., & Short, L. (1997). An approach to defining and operationalizing critical thinking. Journal of Nursing Education, 36, 19-22. Kramer, M. (1974). Reality shock: Why nurses leave nursing. St. Louis: Mosby. Laforet-Fliesser, Y., Ward-Griffin, C., & Beynon, C. (1999). Self-efficacy of preceptors in the community: A partnership between service and education. Nurse Education Today, 19, 41-52. Laschinger, H. K. S., & McMaster, E. (1992). Effect of pregraduate preceptorship experience on development of adaptive competencies of baccalaureate nursing students. Journal oj Nursing Education, 31, 258-264. LeGris, J., & Cote, F. H. (1997). Collaborative partners in nursing education: A preceptorship model for BScN students. Nursing Connections, 10(1), 55-69. Letizia, M., & Jennrich, J. (1998). A review of preceptorship in undergraduate nursing education: Implications for staff development. Journal oj Continuing Education in Nursing, 29(5), 211-217. Limon, A., Spencer, J. B., & Walters, V. (1981). A clinical preceptorship to prepare reality-based ADN graduates. Nursing and Health Care, 11, 267-269. Lunday, K., Winer, W. K., & Batchelor, A. (1999). Developing clinical learning sites for undergraduate nursing students. AORN Journal, 70(1), 64-66, 69-71. McGrath, B. J., & Koewing, J. R. (1978). A clinical preceptorship for new graduate nurses. Journal of Nursing Administration, 8(3), 12-18. McGregor, R. J. (1999). A preceptored experience for senior nursing students. Nurse Educator, 24(3), 13-16. Myrick, F. (1988a). Preceptorship: A viable alternative clinical teaching strategy? Journal of Advanced Nursing, 13, 588-591, Myrick, F. (1988b). Preceptorship—Is it the answer to the problems in clinical teaching? Journal oj Nursing Education, 27, 136-138. Myrick, F. (1998). Preceptorship and critical thinking in nursing education. Unpublished doctoral dissertation, University of Alberta, Edmonton, Alberta. Myrick, F. (2002). Preceptorship and critical thinking in nursing education. Journal oj Nursing Education, 41(4), 154-164. Myrick, F., & Barrett, C. (1992). Preceptorship selection criteria in Canadian basic baccalaureate schools of nursing—a survey. Canadian Journal of Nursing Research, 24(3), 53-68.
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Myrick, F., & Barrett, C. (1994). Selecting clinical preceptors for basic baccalaureate nursing students: A critical issue in clinical teaching. Journal of Advanced Nursing, 19, 194-198. Myrick, F., & Yonge, O. (2001). Creating a climate for critical thinking in the preceptorship experience. Nurse Education Today, 21, 461-467. Nehls, N., Rather, M., & Guyette, M. (1997). The preceptor model of clinical instruction: The lived experiences of students, preceptors, and faculty-ofrecord. Journal of Nursing Education, 36, 220-226. Palmer, I. (1983). From whence we came. In N. L. Chaska (Ed.), The nursing profession: A time to speak. New York: McGraw-Hill. Ridley, M. J., Laschinger, H. K. S., & Goldenberg, D. (1995). The effect of a senior preceptorship on the adaptive competencies of community college nursing students. Journal of Advanced Nursing, 22, 58-65. Rittman, M. R. (1992). Preceptor development programs: An interpretative approach. Journal of Nursing Education, 31, 367-370. Robinson, A., Mclnerney, F., & Sherring, M. (1999). Developing a collaborative preceptor program involving registered nurses, student nurses and faculty. Australian Journal of Advanced Nursing, 17(1), 13-21. Scheetz, L. (1989). Baccalaureate nursing student preceptorship programs and the development of clinical competence. Journal of Nursing Education, 28, 29-35. Scherubel, J. C. (2001). A global analysis project for baccalaureate nursing students. Journal of Professional Nursing, 17, 96-100. Shamian, J., & Inhaber, R. (1985). The concept and practice of preceptorship in contemporary nursing: A review of pertinent literature. International Journal of Nursing Studies, 22, 79-88. Stevenson, B., Doorley, J., Moddeman, G., & Benson-Landau, M. (1995). The preceptor experience: A qualitative study of perceptions of nurse preceptors regarding the preceptor role. Journal of Nursing Staff Development, 11, 160-165. Usher, K., Nolan, C., Reser, P., Owens, J., & Tollefson, J. (1999). An exploration of the preceptor role: Preceptors' perceptions of benefits, rewards, supports and commitment to the preceptor role. Journal of Advanced Nursing, 29, 506-514. Willis, L. (1981). Issues in nursing education. In L. Hockey (Ed.), Recent advances in nursing: Current issues in nursing. New York: Churchill Livingstone. Yonge, O. (1990). Aloha: Clinical rotation in Hawaii. Canadian Nurse, 86(3), 26-28. Yonge, O. (1997). Assessing and preparing students for distance preceptorship placements. Journal of Advanced Nursing, 26, 812-816. Yonge, O., Krahn, H., Trojan, L., & Reid, D. (1997). Preceptors evaluating nursing students. Canadian Journal of Nursing Administration, 10(2), 77-95. Yonge, O., Krahn, H., Trojan, L., Reid, D., & Haase, M. (2002a). Being a preceptor is stressful! Journal for Nurses in Staff Development, 18, 22-27. Yonge, O., Krahn, H., Trojan, L., Reid, D., & Haase, M. (2002b). Supporting preceptors. Journal for Nurses in Staff Development, 18, 73-79. Yonge, O., Myrick, F., & Haase, M. (2002). Student nurse stress in the preceptorship experience. Nurse Educator, 27, 84-88.
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Yonge, O., & Profetto-McGrath, J. (1990). Co-ordinating a preceptorship program. Canadian Nurse, 86(9), 30-32. Young, S., Theriault, J., & Collins, D. (1989). The nurse preceptor: Preparation and needs. Journal of Nursing Staff Development, 5, 127-131. Zwarenstein, M., Reeves, S., Barr, H., Hammick, M., Koppel, I., & Atkins, J. (2002). Interprofessional education: Effects on professional practice and health care outcomes. In Cochrane Review (On-line). Oxford: Update Software. Available: http://-www.cochranelibrary.com
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Chapter 6 From Partners to Passionate Scholars:
Preparing Nurse Educators for the New Millennium
Kathleen I. Heinrich, with contributions by Judith A. Cote, Sheila B. Solernou, Korrine A. Roth, Dale K. Chiffer, Georg'Ann Bona, Michele McKelvey, Deborah Newell Carpenter, Christine Bracken, M. Ruth Neese, Dorothy Varholak, Elaine McCaffrey, Alice Facente, and Dori Rogers
an you recall a time when you collaborated as a student with a faculty member on a project that benefited you both? When we asked nurses this question, none of them, and they ranged from generic undergraduate students to doctorally prepared faculty, could tell us about such an experience. This confirmed what we suspected. The Partnership Program we are creating at the University of Hartford is not only unique, these faculty-student partnerships carry the potential to revolutionize the way we educate nurses and prepare them as educators.
C
BACKGROUND Bunkers (2000) challenges doctoral nurse educators to prepare scholars for the new millennium. Since little is known about how best to prepare nurses to become scholars (Heinrich, 2001), this represents a significant challenge. Given that the national shortage of nurse educators is threatening the quality of nursing education (Kelly, 2002), this challenge is 109
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assuming crisis proportions. My research suggests that nurses cholarly identity development begins with the dream of a doctoral degree in their master's programs and takes another 10-15 years to internalize (Heinrich, under review). At the University of Hartford (UH), we are "social inventors" (Spayde, 2002) experimenting with an innovative approach for preparing nurses in our master's program to become educator/scholars. This innovation is called the Partnership Program. As opposed to traditional learning experiences that primarily benefit either faculty OR students, in partnerships, faculty AND students engage in mutually beneficial relationships that support both partners' scholarly work. These partnering relationships are altering the ways we learn and teach, thereby transforming the ways we interact with one another. By deconstructing hierarchical, relational boundaries, faculty and students are reconstructing partnering relationships that are "tipping the culture" (Gladwell, 2000) in the Division of Nursing toward passionate scholarship fostered by a community of scholarly caring (Meleis, Hall, & Stevens, 1994). Passionate scholarship is exciting and risky, personally meaningful, and socially relevant life's work, while a community of scholarly caring is a network of faculty and students who care about each other individually and as scholars (Heinrich, 2001). This chapter describes how a group of graduate faculty and students are engaged in a partnering process that is fostering a community of scholarly caring within UH's Division of Nursing. Partners' reflections will be used to convey the joys, challenges, and learnings of their partnering experiences along with recommendations for prospective student and faculty-partners for "tipping" their own cultures by partnering with their students. Partners' first names will be used throughout this chapter and their complete names appear in the list of co-authors.
THE CHALLENGE THAT CALLED US TO THE ADVENTURE OF PARTNERING Proponents of the emerging social inventiveness movement believe that the best ideas to address the most profound problems facing us come, not from well-endowed think tanks, but from ordinary people "using their creativity to change the world" (Spayde, 2002, p. 62). Five steps of social inventing will be used to describe the evolution of the Partnership
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Program: (1) take your wildest idea and bring it down to earth; (2) look for inventions that solve more than one problem; (3) accentuate the positive; (4) practice "yes, and" instead of "yes, but"; and (5) get your ideas into the world (Spayde, 2002, pp. 62-63). The three ways we are using to get the partnership idea out into the world are borrowed from Gladwell's The Tipping Point: How Little Things Can Make A Big Difference (2000).
TAKING OUR WILDEST IDEA AND BRINGING IT DOWN TO EARTH When I returned to UH in 1994, I found myself teaching 3-4 courses a semester with a heavy committee load, no money for graduate research assistants, little internal funding for research, and a modest travel budget. My creative energy was being sapped in a system with few resources to support scholarly activities, and my scholarly work languished. I had the wild idea of creating a community of scholarly caring composed of student and faculty colleagues to support my and our scholarly endeavors. In 1998, 1 landed my dream job, coordinating the nurse educator track in the master's program. My vision—me encircled by students who were passionate about teaching, learning, nursing education, and educational research. My reality—me surrounded by students who were angry and counting the days until they graduated. The disconnect between my vision and my reality became so painful, I was ready to resign.
LOOK FOR INVENTIONS THAT SOLVE MORE THAN ONE PROBLEM Obstacles became an opportunity when Judy Cote, a transfer student, told me she was frustrated because she had to take a UH research course that repeated a course she just completed. Her wild idea was a "meaningful" master's degree. When I shared my vision of creating a community of scholarly caring among faculty and students, Judy wanted to make her master's education meaningful by helping me realize my vision. I knew that Judy had the intellectual capacity to become a passionate scholar and the charisma to sell our wild ideas to students.
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Our invention was simple—an independent study. Judy substituted an independent study for the redundant research course. To design this independent study, each of us compiled a "wish list" of items we wanted from our partnership and negotiated a mutually beneficial contract. Our contract simultaneously met her need for learning more about the nurse educator/consultant/editor/author roles and my need for help with my scholarly work. Specifically, Judy agreed to coteach the graduate course "Feminist Perspectives on the Caring Professions" with me, to review and peer edit all my conference proposals and manuscripts, to co-author an article on partnerships, and to co-facilitate workshops and conference presentations. We agreed to meet an hour before and after each class we taught to process our experiences and plan for the next class, and to meet as needed to collaborate on other scholarly projects. We began to refer to this independent study as a partnership. Although our partnership took time, I found my energy for teaching and my passion for scholarship being rekindled by the joyful zest of our collegial relationship. Judy was similarly energized. That first independent study was so successful that we designed a second independent study in which Judy cotaught a second, graduate course with me.
ACCENTUATE THE POSITIVE As Judy and I shaped our second partnership, we never lost track of our wild idea of creating a community of scholars. The natural next step in creating a community of scholars was opening the independent study partnership opportunity to other students. The feminist course turned out to be an ideal course for preparing partners since the feminist pedagogic approach espouses that teaching and learning are mutually respectful and trusting personal interactions between teachers and students (Ironside, 2001). So I extended a general offer to all students taking our "Feminist Perspectives" course, who also were enrolled in the nurse educator track, to interview with me for a partnership. Judy and I identified the most promising candidates. We invited those students who demonstrated scholarly potential by being able to express verbally and in writing ideas informed by the literature to apply for the partnership. Sheila accepted our invitation and became the second partner. By that time, Judy had completed the number of independent study credits allowable. Our collaboration was so energizing and intellec-
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tually stimulating that we extended our partnership to teaching two more graduate courses to meet her 80-hour practicum requirement. When Sheila's partnership ended, she chose Korey, who chose the next partner to coteach the feminist course with me, and so on. To market the partnerships, Judy and I designed a flyer and began to introduce the partnership to the newly matriculated master's students who attended the orientation program. Accentuating the positive, we told them how our "eyes were glittering" (Hedin & Donovan, 1998) as we engaged in partnerships that mutually benefited both students and faculty. Faculty colleagues' interest in partnerships was piqued when I told them that my teaching evaluations were becoming more positive, that course readings were cutting edge as partners conducted literature reviews that informed the redesign of courses, and that my teaching was becoming re-energized. My scholarly work also was blossoming with partners' assistance in peer editing, coresearching, and coauthoring as we initiated research projects, presented, and published with increasing frequency.
PRACTICE "YES, AND" INSTEAD OF "YES, BUT" To respond to faculty members' queries, Judy and 1 circulated our article for faculty to review before we presented the partnership program at a faculty meeting (Heinrich, Cote, & Solernou, 2000). The faculty concern raised most often was that students who were not partners were jealous of the students who were partners. The second was that faculty outside of the nursing education track had difficulty envisioning how to extend partnerships to their programs. We overcame the initial concerns of faculty and students alike by practicing "yes, and" rather than yielding to "yes, but." In response to the concerns about student jealousy, we reframed it as an emotion arising from wanting something deemed precious. I was thrilled to hear that students were jealous. This meant that students wanted to experience for themselves the scholarly energy generated by studentfaculty partnerships. I encouraged faculty members to extend the partnership program by partnering with students in relationships congruent with their personalities, scholarly endeavors, and specialty areas. Dorothy, who coordinates the graduate management track, met the challenge of extending faculty-student partnerships. She wrote faculty-
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student partnerships into a grant involving administrative responsibilities for a geriatric program. I designed collaborative research projects that allowed students an opportunity to become coresearchers, cofacilitators of focus groups, copresenters, and coauthors on collaborative, research projects (Heinrich, Bona, McKelvey, & Solernou, 2002; Heinrich, Mathews, Varholak, & Cote, 2002; Heinrich, Witt, McGuinness, & Ambrosiatis, 1999).
GETTING OUR WILD IDEA OUT INTO THE WORLD Unwittingly we used Gladwell's (2000) principles to tip our culture toward a community of scholarly caring. Gladwell suggests that social change and epidemics share three characteristics: (1) contagiousness, (2) small causes can have large effects, and (3) change happens at one dramatic moment, the "tipping point." He offers three rules: the Tipping Point, the Law of the Few, the Stickiness Factor, and the Power of Context, to make sense of social change. The Law of the Few specifies that to spread an epidemic you need three types of people: Connectors who know a lot of people, Mavens who are teachers, and Salesmen who are persuasive. You need a "sticky message" that is irresistibly contagious, and you need the proper context that grows a social change like bacteria proliferating on a petri dish. Gladwell further gives the example of Georgia Sandier, a nurse on a small budget, who wanted to spread the word about diabetes and breast cancer in the San Diego black community. She set up seminars in churches. From the small turnouts, she knew she needed to access women where they were comfortable, relaxed, and stayed put for awhile. She needed new messengers who were a combination of Connectors, Mavens, and Salesmen and a "stickier" way of presenting the information. She experimented by moving the venue to beauty parlors, training stylists to share information in an engaging way, and regularly supplying them with new facts that were also printed on laminated fact sheets strewn around the beauty parlors. Her evaluation showed her program was working, thereby supporting Gladwell's hypothesis that it is possible to do a lot with a little. Like Sandler's church meetings, I tried different ways to transform the UH culture into a community of scholarly caring—from bringing flowers and music to class, to inviting students to bring food to share, to
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enticing students to become engaged learners by rewarding or punishing them with grades. None of these worked until 1 changed the messengers, the message, and the context. As a Maven-teacher, I needed students who shared qualities of Connectors and Salesmen to sell the idea of partnerships to their fellow students. The first three partners, Judy, Sheila, and Korey, all charismatic extroverts, fit the bill. By their partnering and encouraging others to partner, they started a "word-of-mouth epidemic" (Gladwell, 2000, p. 256). We changed the message. Instead of trying to create a community of scholarly caring, we offered a three-credit, independent study opportunity that was mutually beneficial for both faculty and students. Rather than attempting to impact the entire population of the master's program, we started small with a select group of students in the nursing education track. By making the partnership an exclusive opportunity available only to students who successfully completed the feminist course and who demonstrated scholarly potential, the partnership developed a cachet. The culture within the Division of Nursing gradually shifted as more students wanted to make their master's education meaningful by becoming a member of a group of passionate scholars. Currently, I partner with students who coteach every one of my courses. There are eight partners who have extended their partnership experiences by coteaching four required graduate courses beyond the feminist course. A graduate of the master's program partnered with me over the last academic year to teach the two capstone graduate courses in the nursing education track in exchange for learning more about course design and curricular development. Four other faculty members have initiated partnerships with graduate students. This brings the total of courses cotaught by student-faculty partnerships to one RN-BSN and nine graduate courses. Fifty students, including partners and nonpartners in and beyond the Division of Nursing have been involved in research projects. So, in our small world within the Division, partnerships are taking on new and exciting forms. After almost 5 years of experiences with various forms of facultystudent partnerships, we are in the process of getting our wild idea out into the world of nursing education. In addition to conference presentations, I am writing a book about the evidence-based, transformative curriculum we are piloting in the Division (Heinrich, Bona, McKelvey & Solernou, 2002). The partnership program is at the heart of this curriculum and the cultural shift to a community of scholarly caring.
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The six partners who just graduated will undoubtedly join Judy in extending partnerships in formal and informal ways wherever they are employed as nurse educators. Now that the history, original design, and ways partnerships are being extended have been described, faculty-student partners' reflections tell the "real-life" story of the joys and the challenges of living out partnerships.
PARTNERSHIPS: THE JOYS, THE CHALLENGES, AND THE LEARNINGS As part of coauthoring this chapter, faculty and students responded to five questions about their experiences: • What was the greatest joy of your partnership? • What was your greatest challenge (catalyzing event/critical incident)? • What was your greatest learning? • What do you want to tell prospective student-partners? • What do you want to tell prospective faculty partners about the partnership experience? Responses to each of question will be discussed separately, first citing Dorothy's and my reflections as faculty-partners, and then citing student-partners' reflections.
WHAT HAS BEEN YOUR GREATEST JOY IN YOUR PARTNERSHIP? Although the joys of partnering varied widely, our responses to this question consistently harkened back to relationship. For Dorothy, "What I most enjoyed was watching Elaine get so excited. She was so excited about learning that it was very energizing." For me, it was "the love and passion for teaching and the scholarly endeavors that has surrounded us and our connections." Judy's "greatest joy is the relationship with Kathy that has enriched and continues to enrich my life as a scholar and person."
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Dale's first impression of the partnership was a combination of joy and trepidation: I met Sheila when she was already a partner with Kathy and was coteaching the feminist course. It was fascinating to see how they worked so well together. Kathy was the professor; it was her course design. Yet Sheila was free to contribute her insights, thoughts, and creativity to the class each week. I had never taken a course before where every individual was recognized for who they were and what they thought, wrote, drew, or created. The concept of a fellow student as coteacher was certainly a novel idea for me. At the end of the course, when Sheila extended the invitation to me to become a partner and a coteacher, I was completely surprised. Who me? I didn't know who I was myself. I had returned to school for a master's degree in nursing to revive career possibilities. Someone actually thought I had partner potential? I gave it much thought, verified that Kathy and Sheila would welcome the chance to work with me, and finally said yes.
Each partner came to the partnership in her own unique way. Some, like Dale, pondered the decision while others seized on the opportunity after hearing about it for the first time. Ruth recalls her own experience: The Pueblo Indians of the American Southwest believe Spider Woman created the world by spinning a web. The wisest of Spider Woman's people remain in contact with Her through the web strands attached to the top of their heads. I walked into a web of creation on May 4, 2000. This was my first advisement session in the graduate nursing program and the first time I met Kathy. After the usual take-this-class-first discussion, Kathy described an unusual program offering a graduate teaching partnership. An opportunity to coteach at the graduate level? What a find! I decided that day to become a partner. I never saw the web coming, but I was eagerly entangled in the strands before I even heard the prerequisites.
Ruth's allusion to the web underlines what makes partnerships unique. What is unique is not only the intimate, collegial friendships that develop between faculty and students, but the connected relationships that develop between and among the partners themselves. Sheila names both of these among the "seven wonders of partnership." The first joy occurred when I was invited into the partnership. I was elated that I was asked to join and humbled that Kathy and Judy thought I had something special to offer to it. The second joy came when I cotaught Feminism with Kathy and silently watched her in awe. The third occurred when I chose my partners and encouraged them to accept
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the invitation. The fourth came when they both accepted the challenge. The fifth, when I continually see how the partnership has grown. The sixth, each time the partners are together, the excitement and intellectual stimulation from each encounter. And seventh, the most important and irreplaceable one, is the connected relationships I share with the partners. Knowing what we have created is rare and eternal in heart. The beauty of watching this flourish and extend within our community is more joy than I could have asked for from the partnership.
The process of partners choosing the next partners is the special way we grew our community of scholarly caring. Korey compares her partnership experience to an "invitation to dance." As she stands poised on the threshold of graduation, Korey is grateful to those who "tapped" her and those whom she "tapped" during her partnership dance: Peggy Chinn described a thought in relation to aesthetic knowing that appeals to me as a possible conceptual framework for my partnership experience. She stated that the key to aesthetics is to 'find your own rhythm while working in the moment. . . one can be inspired by another's rhythm . . . yet one needs to remain true to one's own rhythm.' It is through the partnership that I have been able to put aside my fears and have had the strength to develop and dance with my own rhythm. I thank you, Kathy, for your scholarship that creates, develops, and nurtures new scholars. I recognize the obstacles that you have faced and thank you for defeating your dragons in an effort to promote this scholarship. I also thank Sheila for her role in my partnership development. This reflection brought about an added appreciation and realization for her importance in this process. I also thank Michele for her gifts and her reminders to me that I am a scholar and have helped her define her voice. Until now I had minimized my own influences in the expansion of the partnership rhythm. Each stage in the partnership is important for growth and development. From the invitation to dance to stepping on toes, each phase is necessary. I am immensely grateful for the opportunity to be inspired by Kathy's rhythm and to have been able to define my own rhythm.
From experimenting with coteaching courses with two partners at a time, I have learned that threesomes can be a potent and synergistic combination. After coteaching the "Writing for Publication" course, a two-day workshop with Dori and me, Alice observed: Seeing tangible results from our collaborative efforts was a real joy. When we could see the 'lights flashing' in the eyes of the students at the conclusion of the workshop, we were thrilled as a partnership unit. I feel the success we witnessed could not have been achieved without the collaborative efforts of the partnership. One educator or facilitator would not have been as effective.
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By definition, passionate scholars are willing to devote tremendous amounts of time and energy to pursing their scholarly activities. Faculty and students in partnerships transcend the boundaries of time energized by the collegiality of their scholarly dialogue. The Greeks call this experience of moving outside of time when engaged in a pleasurable activity "kairos." Georg'Ann describes one such experience: When thinking of the greatest joy, the scene at last year's Sigma Theta Tau Research day comes to mind, a warm, sunny day by the poolside with good conversation and fellowship. We were brainstorming the beginnings of the research study and course 'Perspective Transformation.' There was this feeling of connectedness and passion that made time stand still. This feeling and moment occurred again during the spring and fall as the course and research study developed.
WHAT WAS YOUR GREATEST CHALLENGE (CATALYTIC EVENT)? The theme of relationships again surfaced in our responses to this question. Dorothy's greatest challenge as a faculty-partner was linked to being honest: Doing the contract, which sounds like a boring catalytic event, was a good opportunity to look at what Elaine's goals were, what my goals were, and to try to marry the two and figure out how could we have a win-win situation. That's important in the partnership, that initial sitting down. That's the time when you have to be really honest and say okay, what are your goals and what are my goals. Is this something that is going to work? Then we set goals about those learning objectives, but we also looked at our personal lives—what's going to fit for us, how are we going to contact one another, are you going on vacation at a particular time? If I get an idea in the middle of the night, can I e-mail you? So the contracting wasn't only about what you want to learn, what you need. There are other dimensions, finding out about each other's work habits.
Deborah (Deb) and I found our contracting process also involved courageous conversations. However, it was not until Deb linked her joy and her challenge, that I realized that each partner's greatest challenges was intimately linked to her greatest joys. Deb remembers: My greatest joy was related to my greatest challenge. Kathy and I had decided to enter into a mutually beneficial postmasters teaching partnership. With Kathy's support, I would gain more teaching experience and
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the opportunity to transition my role from student to faculty. With my help, Kathy had a teaching partner to share the course workload and a collaborator on curricular revision. We were both very excited about the prospect of teaching together. During planning meetings, issues surfaced in our working relationship. When Kathy put voice to the concerns she was having, my dragons of self-doubt appeared. Suddenly, I felt like a failure consumed with fear and overwhelmed by sadness for disappointing Kathy; 1 was devastated. In the context of a courageous conversation my greatest challenge emerged and my full-blown imposter had appeared. Alas, my worst fear had been realized: I had finally been found out! The concerns Kathy raised were about commitment. She told me what she wanted to go on with our partnership and voiced a willingness to continue. My impostor would not let me believe her, despite her assurances. She suggested that I take time to decide. After careful thought, I made my decision: 1 accepted her terms, negotiated some of my own, and our partnership resumed. My greatest challenge was accepting our partnership and committing to myself, to Kathy, to our relationship, and to the partnership by facing my dragons and defying my impostor. My greatest joy was learning that I could fulfill the commitment, slay the dragons, and put the impostor to rest. If 1 had declined the opportunity, I would never have known my greatest joy. Two terms, "impostors" and "hero's journey," are commonly used by partners and require a brief explanation. Kathleen Noble's (1995) metaphor of the hero's journey can be used to frame the challenges of graduate study and the partnership. Three stages that characterize all such journeys include a call to adventure, an initiation, and a transformation. During their journeys, heroes come to acknowledge their gifts and allies as well as to face and tame their dragons through experiencing challenges and catalyzing events. When student-partners talked about challenges, they spoke of two "dragons," the dragon of self and the dragon of other people. The dragon of self often wore the mask of the impostor. On the basis of her research, Macintosh (1985) gave this name to highly successful women who believe their success is a fluke and who fear they will be found out. A shape shifter, partners' impostor, often appeared when the partner was faced with a new challenge and manifested in a myriad of forms. It was clear to both of us that Deb's impostor was "busted" when she told me this story: My friend was offered the opportunity to develop and teach a course for CNA's. She called me, feeling unsure of her ability to develop a course. I said to her, "Do it! I'll help you. You know the content and how to teach and I have the experience of curriculum development." As I stated
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this, I realized that I was identifying one of my gifts as well as an educational strength. After our discussion, she phoned the contact person to express her interest in the position. She indicated that her friend (me) had "a little experience" with course development and that I had offered to help. When I heard this, "a little experience," I was indignant! This statement, made by a good friend, was diminishing my knowledge and experience. I KNEW I could do this! Until my partnership, I never would have acknowledged my gifts or displayed this level of self-confidence.
For Judy, the dragon of other people was more the challenge. As the original partner, she faced feelings of envy and jealousy head on: Excellence was my greatest challenge. I recently found a definition of excellence as "the result of caring more than others think is wise, risking more than others think is safe, dreaming more than others think is practical, and expecting more than others think is possible." I needed to justify the passion for my education and the partnership until it "caught on." Peers, faculty and administrators confronted my actions and practice. The questions, probes, and comments covered a multitude of emotions both positive and negative. Curiosity motivated by jealousy angered and upset me until I resolved, "it was their problem and not mine." They wasted their time and sought the letters after their names; it was too late for them to have what I had or to accomplish what I was able to.
WHAT WAS YOUR GREATEST LEARNING? I have learned many valuable lessons from my partnerships. First and foremost, I understand that each partnership is as unique as the two people involved in the partnership. As Elaine observed, "A partnership may be different for different people." And each coteaching experience is unique given the alchemical mix of partners, students, and subject matter. Over time, I also began to notice that each partner gets the lesson they need. For example, Korey, a self-proclaimed "raving extrovert," drew a quiet, introverted group to her when she cotaught Feminism with me. She wanted to make them talk. Her lesson was "trust the process." She learned to listen carefully, to read their journals to discover how they were experiencing the course, and to know that once they feel safe, introverted students would begin to share their gems of insights more freely. I also have learned that honest and authentic communication transforms partnerships between women. My greatest learning was that a
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mix of love, caring, and mirroring of gifts combined with explicit limits and clear consequences breeds respect for each other and for the work. Admitting when I have made a mistake, apologizing, and carrying my share of the weight of all we have to do makes these real partnerships So does authentic communication, being sensitive to the process in hopes of addressing issues as they arise rather than letting them fester. And always, even if they have festered for a bit, confronting them with a desire for consciousness that breeds connection, rather than disconnection. This has convinced me that women can be in a group, a highly accomplished group, and not do horizontal violence or interpersonal aggression. Our partnerships have shown me that our socialization as women, while it is powerful, is not a dictum of inevitability. Dorothy credits the partnership with helping her grow through reflecting on her teaching practice. And it helped me to reflect on my own practice, which is important. To explain it to Elaine and to justify it, if you will, I was also justifying it to myself and explaining it to myself. Sometimes when you teach something for a while, you get into habits and you never really think about it. The partnership caused me to look at why it is that I do this, how do I do that, and why does it work? To be able to verbalize, to articulate, those reasons really helped me to grow.
Judy's greatest learning was, "I discovered my true self, my passion for education, teaching, and a commitment to lifelong learning." Michele's greatest joy was her greatest challenge and her greatest learning. She, Georg'Ann, and I codesigned and cotaught a new course entitled "Perspective Transformation: Socialization Into a Community of Scholarly Caring," intended to introduce newly matriculated students to the scholarly skills they need to be successful in the master's program. Michele remembers: My greatest joy as a partner was teaching the Perspective Transformation course. The relationships with my students and coteachers have been the most special part of my MSN experience. During the semester it was very satisfying to see the students as they underwent this transformation, both individually and as a group. 1 also experienced a transformation over the semester. In the beginning of the semester, I felt like an "assistant teacher." Although I had an equal part in designing the curriculum with the other coteachers, it was the relationships with the students that allowed me to really feel like "their teacher." My relationships with the other co-teachers also were an integral part of my experience. I remember our first meeting together. I was
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overwhelmed and unsure of what I could offer to this experience. I was having a "full blown case of Imposter Syndrome." As we worked together (over many sessions), it was obvious that each member of our team brought a unique gift to the table. We valued and respected each other. We were all fully committed to our relationships with the students and to each other as well as to our scholarship. In essence, we were committed to the partnership. We were committed to the community of scholarly caring at the University of Hartford.
One of the course assignments involved group presentations. These presentations followed the tragedy of September llth and were scheduled during the height of the Anthrax scare. Michele recalls her greatest challenge: A small group of students shared their ideas for a presentation with Kathy and me. The idea sounded clever, creative, and informative. I never imagined the chaos and conflicts that would come from this presentation. After the presentation, one student in particular exclaimed that her safety zone (in the classroom) was destroyed. Some felt verbally attacked. I took personal responsibility for this. I left the class shattered and heartbroken. I loved this group like they were my own children. (I know that they are adult professionals, but that is how I felt.) Teaching this class was one of my greatest joys in life. I felt that I had contributed to the breakdown of their community. That evening I believed that everything Kathy and I had created had been lost. I initially even feared that I would never be able to be a teacher after graduation because I had made such a risky judgment by approving this presentation. I was fortunate to have Deb as my mentor who was coteaching my Nursing Education theory class. She is so sensitive and understanding. I shared the situation with Deb and processed the events as they related to our group process in class with her. Deb challenged me to look at this as a learning experience and to trust the process. My greatest learning was the power of Chinn's Peace and Power process. This situation really tested the strength of our community. The students reminded each other of Chinn's concepts as they dialogued, debated, and argued over the situation. A few exemplary members urged the group to apply the Peace and Power process as the framework to resolve this conflict. I was in awe and this was proof to me that an amazing perspective transformation had taken place. I also learned the power of a community of scholarly caring. I was so proud of the group. There was a period of healing for a week or two, but the group emerged stronger and more cohesive than ever. When we were planning the course, I urged us to select Peace and Power as our text. Intuitively I knew that this text would be an instrumental part of our learning. I did not realize at that time, however, that Peace and Power would provide me with my greatest learning as a partner.
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Michele likes harmony. She drew to herself a valuable lesson—that we could emerge more strongly connected by working through the disharmony. It is Michele who chose the perfect textbook to guide us through this creative, conflict resolution process. Georg'Ann's "greatest learning has been about the rewards of connection—connected learning, connected fellowship, connected work." Chris's metaphor of a road trip conveys how she experienced being a member of a community of scholarly caring: I imagine all of us partners in a car on a special journey. On this journey, no one person drives the car (not even Kathy who is teaching us how to drive). We all take turns at the wheel, reading the map, giving directions, and supporting one another's decisions wherever we go. Sometimes one of us has been on that particular road before and takes the wheel or describes the landscapes we pass. The group has insight—stories about the places we have been and where we are going. No one is 'along for the ride.' Every single one of the partners is 100% committed and invested in the process of personal and professional advancement. The partners are committed not only to the process, but to each other. Everyone helps one another, and together we do amazing things and cover much territory. The seven of us together can create, analyze, develop, and do anything that we set our minds to. I am in awe of what takes place every time we meet. The process of involving our 7 minds (and Kathy's), instead of one, can take everyone beyond anything we might have dreamed. Wherever our car takes us, the journey together is sure to be educational, memorable, and fun for everyone.
WHAT WOULD YOU LIKE PROSPECTIVE PARTNERS TO KNOW ABOUT THE PARTNERSHIP? I have told so many students about partnerships that I have the script down pat: Read our Nurse Educator article. Speak with others who have been partners. Take the Feminist course. See how you like the content, the teaching strategies, and the community. Partners must demonstrate scholarly potential. You also need to consider your personal and professional learning goals as educators. Do you want to learn more about experiential teaching strategies, the art of facilitation, the gift of mirroring other's gifts, creating community in classrooms, and stimulating passion for scholarly endeavors? Do you want to learn more about the roles of educator, educational researcher, scholar, and consultant? If you say yes, then consider interviewing for a partnership.
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Ruth wants prospective students to know that: The partnership is an amazing, energizing opportunity and challenge that is more work than you imagine but worth the extra effort. Your definition of community, scholarly, and caring will be revised in creative ways. If you want more from your MSN than a piece of paper and a better differential, the partnership is the way to stretch yourself.
Chris encourages students to: Catch partnership fever! Become part of it—an opportunity not to be missed! Working with a group of women who are committed to learning, educating, supporting, and encouraging scholarship is not to be missed. It offers chances to become involved in areas of scholarship that without the partnership would only have been talked about in school. It is a chance to push yourself to reach your fullest potential in a safe, caring, supportive group environment. Oh, the places you will go!
Sheila balances caution with invitation when she advises: Know what you are getting into. It is a commitment to excellence, commitment to self, and commitment to relationship with other partners. Know the advantages and the pitfalls. The partnership will offer you growth beyond what you can imagine, both personally and professionally. The pitfalls may be the envy of others—be ready and able to deal with this. Take the plunge to be a partner; it will reignite the fire within and bring back the glitter to your eyes.
WHAT WOULD YOU MOST LIKE NURSE EDUCATORS TO KNOW ABOUT PARTNERSHIPS? As a nurse educator, I compare initiating partnerships to a new world: To move beyond our socialization and to regard students as colleagues is to enter a new world. It is a world where I have learned I need to own my own expertise. This is the ground from which I mine the gifts I have to share. It is a world where I must choose students who have the commitment, time, energy, and intellectual promise of becoming scholars. It is a world where I must mirror students' gifts so they will be able to overcome the dragon called Impostor that would keep them from becoming all they can be. It is a world where I must share the spotlight with my partner while keeping an eye always to my responsibility for other students and their learning—a delicate balance. It is a world where I gain a colleague to share the joys and pains, the highs and lows, and the
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respect and challenges that come with being in the trenches of teaching. It requires humility in sharing my vulnerabilities, my questions, my doubts, and my fears openly, so they will share theirs, and a willingness to take time to be in a relationship. As in all meaningful connections, perhaps the greatest gift 1 give to partners is my time and my undivided attention. And the gifts back are no less great—partners' time, energy, commitment, growth, and maturation into graduates prepared to enter doctoral programs.
Michele wants educators to understand the five, developmental stages that mark partnerships: Stage One: The Starstruck Student (a.k.a. The teacher wannabe'): The student identifies the teacher as a mentor. The idea of the partnership is an exciting possibility. The student recognizes that she can learn a great deal from the teacher and envisions herself coteaching with the teacher. Stage Two: The Impostor Teacher (a.k.a. 'I am not worthy'): The student feels unworthy of teaching. Her role as a coteacher is observational. She does not feel like a coteacher. She feels like she has nothing to bring or to teach the students. She needs to communicate with another partner (or partners) to understand the evolution of her role as co-teacher. Stage Three: The Birth of Partnership (a.k.a. The Ah, hah! Moment'): After dialoging with another partner, the student begins to see that it is necessary for her to initially be an observer. She must learn how to teach. It is necessary to see excellent teaching to learn how to teach. After a period of observing the class and teacher, the student finds ways to share herself with the class. It might be bringing in articles, sharing music, creating the atmosphere for community. The student realizes that the group process and the class community are as important as the class agenda. The students look to the student-partner for clarification of concepts and validation of their learning. The student-partner and teacherpartner dialogue together to plan every class. Somewhere in the middle of the semester [or length of class], the student feels like she is more than an observer but also an important part of the students' learning. Stage Four: Educator Identity (a.k.a. 'I really can do this'): The student-partner begins to see herself as a teacher. She refers to the students as our/my students. She is more autonomous. She sees herself taking the knowledge that she learned in the initial partnership coteaching experience and applying it to other courses and teaching opportunities. She seeks out opportunities to teach within and outside of formal classrooms. The student and teacher (partners) might collaborate on additional projects. The student-partner feels confidence in her role as an educator. Stage Five: Scholarly Identity (a.k.a. 'Me, a scholar?'): The student-partner begins to see herself as a scholar. This, too, is a developmental process. The student looks at education more globally.
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She sees that education needs to be reformed, and she collaborates with the teacher-partner (and other partners) to improve education for future students. She might be involved with collaborative research. She consults literature and is well-informed. This is a difficult stage, and the Impostor Syndrome might return. It is helpful that the student is now part of a community of partnership (the teacher-partner and the other studentpartners). The student shares her knowledge and experience publicly in classes, writing, conversations, and presentations. The student partner feels an obligation to give back to the discipline and the partnership experience. She encourages newer students to become partners. She fosters scholarly development of others.
Mezirow and colleagues (2001) speak of the balance of challenge and support that is optimal with adults in new learning situations. In Stages One to Three, student-partners need lots of support and a bit of challenge, while in Stages Three to Five the student partner is ready for more challenge and less support. Partners encouraged educators to pursue partnering relationships because a "partnership benefits all—professor, student partner and student body. It impacts the culture and affects the climate of the learning environment; it creates a community. When it works, it is magic and personally and professionally rewarding for both parties." Their caveats are woven into a composite below: The partnership is not for every student or for every faculty member. Know how much work and commitment the partnership will demand of you as an educator. The students are not graduate assistants hired to do a job. In fact, it is a privilege and opportunity the students pay for. Awe is enough without forced obeisance or authoritarian behavior. It is not a power-over relationship; it is truly a collegial relationship. If you can't buy into this, don't set up partnerships. The relationship is fluid and will change over time, so be flexible. Be prepared for changes you did not expect. Be prepared for jealousy from other faculty and other students. Those feelings and judgments of other students and faculty are real and need to be discussed, both the positive and negative. A partnership can be risky, but you need to believe in the process, to know that what you are part of creating is worth the risk. The benefits far outweigh the risks.
PARTNERSHIPS DEFINED So what is a partnership? According to Dorothy, "The partnership is an opportunity for both parties to grow in an environment that is friendly and supportive of each other." She advises:
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It's a collegial experience. In a situation where we talk about studentteacher relationships, it's a teacher-teacher/student-student relationship. That's why I say it's collegial; we both learned and we both taught at one time or another. I was learning from Elaine while Elaine was learning from me. It was a win-win situation. We talked about the midwife teacher, trying to get the best, to use Elaine's strengths to build on, her past experience with that course, to look at it differently . . . that introduced Elaine to a new level of teaching [that is facilitation]. We were both continually learning.
Contract learning, independent studies, clinical practicums, and fellowships foster student learning, while graduate assistantships enhance faculty productivity. Partnerships differ from these learning experiences in two crucial ways. Partnerships mutually benefit both partners, and they are formed and fostered within a community of faculty and student scholars. Partnerships more closely resemble a cross between peer mentoring (Vance & Olson, 1998) and the apprenticeship model of medieval guilds. The definition the partners agreed on as a group addresses both the individual and the collective. Partnerships are the embodiment of feminist and adult learning pedagogy. They offer unexpected opportunities that allow students to link with faculty and each other in ways they never imagined or envisioned. Partnerships are energizing, enthusiastic, motivating. Chris puts her reflections on partnerships into poetic form below: The choice to do more The choice to explore more The choice to be more Being open to possibilities Exciting, energizing, inspiring, motivating Commitment to the process Commitment to each other Commitment to ourselves Commitment to Kathy for the investments she makes in us Opportunities for personal growth Opportunities for professional growth, validation, networking, *A PRIVILEGE TO BE A PART OF* One of the only reasons I don't want school to end.
TIPS FOR CREATING PARTNERSHIPS Partnerships are as individual as the partners themselves. When sensitively crafted, faculty-student partnerships are a win-win situation. Inter-
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ested in initiating a partnership? Then see yourself as a social inventor and the partnership as your laboratory. If you give yourself and your students permission to experiment with different ways to partner until you find what works best, your partnerships will succeed. Using the 12 C's of partnership as a guide, design your own partnerships: • Choose to initiate a partnership. Identify a student who is bright, whose work ethic and style match yours, whom you like as a person, and with whom you would enjoy spending time, lots of it. • Commit to setting aside the time that partnership relationships require. • Compose a wish list that makes your eyes glitter and ask your prospective partner to do the same. • Create a contract that is mutually beneficial, flexible, and negotiable. Remember to allow for synchronicity. Leave spaces in your calendar for the unexpected so you can respond to opportunities. • Congratulate yourself and your new partner on your courage for entering into this pioneering relationship. • Communicate courageously. Risk being authentic and vulnerable to keep your partnering relationship vibrant. Process everything from imposter feelings to catalytic events with each other. Dialogue and figure out your own ways of dealing with misunderstandings and conflicts. • Calibrate your partnership relationship. Trading the traditional roles of teacher and student for that of partner is a challenge! Admit you are both beginners. Check in with each other about how you're doing as partners. Share decision-making in small ways and you will grow to depend on each other's opinions over time. Gradually give over your power as you feel comfortable and when your partner is developmentally ready. Eventually you will move away from being the "sage on the stage" to become the "wind beneath your partner's wings." • Create safe space. For partnerships to flourish, both partners must feel comfortable and accepted in the partnership. If you tend to be formal or informal, like to communicate by e-mail or face-to-face, want to meet in your office or in a restaurant, it's okay! Whatever your style, honor it and negotiate with your partner about what feels comfortable for the both of you.
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• Conspire to tip your culture toward academic excellence and passionate scholarship by modeling both. Be intellectually generous. Glory in your partners' accomplishments! In the end your readings will be cutting edge, your courses will be tailored to students' learning needs, and your teaching evaluations will glow. Colleagues will take note and begin to invite students to partner with them. • Creatively subvert others' jealousy and envy into an invitation for faculty and students to initiate partnerships. • Celebrate and have fun! Recognize your own and your partners' gifts and accomplishments often and joyfully. It is important to give your student partners feedback on their gifts. Let whoever is best at something, do it. Fill your partnership with food and fun. Arrange your meetings over meals, or at least snacks, and laugh a lot as you get your work done. • Collude with other faculty and student partners to foster a community of scholarly caring that is a network of passionate faculty and student scholars.
CONCLUSIONS This chapter introduced faculty-student partnerships as an innovative way to prepare graduate students to become nurse educators and scholars. We told you about our partnerships and gave you ideas for initiating your own partnerships. If you have your own wild idea, then consider this. Find the right student messengers—Connectors, Salesmen, Mavens. Find a message that is contagiously sticky! Keep your efforts focused, small, and grassroots. Use a minimal amount of resources. Test your intuition every step of the way to see if your experiment is working. Then wait and watch your message/movement tip your culture. Once it takes off, there is no telling where it will go. At the University of Hartford, we are changing the way we educate nurse educators, tipping our culture toward academic excellence and passionate scholarship, with the hope of transforming nursing, one partnership at a time. We invite you to join us!
REFERENCES Bunkers, S. S. (2000). The nurse scholar of the 21st century. Nursing Science Quarterly, 13, 116-123.
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Chinn, P. L. (2001). Peace & power: Building communities for the future (5th ed.). Boston: Jones & Bartlett. Gladwell, M. (2000). The tipping point: How little things can make a big difference. New York: Little, Brown. Hedin, B. A., & Donovan, J. (1989). With eyes aglitter: Journey to the curriculum revolution. Nurse Educator, 14(4), 3-5. Heinrich, K. T. What's life like after a doctorate: Five year, longitudinal study exploring life after graduation from a doctoral program in nursing. (Under review). Heinrich, K. T., Bona, G., McKelvey, M., & Solernou, S. (2002, April 25). Journey to the heart of the mind, llth Annual Research Day, Connecticut Chapters of Sigma Theta Tau International, Meriden, CT. Heinrich, K. T., Mathews, M. B., Varholak, D., & Cote, J. (2002, March 21-23). Faculty-student program evaluation research project grounds a curriculum revision. Fourteenth Annual Scientific Session of the Eastern Nursing Research Society. University Park, PA: Pennsylvania State University. Heinrich, K. T. (2001). Doctoral women as passionate scholars: An exploratory inquiry of passionate dissertation scholarship. Advances in Nursing Science, 23, 88-103. Heinrich, K. T., Cote, J., & Solernou, S. (2000). Need help with your scholarly work? Create a community of passionate scholars. Nurse Educator, 25, 162-165. Heinrich, K. T., Witt, B., McGuinness, R., & Ambrozaitis, J. (1999, November 8). Unique contributions of Connecticut nurses to health care. Scientific Sessions of the 35th Biennial Conference, Sigma Theta Tau International, San Diego, California. Ironside, P. M. (2001). Creating a research base for nursing education: An interpretive review of conventional, critical, feminist, postmodern, and phenomenologic pedagogies. Advances in Nursing Science, 23(3), 72-87. Kelly, C. M. (2002). Investing in the future of nursing education: A cry for action. Nursing Education Perspectives, 23(1), 24-28. Macintosh, P. (1985). Feeling like a fraud: Working Paper #18. Wellesley, MA: Stone Center of Developmental Services and Studies. Meleis, A. I. (1992). On the way to scholarship: From masters to doctorate. Journal of Professional Nursing, 8, 328-334. Meleis, A. I., Hall, J. M., & Stevens, P. E. (1994). Scholarly caring in doctoral nursing education: Promoting diversity and collaborative mentorship. Image: Journal of Nursing Scholarship, 26, 177-180. Mezirow, J., & Associates. (2000). Learning as transformation: Critical perspectives on a theory in progress. San Francisco: Jossey-Bass. Noble, K. D. (1995). The sound of a silver horn: Reclaiming heroism in contemporary women's lives. Boston, MA: Shambala Press. Spayde, J. (2002, March/April). The eight steps of social inventing. Utne Reader, 62-63. Vance, C., & Olson, R. K. (1998). The mentor connection in nursing. New York: Springer Publishing Co.
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Chapter 7 Rewarding Teaching Excellence Through a Master Educator's Guild
Catherine Nuss Kotechi
ow can teaching and learning be promoted and recognized in a health science university? That was the question. While there are many excellent researchers and clinicians at our health science university, there also is a cadre of dedicated teachers in various disciplines. Partnerships with other disciplines needed to be formed to promote teaching excellence across academic settings and to elevate the culture of teaching and learning at the University. A review of literature revealed many articles about teaching excellence in different disciplines, countries, and levels of education. In discussing this literature we focused on three areas: barriers to excellent teaching, ways to overcome those barriers, and the relationship of teaching excellence to tenure and promotion. This chapter considers teaching excellence from these three perspectives and describes a program for recognizing and rewarding teaching excellence in the form of a Master Educator's Guild—an interdisciplinary group of faculty charged with making an impact on education within the university. The interdisciplinary partnership strengthens the individual faculty's teaching as well as the culture of education within the university. In one university, this was the answer.
H
RECOGNIZING TEACHING EXCELLENCE The impact of teaching is difficult to define in concrete terms. This was pointed out recently in studies sponsored by The Pew Charitable Trust 133
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(Shapera, 2002). In funding new ways to evaluate education, the intangible nature of teaching, particularly in relationship to students' engagement in learning, was addressed. For example, the National Survey of Student Engagement (NSSE) was developed to measure the academic engagement of students (National Survey of Student Engagement, 2001). In this survey, the impact of teaching and learning is measured as students' engagement in academics, campus life, and a personal pursuit of knowledge. Five benchmarks are used: level of academic challenge, active and collaborative learning, student interaction with faculty, enriching educational experiences, and supportive campus environment (Shapera, 2002). Discussion of the content of the NSSE survey assists students and their parents in asking questions such as, "Does a fulltime faculty member teach English 101?" as opposed to, "How plush are the dorms?" The NSSE survey contrasts with the annual one published in U.S. News <S> World Report, which focuses on financial and physical resources, research dollars, and prestige (Gary, 2002). Many factors enter into the educational process. For educators, a central concern is the work of teaching. Teaching excellence is not easily defined, and is often quantified by describing the barriers to excellence and ways to overcome them.
BARRIERS TO EXCELLENCE Barriers to effective teaching are described by Outcalt (2000) in a review of literature about teaching in community colleges. Outcalt sets the stage by arguing that the community college is the haven of teaching. It is a place where teaching is a craft, the premier activity, and the crucial component of the identity of the faculty. Therefore, it is a place where teaching excellence should be evident or, at the very least, a place to learn about teaching. Faculty at community colleges make up 31% of all United States higher education faculty, so the importance of teaching and learning in community colleges must be underscored when discussing teaching excellence. Oucalt identifies five barriers to excellent teaching: isolation of faculty, growing reliance on part-time faculty, underprepared students, inadequate resources for faculty development, and increasing pressure to engage in research. In baccalaureate and higher degree programs, particularly in the health sciences, another barrier to teaching excellence
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can be identified—retention of excellent clinical teachers who do not meet promotion and tenure requirements. It is evident that the onus of excellent teaching is on the teacher, since the factors related to the faculty clearly outweigh the student factors. Three barriers worth considering in depth are faculty isolation, faculty development, and the retention of clinical teachers. Faculty isolation has been described by Grubb (1999) and Palmer (1998) as occurring across academic settings, for experienced as well as inexperienced teachers, and as a cause of teachers leaving their field of service. Kraft (2000) vividly described his discovery of the loneliness of teaching, in his role as director of a center for teaching excellence at a large comprehensive university with a teaching mission. He discovered themes of loneliness and isolation within the professorate as he hosted an education offering to faculty. Teachers across disciplines attended the offering because they wanted to connect with other faculty to discuss the "nuts and bolts" of teaching and learning. By and large, faculty work in isolation, produce scholarship that is objective and impersonal, and focus on research to get ahead. Kraft argues that faculty members are desperate for a sense of community, a place where teaching and learning can be discussed in pragmatic and philosophical terms with others who are committed to the craft. This is true whether the faculty are full or part time. Faculty development encompasses learning opportunities that occur over the course of the teacher's career, including orientation to the faculty role, mentoring, participation in educational programs about teaching and learning, and development of a teaching portfolio. In many instances, new faculty members are not prepared to assume the faculty role after graduating from their doctoral program. In a study reported by the Pew Charitable Trust, over 4,000 doctoral students were polled about their career expectations after graduation (Golde & Dore, 2001, as cited in The Pew Charitable Trusts, 2001). A mismatch was evident between doctoral training and student goals and career aspirations. Despite a high interest (74%) in attaining a tenure-track position, only 36% felt prepared to teach lecture courses. In contrast, 74% were confident about their research training. Clearly, new faculty need assistance with the development of the teaching role. Further, Proctor (2001) describes three ways in which new faculty need assistance: (1) directing their own learning and setting goals that are compatible with the department's mission and goals, (2) developing
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a plan for their career at the institution, which includes promotion and tenure, and (3) recognizing personal strengths and weaknesses in the area of role development. From the medical education perspective, Proctor describes the new graduate physician in academia as in need of teaching skills as basic as test preparation and lecture development. In medical schools, the emphasis on clinical preparation and expertise overshadows the need for teaching skills. From an interdisciplinary perspective, we experience the same challenges in nursing programs particularly at the master's level. Master'sprepared clinicians who assume teaching roles may have been educated originally as nurse practitioners or clinical nurse specialists. As nursing faculty age, and the demographics of nursing changes, the master's prepared nurse will assume an expanded role in the academic environment as clinical expert and clinical teacher. This will be important as academic settings increase faculty practice assignments and place students in more diverse clinical settings. One strength of the master'sprepared faculty is clinical expertise, but a barrier is the lack of educational preparation to teach others. Kirkpatrick and colleagues (2001) point out that the retention and promotion of these faculty must be ensured so that a competent base of clinical instructors can be maintained in academic communities.
Overcoming Barriers Barriers to teaching excellence can be overcome through the implementation of learning communities, faculty development programs, centers for teaching excellence, and the creation of academies of educators. All of these strategies benefit from an interdisciplinary approach. Learning communities are at the very least a group of faculty committed to sharing and supporting one another in pedagogical endeavors. According to Palmer (1998), a learning community is essential for the life of teaching. Learning communities are where faculty come together to evaluate their own teaching practices, learn from fellow faculty, and engage in public self-reflection about the craft of teaching. The learning community is a place where teachers can understand the underlying motivation for teaching, their own frustrations about teaching, and what to do about the situation. For both reflection and objective evaluation of teaching to occur, the learning community should include faculty of
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different disciplines who may have different teaching approaches. The learning community may not be a formal part of the university community, rather an informal group of interested teachers. Faculty development programs include orientation programs, mentoring opportunities, and educational programming. Orientation programs are desired for new faculty but are not always available. Frequently the crush of work for the new faculty member overshadows the need for an orientation. Orientation programs help to familiarize new faculty with the university. They can be a method of identifying basic policies, reviewing contracts, and sharing the culture of the institution. Ongoing mentoring throughout an academic career contributes to career success and longevity. Mentoring exists as a match between two individuals and is mutually beneficial, personal, and satisfying. Problems with faculty development programs in some settings are that they are limited in planning, scope, and availability. In addition, part-time faculty may not be invited to take advantage of these programs, or teaching schedules may conflict with them. Centers for teaching excellence can be a physical place at the university or a location on the Internet. Centers for teaching excellence may be managed by one department in the university or by many different departments. Centers for teaching excellence provide new faculty with information, courses, and programs on test development, learning styles, teaching strategies, using technology in teaching, and other areas related to learning and teaching. They are generally focused on the pragmatic aspect of teaching and offer a wealth of information for the new as well as experienced faculty member. Online centers for teaching excellence offer a way to connect with others via the World Wide Web. Centers are generous with access to mini lectures on elements of teaching, information on funding of education projects, and articles and essays by teachers about the craft of teaching. A good example of an online site is the Center for Teaching Excellence (CTE) sponsored and maintained by the University of California in Santa Cruz (CTE, 2002). The site contains information on conducting student and faculty evaluations, surveys of teaching, and an online webzine "Faculty Focus" that has articles about teaching and learning. Additionally, On-line University Teaching Centers in the United States can be accessed via the Web at http://ic.ucsc.edu/CTEAinks.html. Links are available for approximately 60 different community colleges, technical colleges, and universities with online centers for teaching excellence.
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Concerns about the preparation of physicians for teaching have prompted two medical schools to develop academies to promote teaching excellence. The worry that teaching has been "lost in the shuffle" of health care and therefore has been compromised prompted these efforts to improve how physician educators are prepared. The emphasis in these academies is on teaching. Physicians who demonstrate teaching excellence are rewarded financially on par with their clinical and research counterparts. Another role of the academies is to advocate for promotion, faculty development, and curriculum reform (American Association of Medical Colleges [AAMC] Reporter, 2001).
PATHWAY TO PROMOTION AND TENURE Tenure is harder to come by in the university setting than ever before, yet is as desirable as ever (Shea, 2002). Despite this, new ways to achieve tenure, other than the research venue, are being discussed and debated. Traditionally, promotion and tenure have been based on scholarship and research, on teaching, and on service. The heavy emphasis on research as the primary path served to undercut the value of the role of teacher and clinician. Ways to achieve promotion and tenure other than research productivity are being sought and have been reported in the literature. The influence of Boyer (1990) is paramount in the development of a new model of scholarship, which is particularly useful in nursing. As described by the American Association of Colleges of Nursing (AACN) (1999), four aspects of scholarship should be adopted in nursing education: the scholarship of discovery, teaching, application, and integration. The rationale for this is the current demands of health care, competition for scarce resources in higher education, and the broadening context of nursing in face of shortages. Further, a definition of scholarship in nursing underscores the need for emphasis on all elements in the profession of nursing. Scholarship in nursing is "those activities that systematically advance teaching, research, and practice of nursing through rigorous inquiry that (1) is significant to the profession, (2) is creative, (3) can be documented, (4) can be replicated or elaborated, and (5) can be peer reviewed through various methods" (AACN, 1999, p. 2). In nursing, teaching scholarship includes professional role modeling, curriculum
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development, learning outcome evaluation, development of innovative teaching and learning strategies, and the development of knowledge and theory specifically related to teaching and learning in nursing. Boyer's (1990) model of scholarship is being adopted in nursing education (Everett et al., 1998). In describing how clinical faculty were promoted at their institution, Kirkpatrick and colleagues (2001) considered the four aspects of scholarship in relationship to the traditional components of research, teaching, and service. They demonstrated a more comprehensive view of clinical teaching when it was viewed through the lens of the four aspects of scholarship. The authors developed a scholarship interaction model that served to expand the definition of excellence in clinical teaching, bringing it in line with the university's model of promotion and tenure. In an interdisciplinary project, faculty from the schools of nursing, pharmacy, and veterinary science pooled their resources to institute the development of a clinical faculty track within the university. Each school developed criteria for appointment and promotion of faculty on the clinical track. No more than 15% of the total faculty or 5% from each school could be on the clinical track. Clinical teaching can be a pathway to promotion and tenure.
MASTER EDUCATOR'S GUILD Teaching excellence and innovation became an important part of the University of Medicine and Dentistry of New Jersey (UMDNJ) with the creation of a Master Educator's Guild, which was formed to recognize teaching excellence and promote the mission of teaching at the University. The UMDNJ is the nation's largest health science university with eight schools and campuses located throughout the state of New Jersey. To promote teaching at the University, an advisory committee was formed in the spring of 1999, at the direction of the University President. The goal was to focus the attention and resources of the University on the climate of teaching and learning. The advisory committee constituted faculty and administration from the existing schools. From the committee came the idea of a Master Educator's Guild to support the educational mission of the University. Main features of the program were to:
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• Assure outcome standards of student performance through educational effectiveness and innovation • Continue support of scholarly activity directed toward educational programming and continuing professional education • Initiate service programs to support teaching at every level of the institution and the larger academic community The advisory committee recognized that faculty were best suited to move the educational goals of the University forward and supported recognition of the practice of teaching and scholarship related to teaching. The advisory committee envisioned a group of master faculty, innovators and scholars, who would be empowered to make a difference in the educational climate at the University. The notion of a guild seemed to embody the beliefs about teaching and learning discussed by the advisory committee. The guild members would be master teachers who come together for support, to share knowledge of their teaching craft with inexperienced teachers, and to ensure standards of excellence in the academic community. Further, it was recommended that medals be created, with the seal of the University, to identify members of the guild at graduation and other important University events. An important part of the discussion of the advisory committee centered on the attributes of the master teacher and what constitutes teaching excellence. The discussion that occurred focused on characteristics of quality teaching, reflecting the ideas introduced in the earlier part of this chapter, and emphasized clinical teaching, an important role of faculty at the University. As discussion progressed, it was evident that there were more commonalities than differences among group members. General attributes of the master educator can be grouped according to teaching skill, relationships with students, and relationships with peers. The master educator possesses teaching skill that is current, scholarly, and innovative. The master educator teaches with innovation in traditional venues such as the classroom, laboratory, and clinical setting, or in alternative venues such as the World Wide Web. Table 7.1 summarizes the identifiers of master educators, the data used to document quality of teaching. The advisory committee drew up a document describing the master educator program and guild, which went to the Vice President for Academic Affairs and the President of the University. On approval, each
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Master Educator Identifiers
Performance evaluations submitted by administrators Evaluations of teaching submitted by peers, students, or both Development of teaching materials Observations of communication skills Student performance outcomes on examinations Graduate outcomes on state licensure and certification examinations Development of innovative teaching-learning strategies and technologies Data on successful retention of at-risk students Employers' surveys that address an area of competency, that can be ascribed to specific teachers or entire departments Development and revision of patient practice protocols Improvement of existing courses and development of new courses Honors and awards relating to teaching Articles, invited presentations, and workshops on teaching strategies and effectiveness
school was charged with identifying a selection process for faculty to be admitted to membership in the Master Educator's Guild. The master educator is the designee for a period of one year, after which he or she becomes a member of the guild and a new master educator is nominated. The period of membership in the guild is 5 to 7 years. The School of Nursing (SN) bylaws were amended to give oversight to the committee on faculty appointments and promotions for selecting the master educator from nursing. The deadline for generating a candidate is May 15th. The master educator is inducted into the guild at University Day, which occurs annually in September.
SELECTING THE MASTER EDUCATOR The committee on faculty appointments and promotions of the SN is responsible for initiating the process and recommending a candidate/s to the Dean. The Dean of the SN then selects the candidate for the Master Educator's Guild and forwards the name to the Vice President for Academic Affairs who oversees University Day and the induction of the faculty into the guild. During the first week of the spring semester, letters are sent to all faculty, staff, and students announcing the master educator program
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and criteria for selection into the guild. Since the SN has campuses on five different sites throughout the state, nominations are encouraged from all of the sites. Nominations are then forwarded via e-mail, campus mail, or U.S. mail to members of the committee on faculty appointments and promotions. The announcement period is the first five weeks of the semester. During this time, frequent reminders are made to all members of the SN community to think about appropriate nominations. Master educators already in the guild help to facilitate the process. At the sixth week of the semester, the nominations are gathered and reviewed by the committee. Each nomination is signed and accompanied by a brief rationale showing why the faculty has been nominated. Faculty who do not meet the selection criteria are sent a letter acknowledging their nomination and contribution to the school. Selection criteria are as follows: • • • •
Be employed full time at the SN Have teaching as the primary responsibility Hold the rank of assistant professor or higher Be nominated through the master educator selection process
Eligible candidates receive a letter informing them of their nomination and inviting them to submit a portfolio that reflects the characteristics of teaching excellence (Tables 7.1 and 7.2). Specifically, faculty must submit: • Student evaluations of the course and faculty for the three preceding years • Peer evaluation or two letters of support from faculty • Administrative evaluation from the three preceding years • Written exemplar of teaching: A narrative of a teaching-learning situation in which the characteristics of teaching excellence are demonstrated • Curriculum vitae Candidates must submit the portfolios by week 12 of the semester. Portfolios are reviewed by the committee on faculty appointments and promotions, and a decision is made by week 13. One or two names are forwarded to the Dean of the School of Nursing for the final selection. The process is complete when the selection is made, usually by week 15 of the semester.
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TABLE 7.2
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Excellence in Clinical Instruction
Excellent clinical instructors: Provide students with an orientation for their clinical experience Are accessible and available to students at clinical sites Provide timely and constructive performance feedback Relate the scientific basis to patient care protocols Encourage students to acquire new knowledge and ask questions Tailor experiences to each student's level so the student is challenged Integrate concepts and didactic learning into clinical encounters Cultivate students' analytical abilities and critical judgments Develop students' clinical skills pertinent to the current clinical rotation Demonstrate enthusiasm about teaching in a clinical setting Provide direct observation of the student's clinical practice Serve as role models with high professional standards in interpersonal relationships with patients, students, colleagues, and staff Exhibit sound teaching practices in multiple clinical sites Incorporate students' suggestions into teaching practice
OUTCOMES Since the inception of the program, a number of outcomes has been achieved by the master educators as well as the University. A tangible award for the master educator is unrestricted grant money to support educational efforts and research. The program has been funded by the University, and each master educator receives an award in the amount of $3,000 to $5,000. The award can be used for education, equipment, or research efforts that are educationally based. In addition to the award, faculty are recognized at the University and state level. The program was featured in University publications (Jacobs, 2000), and the master educators march together at graduation. One of the most important aspects of the program is the supportive nature of the guild, which counteracts isolation and builds bridges between disciplines. Student educational problems are similar across disciplines. These problems, solutions, and challenges in teaching are discussed in guild meetings. For example, meeting the needs of at-risk students is a challenge in all disciplines. Many of these students speak English as a second language and have special educational needs. During guild discussions, educators across disciplines share strategies that have worked.
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Finally, election to the guild contributes to faculty promotion and tenure efforts. A revamping of the promotion and tenure system within the University has resulted in the creation of different tracks for tenure including research, clinical, education, and administrative. Criteria for each track have been established. The system has been in existence for two years. To date, no one has applied for tenure on the education track, but the designation of master educator is a component of this track. Along with improving teaching, the academic community has benefited from the program through the development of a Web site and educational offerings. The Web site was funded with seed money from a competitive University technology grant. The Web site provides a virtual home for the Master Educator's Guild and includes links to educational resources for the health sciences, advice from master educators, and computer searches. A University-wide program on using technology in education was convened the second year the guild was in existence. Master educators served as facilitators of discussion groups and hosts of a variety of sessions on technological innovations for teaching. The program drew participants from health science disciplines as well as the larger academic community. A University-wide mentoring program is being developed based on one of the medical school's existing program. The guild provided the opportunity for other schools to hear about this existing program and discuss how it might be adapted across the University. The exchange of ideas, programs, and problem solving fostered by the guild contributes the educational climate of the University.
SUMMARY Nursing faculty can benefit from participating in learning communities with faculty from other professions. At the very least, nurse educators can seek out others in their workplace and professional environment to create a learning community. The creation of the Master Educator's Guild at the UMDNJ has afforded that opportunity. The unity of educators in the health sciences serves to reduce isolation and create opportunities for faculty to continue to learn about teaching. Because nurses play a role in the interdisciplinary team of bringing team members together, they are a logical choice to reach out to col-
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leagues to form academies, guilds, and centers of teaching excellence wherever they work. Through their participation, they can influence nursing and health professions education, contribute to a new generation of educators, and contribute to excellence in the profession.
REFERENCES American Association of Colleges of Nursing (AACN). (1999). Position statement on defining scholarship for the discipline of nursing. Retrieved March 11, 2002, from http://www.aacn.nche.edu/Publications/positions/scholar.htm American Association of Medical Colleges. (2001, January). Academies reward excellence in teaching). AAMC Reporter, 10, 1, 4, 5. Boyer, E. (1990). Scholarship reconsidered: Priorities for the professoriate. Princeton, NJ: Carnegie Foundation for the Advancement of Teaching. Cary, P. (2002). The challenges of striving to measure academic excellence. Retrieved March 28, 2002, from http://www.usnews.com/usnews/edu/college/rankings/ about/challenges.html Center for Teaching Excellence (CTE) Online. (2002). Retrieved March 11, 2002, from University of California, Santa Cruz, Instructional Computing Web site: http ://ic. ucsc. edu/CTE Everett, L., Brown, S., Pokorny, M.,Barnes,J., Lee, X., Leggett,J., & Poston, I. (1998). Approaches to implementing a philosophy of scholarship. Nurse Educator, 23, 13-14. Grubb, N. W. (1999). Honored but invisible: An inside look at teaching in community colleges. New York: Routledge. Jacobs, E. (2000, Fall). Meet the masters. Health State, 18, 14-23. Kirkpatrick, J., Richardson, C, Schmeiser, D., Schafer, K., Valley, J., & Yehle, K. (2001). Building a case for promotion of clinical faculty. Nurse Educator, 26, 178-181. Kraft, R. G. (2000, May). Teaching excellence and the inner life of faculty. Change. Retrieved February 26, 2002, from http://www.findarticles.com/cf_0/ml254/ 3_32/62828428/print.jhtml National Survey of Student Engagement (NSSE). (2001). Retrieved April 18, 2002, from NSSE Web site: http://www.iub.edu/~nsse/ Outcalt, C. L. (2000, Fall). ERIC review: Community college teaching—Toward collegiality and community. Community College Review. Retrieved February 26, 2002, from www.findarticles.com/cf_0/mOHCZ/2_28/67373850/print.html Online University Teaching Centers in the United States. (2002). Retrieved March 11, 2002, from University of California, Santa Cruz, Instructional Computing Web site: http://ic.ucsc.edu/CTE/links.html Palmer, P. J. (1998). The courage to teach: Exploring the inner landscape of a teacher's life. San Francisco: Jossey-Bass.
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Pew Charitable Trusts. (2001, June). At cross purposes (Trust magazine briefing). Retrieved March 11, 2002, from www.pewtrusts.com Proctor, J. (2001, January). Faculty development programs gain ground: Medical schools invest in their most valuable resource. AAMC Reporter, 10, 8, 9. Shapera, T. (2002, March). Higher education performance: The best college in the country. The Pew Charitable Trusts. Retrieved March 11, 2002, from www.pewtrusts.com Shea, R. (2002, March 25). The new insecurity. Retrieved March 28, 2002, from http://www.usnews.com/usnews/issue/020325/ideas/25tenure.htm
Chapter 8 Using Care Groups to Mentor Novice Nursing Students Richard L. Pullen, Jr., Patrice H. Murray, and K. Sue McGee
he emphasis on a caring curriculum has led to the development of new teaching and learning strategies in nursing education (Evans, 2000). A caring curriculum is one in which faculty members and students share effective interpersonal skills and develop a trusting and caring relationship (Watson, 1979). Our prenursing students were experiencing anxiety, frustration, and confusion because of inconsistencies in evaluation among faculty. We realized the need for a change in our curriculum and teaching methods. A new approach was developed to teach prenursing students by incorporating special groups, called "Care Groups," in the curriculum. These Care Groups promote caring relationships and help students succeed by decreasing their apprehension and anxiety when demonstrating basic nursing skills in a laboratory environment. This new approach guides the novice student through the development of basic nursing skills incorporating the cognitive, affective, and psychomotor domains of learning (Pullen, Murray, & McGee, 2001).
T
PSYCHOMOTOR LEARNING IN NURSING STUDENTS The acquisition of basic psychomotor skills in nursing has traditionally been associated with demonstrations by the instructor. However, students who pay attention to key principles, receive a demonstration, and practice the skill with supervision are more likely to be successful in a 147
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testing scenario (Knight, Moule, & Desbottes, 2000). Knight and colleagues (2000) discussed the importance of demonstration of a skill by a facilitator, followed by analysis of the demonstration by the student into its component parts, and then followed by practice. However, the use of skill analysis to teach skills should not be reduced to a succession of isolated tasks. In addition, nursing skills should not be viewed purely within the psychomotor domain, with little attention paid to the affective component and knowledge base that underpins the skill. Melby and colleagues (1997) recommend the self-learning of psychomotor skills because they believe students become independent learners and can learn psychomotor skills with or without demonstrations and active participation by the instructor. In contrast, other educators (Knight, 1998; Knight & Mowforth, 1998; Snyder, Fitzloff, Fiedler, & Lambke, 2000) emphasize the need to provide beginning students with a structured learning environment in a nursing laboratory for the development of psychomotor skills, with an instructor present. Jeffries, Rew, and Cramer (2002) compared two teaching methods for learning psychomotor skills: a student-centered interactive approach and a traditional lecture and demonstration. Students in the studentcentered interactive groups, which were self-paced and reflected principles of adult learning, had a more positive learning experience. Students had individual ownership of their learning. When students have the opportunity to take responsibility for their own learning, critical reflective thinking, problem solving, and communication skills increase, thereby enhancing students' self-efficacy in relation to learning (Ewell, Jones, & Lenth, 1996; Pesut & Herman, 1999). The most comprehensive approach to teaching psychomotor skills to date was developed by Benner (1984) using the Dreyfus Model of Skill Acquisition. The model postulates that in the acquisition and development of a skill, a nursing student passes through five levels of proficiency: novice, advanced beginner, competent, proficient, and expert. Novice students have no experience and must be given rules and structure, with guidance by faculty to skills attainment. A positive and structured learning experience enhances personal and professional growth and the acquisition of skills as the novice progresses through the levels of competency. Gaberson and Oermann (1999) discussed the importance of a structured and controlled environment in the nursing laboratory for students to learn and practice psychomotor skills. When demonstrating psycho-
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motor skills to students, teachers should keep in mind that skilled performance has cognitive, motor, and affective components. The authors further discussed the importance of faculty demonstration, feedback, and student practice in the attainment of basic skills. Other approaches to teaching psychomotor skills are recognizing the uniqueness of students' own methods of learning and teaching the cognitive and affective dimensions of the skill as well as in the psychomotor domain (Minnesota Baccalaureate Psychomotor Skills Faculty Group, 1998). Psychomotor skills laboratory instruction is an area of specialization and plays a pivotal role in a students' skills acquisition. The integration of various teaching methods is necessary in the nursing laboratory to promote competency in psychomotor skills (Beeson & Kring, 1999). A major theme in the literature in recent years is the faculty role as facilitator or mentor. Chow and Suen (2001) discussed the importance of mentoring students as a way of facilitating the integration of the student into the clinical setting. Mentoring results in a supportive relationship between mentor and student, which promotes professional development, academic success, and leadership (Ryan & Brewer, 1997). Mentoring requires patience, time, and a willingness to help shape the career of a future professional. Mentoring reflects a positive attitude of the profession to nurture novices and provide the guidance needed to alleviate their anxiety and frustration (Alexander, 1998). Mentoring nursing students helps them to attain excellence and develop professional values in practice. Nurses who have learned from powerful mentors are more likely to grow professionally and develop effective caring relationships with others (Goran, 2001; Murdaugh, 1998). Shared partnerships complement mentoring approaches to teaching psychomotor skills. Lockie and Burke (1999) found that partnerships in the Partnership in Learning for Utmost Success (PLUS) program increased sensitivity of faculty to the diverse needs of students, particularly multicultural needs. The most unique part of the PLUS program was the establishment of a positive environment that stimulated active learning, formation of study groups, and use of mentoring activities that helped to ensure student retention in a baccalaureate nursing program. Lee (2001) also supported the formation of groups to develop partnerships in learning. Partnerships between preceptors and junior nursing students were effective in facilitating student learning and retention (Beeman, 2001). Nursing education must adjust to the changing student population (Wieck, 2000). New nursing students think differently, work differently,
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and tend to be largely concerned with themselves. Many of the students have had few role models who have exhibited the core values traditionally treasured in nursing: trustworthiness, honesty, trust in others, faithfulness, and respect. Contemporary students value quality time and want personal attention from the teacher as they learn, socialize, and integrate themselves into the nursing profession.
Need for Change and a New Paradigm We reviewed theories on the cognitive, affective, and psychomotor domains of learning. Partnerships and mentoring activities are important themes in the literature on skill development. We tried to understand our students and realized that the learning needs of our student population had changed. Contemporary students want more time and attention from faculty as they progress through the nursing program. We were willing to accept our new challenges. It was time for a new model that promoted skills acquisition incorporating the cognitive, affective, and psychomotor domains of learning with partnerships, faculty role modeling, and development of professional values in novice nursing students. We hope your journey to meet this new, exciting, and challenging generation of students is as much as an adventure as ours is continuing to be.
EVOLUTION OF CARE GROUPS Evaluation Inconsistencies Among Faculty Our introductory nursing course, which is a prerequisite to the nursing program, includes both lecture and a laboratory component in which students are introduced to nursing concepts and seven basic psychomotor skills. One instructor manages the course with all nursing faculty assisting in laboratory demonstrations and evaluation of skills. Prior to establishing Care Groups, students could have different faculty members in the laboratory teaching and evaluating their skills. Faculty were not consistent in evaluating student competencies, despite demonstration videos, specific guidelines, and competency checklists (Pullen, Mur-
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ray, 6s McGee, 2001). They often had different views of how the skills should be performed even though each skill had a competency checklist. Students in turn were confused, frustrated, and anxious because of the evaluation inconsistencies, with several students failing the course each semester because of inability to perform the basic skills successfully. Faculty knew it was time to improve the way skills were taught and evaluated in the laboratory, and to improve reliability among faculty when evaluating competencies. Students suggested that faculty (1) be consistent in their skill evaluations, (2) have more patience, and (3) be available to answer questions and practice skills with them (Pullen, Murray, & McGee, 2001). Faculty decided it was necessary to develop a strategy so students would experience a caring relationship while they learned, practiced, and demonstrated basic psychomotor skills.
The Old Way of Doing Things Several concerns were identified through faculty dialogue. One concern was that some faculty were not following the policies and competency checklists for skills demonstrations due to personal bias. Their approach was to teach students the skill they way they learned it. This rigidity increased student apprehension and anxiety. Another concern was that faculty who assisted in psychomotor skills evaluation did not know who their students would be from one week to the next. The faculty now realized the importance of knowing each student as an individual. We were nurses of the twentieth century, but our students were now of the twenty-first century. We had to move from a pedagogical way of thinking to a focus on the adult learner. The Care Group concept began to emerge from these dialogues.
Faculty Mentors: A Pilot Study A mentor/student relationship can reduce the novice students' anxiety when beginning a nursing program. It also can assist them in the transition from the introductory skills course to the first clinical course (De Vito-Thomas, 1998). Faculty mentors use teaching and learning practices that are consistent with the values of the nursing profession, which are knowledge, care, service, and compassion (Simonson, 1996), and are complemented by principles of adult learning.
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Faculty mentors develop an environment that is both helping and nurturing, and values the integrity of each student (Knowles, 1980). The environment is based on trust, mutual respect, and collaboration (McNeil, 1996). Based on these beliefs, we conducted a pilot study to determine if faculty mentors would enhance students' learning and development of basic skills in the laboratory. In the pilot study, five faculty members served as mentor for 10-15 students each for all of the laboratory skills during the semester. Our goal was to determine whether student and faculty morale would improve and if students would be more successful in developing competency in these skills. Evaluation of the psychomotor skills included video and live demonstrations by the student, and faculty agreed on expectations for skill performance and on the competency checklists. Faculty defined the goals and objectives, demonstrated skills, supervised the practice with his/her group, and evaluated each student's performance. The faculty also modified the laboratory schedule to meet the needs of the students who had family and job responsibilities. After each skill evaluation, faculty sent a list of the names of students to the primary instructor, indicating whether the student passed or failed a skill (Table 8.1). When students failed a skill, they received a
TABLE 8.1
Care Group Lab Record
Tarp Grrmp Mpnfnr-
Skill: Dafp-
Care Group Member (Student)
*S = Satisfactory
*Grade (S or U)
Comments/Suggestions
U = Unsatisfactory
Reprinted by permission of Amarillo College Associate Degree Nursing Program, Amarillo, Texas.
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skills deficiency slip (Table 8.2) in triplicate form, with copies to the student, primary instructor, and director of the nursing laboratory, which detailed the plan for remediation. The faculty mentor and primary instructor worked collaboratively to develop an individualized remediation plan for students who did not demonstrate competency and set a time for further teaching and retesting. Remediation with a faculty mentor was mandatory for all students, ensuring that students would have individualized teaching and supervised practice prior to retesting. The primary instructor of the course did the retesting, instead of the faculty mentor, to ensure objectivity in the evaluation process. Unsuccessful demonstrations with the second attempt resulted in failure of the course. A follow-up survey showed that students were less anxious when being evaluated in the laboratory with their faculty mentor. They reported that their success was due to the flexibility in scheduling laboratory times, smaller group activities, one-to-one dialogue with the faculty
TABLE 8.2
Amarillo College Nursing Skills Deficiency
CARE GROUP STUDENT NAME:
DATE:
LAB DEFICIENCY FOR SKILL OF: Prior to the second attempt, the student is required to view the teaching video and practice the skill under the supervision of a Registered Nurse in the Nursing Resource Center (NRC). The skill may be repeated only one time for grading purposes. 1. 2.
3.
Review teaching video: Care Group Faculty Signature: Scheduled appointment with a Registered Nurse in the NRC to practice the skill under supervision. Date: Time: The skill was practiced under supervision: RN
The student is required to reschedule the second attempt with the primary instructor within one week of receiving the unsatisfactory grade. Original to student, yellow copy to primary instructor, pink copy to the director of the NRC. Reprinted by permission of Amarillo College Associate Degree Nursing Program, Amarillo, Texas.
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mentor, having the same faculty throughout the semester, and opportunities for the mentor to offer study suggestions and strategies to reduce their anxiety (Pullen, Murray, & McGee, 2001). Students also perceived that faculty mentors cared about them as individuals. The primary instructor also reported that students had less stress over learning the skills and improved competency and retention of basic skills. In addition, only one student failed the course because of skill deficits, and inter-rater reliability among faculty in the evaluation of competencies also improved. The pilot study was successful because there was consistency among the faculty in teaching and evaluating skills, the faculty focused on the needs of the students as adult learners, and the faculty demonstrated caring behaviors in their interactions with students.
CARE GROUPS: OUR NEW PARADIGM Based on the pilot study, we integrated Care Groups into the introductory nursing course. Care Groups were based on the concept of care grouping, in which faculty and students identify and demonstrate caring behaviors (Grams, Kosowski, & Wilson, 1997). Care Groups involve four to seven novice students with one faculty member who serves as a mentor (Figure 8.1). The Care Group mentor assists, guides, and teaches the novice student in the development of psychomotor skills, socialization skills, and professional values. Care Groups also provide a method for mentors to advise and counsel students on the selection of college courses, trends and issues in nursing, and career mobility.
The Care Group Model The Care Group Model, developed by Richard Pullen, describes a process of skills acquisition for novice nursing students within a caring environment (Pullen, Murray, & McGee, 2001). The model demonstrates the interrelationships between faculty mentors and students in a protective, helping, and nurturing environment (Figure 8.2). A protective environment promotes learning by allowing students and faculty to spend quality time together, in small groups and in one-on-one interaction. Quality time allows faculty and students to learn from each other.
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FIGURE 8.1
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Care Group.
Caring relationships develop in the protective environment as the student is guided through skills acquisition using the cognitive, affective, and psychomotor domains of learning. Care Group members are taught by their mentors that competency includes a balance in the domains of learning (Pike, 1992): Know (cognitive) + Feel (affective) + Do (psychomotor) . The model posits that learning is more meaningful and effective when students feel safe, secure,valued, and special by their Care Group mentors. This allows students to process basic concepts and demonstrate psychomotor skills in a less stressful environment. The relationship in a protective environment may flourish, which stimulates creativity and intellectual processes and enables Care Group members to develop a philosophy of caring (Pullen, Reed, & Oslar, 2001). This relationship provides a foundation for students to be successful throughout their nursing program and after graduation. A protective environment also assures that novice students will value caring in their clinical practice (Zimmerman & Phillips, 2000).
FIGURE 8.2
Care Group Model for skills acquisition.
Reprinted from Pullen, R. L., Murray, P. H., & McGee, K. S. (2001). Care Groups: A model to mentor novice nursing students. Nurse Educator, 26, p. 287. By permission of Lippincott, Williams & Wilkins.
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The philosophy of the nursing program provides a foundation for a protective environment when surrounded by a caring community and principles of adult learning. A caring community is one in which faculty nurture students' development through compassion, empathy, patience, and spending time with them. Adult learning principles encourage students to be involved in the planning of Care Group activities, to think critically, and to develop self-direction (Knowles, 1975, 1984). The faculty mentor guides students in the development of self-direction. The Care Group Model is an interrelated and dynamic system for guiding students in the acquisition of skills.
OUTCOMES OF THE CARE GROUPS Students' Outcomes Care Groups have enabled students to (1) develop professional values, (2) develop socialization skills, and (3) experience less stress not only in developing skills but also in their first clinical course. Care Group members learn professional values and become socialized into the nursing profession by observing their faculty mentors and seeing their teachers as role models. Their experiences in the Care Group help them understand the importance of caring in establishing relationships, which is a program objective for nursing graduates. Faculty mentors report that their Care Group members are beginning to understand the importance of accountability, responsibility, teamwork, and service in nursing practice while they develop psychomotor skills (Pullen, Murray, & McGee, 2001). As students progress through the program, they report that their Care Group mentor played an important part in how they care for patients. Through their mentor relationship in the Care Groups, students have become more confident when they begin their first clinical nursing course.
Supplemental Instruction: College-Wide Support Program for Care Group Students Supplemental instruction (SI) is a college-wide academic assistance program that enhances student performance and retention (Catchpole,
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1996; Hodges, 2001; Martin, 2001; Van Lanen & Lockie, 1997). Each session is facilitated by SI leaders, undergraduate students who have previously taken the course and demonstrated academic competency in the subject area. These SI leaders help students to master course content and skills and to develop learning and study strategies such as note taking, vocabulary acquisition, and test preparation skills. Each SI session comprises students with varying academic abilities, and no effort is made to segregate students based on ability. The goals of SI, similar to Care Groups, are to increase retention and graduation rates and to decrease attrition in targeted courses. Supplemental Instruction can be incorporated with Care Groups to enhance student retention. Care Groups encourage students to learn socialization skills within the nursing discipline, while SI sessions can enhance socialization with students and faculty in other fields. The integration of the Care Group concept with SI prepares nursing students to practice in a multidisciplinary health care environment. Supplemental instruction provides peer collaborative learning experiences and an opportunity for students to develop friendships with other students and staff, an important factor in retention. Supplemental Instruction and Care Groups can complement the academic experience to facilitate nursing students success and development.
Faculty Outcomes To continuously improve the inter-rater reliability of faculty in the Care Groups, each semester a faculty mentor videotapes a skill with subtle and obvious errors. During faculty workshops, the faculty as a group watch the videotape and evaluate the skill using the competency checklist. In these workshops faculty discuss and address evaluation issues. The ultimate goal is to promote consistency among faculty mentors when evaluating students' skills. As a result of the Care Groups, relationships among faculty and between faculty and students are stronger. Faculty also see their Care Group members in later course in the nursing program. This has further enhanced the relationships between faculty and students. SUMMARY Since their inception, Care Groups have created a helping and nurturing environment for students and decreased their apprehension associated
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with learning and demonstrating basic skills. The reason for this success is mutual trust, respect, and collaboration within a caring environment Respecting and valuing the talents of individual students and their learning needs are essential to the success of this new generation of students. The Care Group Model can be of value in any nursing program to promote the acquisition of skills among novice students. The model also is a foundation on which students and graduates can develop caring relationships in their future practice.
REFERENCES Alexander, M. (1998). Mentoring relationships. Journal of Intravenous Nursing, 21, 69. Beeman, R. Y. (2001). New partnerships between education and practice: Precepting junior nursing students in the acute care setting. Journal of Nursing Education, 40, 132-134. Beeson, S. A., & Kring, D. L. (1999). The effects of two teaching methods on nursing students' factual knowledge and performance of psychomotor skills. Journal of Nursing Education, 38, 357-359. Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. New Jersey: Prentice-Hall. Catchpole, R. (1996). Helping students learn from each other: Supplemental instruction. Assessment and Remediation in Higher Education, 21(1), 101. Chow, F. L. W., & Suen, L. K. P. (2001). Clinical staff as mentors in pre-registration undergraduate nursing education: Students' perceptions of the mentors' roles and responsibilities. Nurse Education Today, 21, 350-358. Di Vito-Thomas, P. A. (1998). Barmentoring: Mentoring and critical nursing behaviors among novice nurses in clinical practice. MEDSURG Nursing, 7, 110-114. Evans, B. C. (2000). Clinical teaching strategies for a caring curriculum. Nursing and Health Perspectives, 21(3), 133-138. Ewell, P., Jones, D., & Lenth, C. (1996). What research says about improving undergraduate education. AAHE Bulletin, 48(10), 5-8. Gaberson, K. B., & Oermann, M. H. (1999). Clinical teaching strategies in nursing. New York: Springer Publishing Co. Goran, S. F. (2001). Mentorship as a teaching strategy. Critical Care Nursing Clinics of North America, 13(1), 119-129. Grams, K., Kosowski, M., & Wilson, C. (1997). Creating a caring community in nursing education. Nurse Educator, 22(3), 10-16. Hodges, R. (2001). Encouraging high-risk student participation in tutoring and supplemental instruction. Journal of Developmental Education, 24(3), 2. Jeffries, P. R., Rew, S., & Cramer, J. M. (2002). Student-centered versus traditional methods of teaching basic nursing skills in a learning laboratory. Nursing Education Perspectives, 23(1), 14-19. Knight, C. M. (1998). Evaluating a skills center: The acquisition of psychomotor skills in nursing. Nurse Education Today, 18, 441-447.
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Knight, C. M., Moule, P., & Desbottes, Z. (2000). The grid that bridges the gap. Nurse Education Today, 20, 116-122. Knight, C. M., & Mowforth, G. M. (1998). Skills center: Why we did it, how we did it. Nurse Education Today, 18, 389-393. Knowles, M. (1975). Self-directed learning. Chicago: Follet. Knowles, M. (1984). Andragogy in action. San Francisco: Jossey-Bass. Knowles, M. (1980). The modern practice of adult education. New York: Cambridge University Press. Lee, M. B. (2001). Creating knowledge through partnerships in global education: Using small-group strategies with large groups. Journal of Nursing Education, 40, 222-224. Lockie, N. M., & Burke, L. J. (1999). Partnerships in learning for utmost success (PLUS): Evaluation of a retention program for at-risk nursing students. Journal of Nursing Education, 38, 188-192. Martin, D. C. (2001). Video-based supplemental instruction Journal of Developmental Education, 24(3), 12. McNeil, J. (1996). Curriculum: A comprehensive introduction (5th ed.). New York: HarperCollins. Melby, V., Canning, A., Coates, V., Forster, A., Gallagher, J., McCartney, A., & McCartney, M. (1997). The role of demonstrations in the learning of nursing psychomotor skills. Nursing Times Research, 2, 199-209. Minnesota Baccalaureate Psychomotor Skills Faculty Group. (1998). Conversations: An experience of psychomotor skills faculty. Journal of Nursing Education, 37, 324-325. Murdaugh, C. L. (1998). The value of mentors and facilitators in the pursuit of excellence. Journal of Cardiovascular Nursing, 12(2), 65-72. Pesut, D. J., & Herman, J. (1999). Clinical reasoning: The art and science of critical and creative thinking. New York: Delmar. Pike, R. W. (1992). Creative training techniques handbook. Minneapolis: Lakewood Books. Pullen, R. L., Murray, P. H., & McGee, K. S. (2001). Care Groups: A model to mentor novice nursing students. Nurse Educator, 26, 283-288. Pullen, R. L., Reed, K. E., & Oslar, K. (2001). Promoting clinical scholarship through scholarly writing. Nurse Educator, 26, 81-83. Ryan, D., & Brewer, K. (1997). Mentorship and professional role development in undergraduate nursing education. Nurse Educator, 22(6), 20-24. Simonson, C. L. S. (1996). Teaching caring to nursing students. Journal of Nursing Education, 35, 100-104. Snyder, M. D., Fitzloff, B. M., Fiedler, R., & Lambke, M. R. (2000). Preparing nursing students for contemporary practice: Restructuring the psychomotor skills laboratory. Journal of Nursing Education, 39, 229-230. Van Lanen, R. J., & Lockie, N. M. (1997). Using supplemental instruction to assist nursing students in chemistry. Journal of College Science Teaching, 26, 419. Watson, J. (1979). Nursing: The philosophy and science of caring. Boston: Little, Brown.
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Wieck, K. L. (2000, June/July). Tomorrow's nurses: Are we ready for them? Texas Nursing, 1-4. Zimmerman, B. J., & Phillips, C. Y. (2000). Affective learning: Stimulus to critical thinking and caring practice. Journal of Nursing Education, 39, 422-425.
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Part III
Distance Education
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Chapter 9 Overview of Distance Education in Nursing: Where Are We Now and Where Are We Going?
Kay E. Hodson Carlton, Linda L. Sikiberg, Jim Flowers, and Pamela Scheibel
he purpose of this chapter is to provide an overview of distance education in nursing. Distance Education (DE) continues to increase at a phenomenal rate. It is increasing in traditional degree granting institutions as well as in private educational providers. There also are more partnerships among institutions and corporate partnerships with institutions to provide online supportive services to DE. Eaton (2001) stated "whether the emergence of distance learning spells the end of traditional campuses . . . or whether distance learning instead represents a particularly powerful addition to a growing array of delivery options for higher education, the fact remains that distance learning is already having a very real impact on higher education operation. Distance learning is creating alternative models of teaching and learning, new job descriptions for faculty, and new types of providers of higher education" (p. 3). Reasons for the surging growth of DE are related to societal changes. Technological innovations are one reason for the expansion of DE, but other reasons exist. Among these are the need for higher education for career advancement, the demand for flexible scheduling for students whose daily routines are complex and do not mesh with the traditional educational day, a growing market for personal fulfillment courses, a view of education as a lifelong learning endeavor, the requirement in
T
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many professions for continuing education, a shift from teacher-centered education to student-centered learning, and an increasing awareness among teachers that students vary greatly in their learning styles, among others (Eaton, 2001, pp. 7-9). Distance education offers the opportunity to reach underserved populations who because of geographical location, employment, and/or family responsibilities would not have the availability or freedom to participate in the educational process. As institutions that offer DE programs expand their geographic and jurisdictional boundaries to increase student enrollments, this situation places pressure on other institutions to move into the DE arena for selfpreservation and to prevent the erosion of their student enrollments (Mehrotra, Hollister, & McGahey, 2001). Another impact of DE is the increasing cooperation among institutions of higher education, enabling them to draw from the strengths of each other. This collaboration may be one solution to stretch the limited financial and personnel resources of cooperating institutions so each one can offer quality educational programs (Mehrotra, Hollister, & McGahey, 2001). Distance education for nurses is also growing at a phenomenal rate and may help meet the growing demand for nurses. According to the National Advisory Council on Nurse Education and Practice (1996), by the year 2015, it is predicted that 114,500 full-time equivalent jobs for registered nurses (RNs) will be vacant (American Association of Colleges of Nursing [AACN], 1999, p. 3). In addition, the National Advisory Council on Nurse Education and Practice recommended that a federal policy be adopted to achieve a basic nurse workforce in which at least two-thirds hold baccalaureate or higher degrees in nursing by the year 2010. At present, only 39% of RNs have a baccalaureate in nursing or higher degree (AACN, 1999, p. 9). A survey of a sample of programs accredited by the National League for Nursing Accrediting Commission (NLNAC) was conducted by the authors in March 2002, to determine the enrollment in various DE programs in nursing. The survey revealed that the heaviest DE enrollment is in the RN to BSN programs; the enrollment for this type of program is thirty-five times greater than any other program reported (Table 9.1). One advantage of an online RN to BSN program is that the nurse does not have to significantly reduce workload hours or quit employment positions to earn an educational degree; in turn, it does not create workforce vacancies. Because of the nationwide shortage of nursing
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TABLE 9.1 Program
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Total Annual Distance Nursing Education Enrollment by
Program type
LPN transition Associate degree Baccalaureate (Basic) RN completion Masters Doctoral Continuing education
Annual enrollment in distance education
Percentage of nursing program enrollment
164 1048 977 41515 1669 29 355
0.36 2.29 2.14 90.73 3.65 0.06 0.78
N = 162; NLNAC accredited nursing distance education programs.
faculty, another advantage of online baccalaureate to master's and master's to doctoral programs is that it permits these faculties to remain in their teaching positions while they advance their education.
DISTANCE EDUCATION AND DISTANCE LEARNING Distance education is a broad term that is not uniformly applied. For example, a single university might include off-campus courses taught face-to-face at remote sites under the "distance education" administrative structure, but Internet-mediated learning activities in Web-assisted courses might not be included under that same structure. With the escalation in Internet-based education, some readers may equate distance education with online education. However, "distance learning" is a term that describes a wide range of both formal and informal learning at a distance. King, Young, Drivere-Richmond, and Schrader (2001) defined distance learning as "improved capabilities in knowledge and/or behaviors as a result of mediated experiences that are constrained by time and/or distance such that the learner does not share the same situation with what is being learned." A simpler DE definition by Mclsaac and Gunawardena (1996) is "structured learning in which the student and instructor are separated by time and place" (p. 403). Distance education involves teaching and learning strategies separate from the traditional classroom
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setting and sometimes from the traditional roles of faculty (Reinert & Fryback, 1997). These definitions of DE share the notion of separation and exclude remote site face-to-face education. These broad definitions cover correspondence courses, online courses, and televised courses; distance learning aspects of face-to-face courses also might be included. While "distance learning" may include less formal education not normally associated with courses, it may range from learning by telephone conversations to learning from films, television, and the Internet. For practical purposes, it is reasonable to distinguish the definition of "distance education" by stipulating formal DE such as the form that occurs in college courses. For some, "distance education" implies a geographical rather than necessarily temporal distance. However, the notion of synchrony is critical to a classification and an understanding of the variety of modes of DE. Synchronous communications in an educational setting involve participants communicating in real-time. Chat, live video, phone conversations, and any other "live" communications may be considered synchronous. Asynchronous communication does not require participants to interact at the same time; these typically include threaded discussions or bulletin boards, e-mail, correspondence, videotape-based learning, Web pages, and streaming media that is not a live stream. At one extreme, all students in a course would be involved with the material and with each other at the same time, and at the other extreme, each would be involved at a different time, possibly even on a rolling calendar determined by the learner rather than the instructor. More typically, DE courses seem to include a variety of communications with different degrees of synchrony, for example, students may be required to post messages or take examinations during a specified time window. As instructional designers and teachers choose among DE technologies, the synchrony of the mediation should weigh heavily in devising the instructional plan.
DISTANCE EDUCATION TECHNOLOGIES Over the years, faculty have used various technologies to teach students at a distance. In some cases, multiple technologies have been used for one course. One hopes the primary criteria used in selecting educational strategies would be pedagogical rather than technological. As Gladieux
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(1999) stated, "access to technology is not only about hardware and software, it is about effective use, teacher training, and careful integration of technology into the curriculum" (p. 47). Often faculty members are unsure of what type of technology is available to them and what each type has to offer. Here is a short description of the major types.
Correspondence/Independent Studies The first type is correspondence/independent study courses. These courses were the first true DE technology. The original concept was based on pen and paper. Students paid tuition, books, and course material fees required for the independent learning and submitted assignments by mail to a university professor. Most university extensions were in charge of this method of DE. This type of distance learning also was used by selected publishing firms offering continuing education opportunities for nurses through topic offerings, often published in journals such as the American Journal of Nursing. This type of course and continuing education still thrives and is a good choice for some professors, courses, and students because the cost is low and the ease of use is high. Interaction with other students is low, and generally this form of technology is only two-way, between a faculty and the student.
E-mail The advent of e-mail has provided instant communication to learners and from learners. E-mail and e-mail discussion groups, also referred to as lists or listservs, have become necessary tools for some courses. The cost of this technology is low and is easy to use for both students and faculty. The interaction provided by this form of technology can be high and may be one-on-one with the teacher and expanded to other students. (A good resource for teaching with e-mail and the Web can be found at http://www.acusd.edu/theo/cts/web-teach.html) E-mail may be used easily to supplement face-to-face (F2F) courses, as an aid in DE courses, and as a digital evolution of the correspondent course. E-mail attachments have become a handy means of exchanging files and, unfortunately, computer viruses.
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To aid in e-mail communications, an instructor might consider using file naming protocols for attachments, specifying times when email is normally checked, and sending e-mail to groups of students. Email has the added benefit on some computers of notifying the recipient when there is a new message.
Hypertext (Only) Hypertext is a way of using the World Wide Web and links to augment or teach a course. Faculty have found the use of the Web helpful. However, links on the Web can provide both treasure and trash so both instructors and students must scrutinize the content from the selected sites. A basic primer on how to write hypertext may be found in many books and also briefly at http://www.w3.org/MarkUp/Guide/ This technology is easy to use and low cost. Basic Web pages do not provide significant avenues for interaction. However, advanced Internet materials may be developed that allow students to dynamically interact using simulations and other interactive tools.
Audio Audio files may be particularly useful in nursing education, allowing students to hear diagnostic sounds, such as lung and heart sounds. Twoway audio is used in many institutions. Of course, the telephone is still a valuable option, and faculty members continue to use this personal method. Audio clips can easily be added, along with text comments, to numerous word processed documents. Other two-way audio systems also can be used such as different types of audiographic forms. Audiographic is the combined use of voice transmission, computer networking, and graphics transmission through narrow band telecommunications channels (Kuramoto & Lambrecht, 1997). Connections can be made using standard analog telephone lines or digital communications lines. The instructor and students in academic and continuing education settings each have computer screens, and lectures are heard in real-time while viewing graphics and pictures on a computer screen.
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Video The use of video in DE can serve to provide a humanizing element and can show procedural information otherwise nearly impossible. Some options for using video include the mailing of videotapes, downloadable video files, and real-time, one-way or two-way video. Like mailed videotapes, video files downloaded from the Internet are a form of asynchronous communication rather than real-time, synchronous video. The rather large size of video files can make downloading cumbersome; one alternative is the use of streaming video. With streaming video, a video file is "pulled" from a server on the Internet and begins playing before the download is complete; buffering the file, downloading a few extra seconds of the stream, is used to provide mostly uninterrupted play. The bandwidth required for two-way video connections has been a limiting factor. Typical dial-up Internet connections result in small, choppy video. Greater bandwidth is achieved either within local area networks, or on wide or metropolitan area networks where users have high bandwidth connections. The H323 video standard uses Internet protocol (IP) packet-based information and offers more reasonable twoway or multipoint real-time video. Some subscribers of cable Internet service may find the performance of the two-way video less than satisfactory if their upstream data bandwidth is limited to a fraction of the bandwidth used to browse and download files. Compressed video has become a popular technology with the advent of PIC TEL units. Compressed video images are transmitted electronically to two or more interactive television sites. The images are usually transmitted over ISDN lines and can be bridged to two or more interactive television sets at once. A course taught with compressed video requires the cost of the television sets (e.g., PIC TEL units), a bridging component, and students at the receiving site. The course is taught in a real-time. (More information on using compressed video for distance learning can be found at http://www.kn.pacbell.com/wired/vidconf/ Using.html)
Web-Based Course Management Systems Web-based course management systems (CMS) have become the boxes into which most online courses are placed. There are a number of
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TABLE 9.2
Technology/Media Used in Distance Nursing Education
Technology/media Hypertext (only) Web courses (100% Online) Hypertext with compressed video Web courses CD-ROM or DVD-based instructional materials Courseware management software One-way video, two-way audio Two-way video Desktop video conferencing
Percentage of institutions 28 6 28 46 10 23 4
N = 134.
management systems presently available with the most common ones being Blackboard and WebCT. In these course management tools, some faculty put text, graphics, video, and audio files together often without any knowledge of HTML in a protected location. Most CMS also have quizzing functions, calendars, file transfers, chat, threaded discussion, and a grade book, and some faculty use only these organizational tools opting for other vehicles for content delivery. These CMS are placed on servers, and generally the institution obtains a license to use the CMS; the cost is negotiated by the administration depending on how many students and what tools are used. (Additional information can be found at http://sunil.umd.edu/webct/) Distance Education Technologies in Nurse Education The March 2002 survey done by the authors of NLNAC accredited institutions mentioned previously revealed relative use of various DE technology and media in distance jiurse education programs. The most frequently cited technology/media used in nursing programs was CMS (Table 9.2). DIGITAL LIBRARIES Providing equivalent library access and services to DE students remains problematic. Many university libraries send out books and articles to
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students at a distance. Recently, libraries have increasingly become digital. Remote site passwords to access on-campus libraries have allowed some students greater access to materials. However, due to limitations regarding copyright, digitization, and storage, DE students cannot access a virtual library that is on par with brick and mortar university libraries, but there are plans to remedy this problem. On a national level, the Digital Library Initiative is now in phase two. This initiative is to "collect, store, and organize information in digital forms, and make it available for searching, retrieval, and processing via communication networks—all in user-friendly ways" (Digital Libraries Initiative, 1998).
REUSABLE LEARNING OBJECTS (DATABASES) An interesting new development in online learning has been the introduction of reusable learning objects. A learning object is "any digital resource that can be reused to support learning" (Wiley, 2000). The term "reusable" denotes that a single object may be used in multiple contexts or at different times. The theory is to develop learning objects that help faculty teach concepts that are difficult to teach without each faculty person developing his/her own learning object. Instead, learning objects could be shared, thus reducing the faculty time for development and cost to the institution. The MERLOT (Multimedia Educational Resource for Learning and Online Teaching) project is one example that has a repository of these objects. (More information can be found at www.merlot.org.)
ASSESSMENT OF DISTANCE EDUCATION As the AACN (1999) points out, guidelines or parameters for the use of educational technologies have been available for some time with general applications to higher education and kindergarten through 12th grade from the American Council on Education (1996). Other such reports and recommendations are emerging to provide "benchmarks" or parameters for ensuring quality in electronically delivered DE programs. The statement and guidelines developed by the Regional Accrediting Commissions is one such example of the recognition of accrediting bodies to evaluate the rapidly evolving DE programs across the country
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(Commission on Institutions of Higher Education, 2000). The statement and guidelines, based on some of the earlier findings of the Institute for Higher Education Policy (2000), were developed by the eight Regional Accrediting Commissions to assist institutions and facilitate the review of electronically offered degree and certificate programs. The recommended guidelines or best practice elements are divided into five separate components: institutional context and commitment, curriculum and instruction, faculty support, student support, and evaluation and assessment. The statement and guidelines are available at http://www.neasc.org/cihe/evaluation_electronically_offered_degree. htm. New DE programs may undergo program review procedures designed for non-DE. However, emerging principles can inform the development of DE as emerging standards can assist in more appropriate assessment. One set of 25 developmental principles for DE is described in Innovations in Distance Education (1998). These principles are grouped into five categories: learning goals and content presentation, interactions, assessment and measurement, learner support and services, and instructional media and tools. A typical principle from this document is: 4.2 The selection of instructional media and tools should be influenced by their accessibility by learners. A distance education program should incorporate a technology base that is appropriate for the widest range of students within that program's target audience, (p. 7)
Program assessment should follow the same sound principles used for program development. The Institute for Higher Education Policy (2000) developed a list of benchmarks for online education. Based on a literature review, benchmarks were identified for institutional support, course development, the teaching and learning process, course structure, student support, faculty support, and evaluation and assessment. Each of the 45 benchmarks was rated by faculty, administrators, and students for their relative importance and relative presence, i.e., true for the distance learning program. A typical benchmark of high importance is #16 "Feedback to student assignments and questions is provided in a timely manner." As a subset of program assessment, course assessment may use similar criteria. In nursing education, AACN (2000) recommended that institutions consider the need for adequate planning, the technology infrastructure, faculty development, student support, and the evaluation of outcomes
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in a DE program. The NLNAC (2000) also includes a section related to the evaluation of distance learning programs in the current Accreditation Manual. Criteria of quality of distance programs include student support, faculty support, curriculum and instruction, institutional context and commitment, and evaluation and assessment. The National Organization of Nurse Practitioner Faculties (NONPF) has recently proposed Guidelines for Distance Learning in Nurse Practitioner Education (Resick, 2002). The criteria for quality DE programs include teaching and learning guidelines driven by pedagogical needs; evaluation and assessment; and institutional, faculty, and technical support. The support from the institution is from the mission and strategic plan, budget and policy, electronic security of all online programs, centralized infrastructure, instructional design support, library capabilities, and back-up plans. Faculty support includes assistance with training, reliable technology support from orientation to course delivery, and a peer support system. Technical support for students consists of training options and technical support available 24/7, with a minimum 24-hour turnaround to acknowledge a query or request. The NONPF guidelines also include specific recommendations on clinical preceptorships. Criteria are included for evaluation of the clinical site, student evaluation, and advising. Assuring the quality of the instruction and instructional materials in DE is of paramount importance in all the assessment criteria. In a review reported in the AACN White Paper (1999) of 238 studies, there were no significant differences in the competencies of students taught by traditional classroom methods versus distance education. In a review of the literature on online nursing education, Jacob (2001) also found that in most studies nursing students enrolled in a Web-based course performed similarly with those in a traditional classroom experience. These findings of no significant differences in learning outcomes between DE and traditional classroom courses are consistent with other studies (Billings, 2000; Billings, Connors, & Skiba, 2001; Leasure, Davis, & Thievon, 2000).
DISTANCE EDUCATION FACULTY SELECTION, SUPPORT, AND ISSUES Distance education has opened the confines of face-to-face teaching. Instead of the industrial model of teaching 50 minute lectures two or
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three times a week, faculty and students now have at their disposal a new and different learning environment. The environment of today is based on learning needs and the development of critical thinking skills. The change in environment requires faculty and students to embrace new roles and understand new sets of responsibilities. It is salient for faculty to understand that these new roles and responsibilities are for the success of any distance education course. What are the general steps to helping faculty embrace these new roles and responsibilities?
Faculty Selection The selection of faculty to teach a DE course is critical. The best faculty member to teach a DE course may not be the same person who has been teaching that course face-to-face. Often new instructors are eager to try new technology and elect to assume the new challenge. However, often these instructors underestimate the demands of the three- or fourlegged stool of academia: teaching, research and scholarship, service, and clinical practice. In DE, there is a learning curve for faculty that could affect their ability to meet requirements for research and scholarship (AACN, 2000). Therefore, experienced educators who have a solid background in instructional methods and learning activities who desire to teach in this format should be selected to teach in DE courses (Milstead & Nelson, 1998). Faculty teaching DE courses in nursing are generally tenured or in tenure-line positions and paid their usual institutional salary (Table 9.3). To a lesser extent, adjunct faculty are used. Relatively few institutions in the survey reported paying faculty according to a special student fee or tuition for distance education.
Faculty Support Examples of good courses that have been offered via DE are important for faculty buy-in and as resources for faculty. The course Introduction to Online Teaching offered by Dr. Tom Nolan is a good resource (http:// www.sonoma.edu/users/n/nolan/facultyotl/). Frequently, other departments on campus have had experience with online learning and other forms of DE; these departments also are a resource for nursing faculty.
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TABLE 9.3 Institutions Using Various Types of Faculty and Pay Structures in Distance Nursing Education Type of faculty and pay structure Adjunct (contract) paid according to institutional salary Adjunct (contract) paid according to special student fee/tuition Independent (off campus) paid according to institutional salary Independent (off campus) paid according to special student fee/tuition Tenure/tenure-line paid according to institutional salary Tenure/tenure-line paid according to special student fee/tuition Preceptors (clinical) paid according to institutional salary Preceptors (clinical) paid according to special student fee/tuition
Percentage of institutions 33 5 5 1 69 3 5 0
N = 124.
Some institutions ask that a teacher for a DE course first take a DE course. In some cases, release time and/or stipends are provided for this course participation and enrollment. Some institutions provide extensive faculty support for the development and delivery of online courses such as the TeleCampus unit of the University of Texas (http://www.telecampus.utsystem.edu/ facultyservices/faculty_services.html). There also are resources for faculty and information on best practices available online such as those at the MERLOT Web site (www.MERLOT.org). Other faculty find that attending workshops is helpful.
Faculty Issues Prior to their decision to teach via DE, faculty should be oriented to the policies that address such issues as faculty workload, compensation, intellectual property rights, and faculty evaluation, associated with on-
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line and other forms of distance education courses. For example, information about issues involved in creating and using educational materials, ownership, distribution and publication, and related agreements are available to faculty teaching online courses in the TeleCampus unit of the University of Texas. This information is found at http://www. utsystem.edu/ogc/intellectualproperty/edmatrls.htm. Faculty who design and teach DE courses report improved interaction, collaboration, and learning with their students, referred to as intrinsic rewards (Rockwell, Schauer, Fritz, & Marx, 2000). However, these rewards do not come without a price. A significant increase in faculty time is required to teach a distance course. Students expect faculty to be more accessible, and faculty online interaction with students increases the time spend in teaching. Workload calculations often need to be challenged because of the nature of the delivery method. The issues of faculty workload and scalability of a course, how many students the course would support versus how many students the faculty can teach, are still in debate.
USE OF OFF-CAMPUS FACULTY A new model of DE teaching, prompted by the use of online courses, is to hire off-campus faculty to teach a particular course in a program. A significant number of online colleges and universities hire adjunct faculty who are subject matter experts in a particular area. The use of these courses and faculty may be cost effective for an institution that needs to offer a particular course but does not have the faculty available to teach it or has larger enrollments in particular classes than the onsite faculty can accommodate. At the University of Wisconsin, the five campuses offer RN to BSN degrees and have online courses taught by faculty who are on different campuses; information about this program is at http://www.uwex.edu/ disted/cnp/. This unique collaboration provides a cost-effective way to provide the courses needed by students without each campus creating and teaching each course. Institutions that employ off campus faculty should address the same faculty support issues common to on campus employees. Some institutions elect to have assistance in developing and hosting their courses as seen with eCollege (http://www.ecollege.com).
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FACULTY DEVELOPMENT Once faculty agree to teach by DE, it is important to provide an organized faculty development program for both on-site and distance faculty. Just as it took time and effort to learn how to teach face-to-face, it takes time to learn how to teach in a DE format. Too often, faculty believe that they can simply transfer their syllabus and lectures into a distance format, creating "shovelware," without designing new instruction that takes into account the power of the new environment that teaching at a distance affords. New DE faculty might worry about the platform the course will be in or how the course will look at a distance. Instead, a good faculty development program begins and ends with student learning. Faculty development surrounds central questions that require rethinking and reason before beginning the transition to DE.
ONE APPROACH TO DISTANCE COURSE DEVELOPMENT In developing a course for DE, one approach begins with a course description, faculty member, or development team creating a storyboard for each unit or week. This includes unit goals, objectives, readings, activities to promote learning, discussion questions, and evaluation strategies. One way of writing a storyboard suggested by Gerson (2000) is to use an E-CLASS approach. In this approach, the course is structured around specific elements: explain, clarify, look, act, share, and selfevaluate/submit. Once the storyboard is written, it is time to formulate a team to place the course in a distance format. This team should comprise the following members: an instructional designer, a programmer, if video is needed someone who is familiar with video and audio files, a librarian, and a copyright specialist. Faculty are experts of the subject they teach. Learning to be programmers and instructional designers is not a good use of faculty time. Placing a course in a distance format is a collaborative effort of the team. Once the course is placed into the DE format of choice, the faculty should schedule a series of practice sessions with the instructional designer. Familiarity with the program allows the faculty to concentrate on the learning of the student and not on the technology. Students who
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are required to complete a tutorial on online learning technologies before the class begins are better prepared. New on campus students in faceto-face classes often walk through their schedule to find their classes prior to the beginning of the semester. By opening up the distance course a week early, students can search around the site and become more familiar with the delivery method. Generally after two weeks, the technology recedes into the background, and teaching and learning come forward. The final design and implementation of a distance course should allow the student a way to obtain relevant learning resources effortlessly, communicate and collaborate easily, and spend more time on learning. Students in successful courses feel their learning is highly personalized and relevant. Supported by the use of real-time feedback and assessment, students are motivated, and their learning experiences and outcomes improve.
STUDENT PERCEPTIONS Prior to enrollment in DE, prospective students may believe that their education through DE courses and programs will suffer from poor quality and little or no human contact (Flowers, 2001). Some may even think that all DE programs are "degree mills" with little educational value. They may not know where to look to locate DE offerings, often considering only a local university. These perceptions could present a barrier to students' initial enrollment in DE. The benefits to students most often associated with DE include: (a) flexibility of learning in terms of time and place, (b) access to more resources, (c) more and varied learning and teaching strategies, and (d) individuation of learning (Niemi & Cooler, 1987). Unlike studies of a single online course, Swan, Shea, Fredericksen, Pickett, Pelz, and Maher (2000) examined student perceptions of online courses based on a survey of 3800 students in 264 courses. Students who reported higher levels of computer skills before taking the course were no more satisfied and had similar levels of learning than students with little or no computer experience. Interaction in an online course was important to students. When students experienced a high level of interaction with the teacher and with their peers, they were more satisfied with the course and learned
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more in it. Along the same line, students in courses involving active learning and discussion were more satisfied and reported higher levels of learning. Students also reported the benefits to them of consistency among course modules.
INSTITUTIONAL CONSIDERATIONS Before committing to developing and implementing a total online program, institutions should consider first what resources are needed, both financial and personnel, and if the program is affordable and feasible. Although the costs for the technology tend to decrease with time, the newest innovations are often the most costly (AACN, 2000). For a nursing program to remain on the cutting edge, the institution's mission needs to support DE, and the institution must have a long-term strategic plan for financial investment to purchase the newest technological equipment, update equipment based on a cyclic three-year plan, cover institutional site license fees for software use, support institution infrastructures, and support faculty development. A second consideration is the availability of nursing faculty, considering the current shortage. With the growth in DE programs, institutions are hiring full-time faculty from traditional institutions to teach parttime or in adjunct positions for a virtual institution. A third consideration is institutional residency requirements. Some institutions may require students to enroll in additional courses offered by the institution to meet the residency requirements. With multiple avenues for learning, it is feasible that students could take several types of DE courses from different institutions and have those credits transferred to the student's selected degree-granting institution. This process, however, may result in the student not meeting the degree-granting institution's residency requirements. The question is whether institutions will waive the residency requirement for students who meet program requirements through DE courses from multiple institutions. A fourth consideration is ownership of intellectual property. The following questions need to be answered by the institution. Does the original faculty member who develops the course maintain ownership, does the ownership change when another faculty teaches the course and modifies the course content and syllabus, or is there joint ownership? If a course has multiple sections with different faculty assigned to each
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section, who has ownership of that section? Interwoven in the issue of ownership of intellectual property is academic freedom. A fifth consideration is the relationship of student to the institution, student to faculty, and student to student. Students are not physically on campus, so how does the nursing program and the institution connect to students and address these relationships?
MARKETING Certainly, if an institution decides to offer a DE program, the institution first should conduct a needs analysis and identify the characteristics of the target population. Without students, the program will not be financially viable. Institutions who have a history with DE are in a better position to identify the probable need and demand for the DE courses than an institution without that experience (Mehrotra, Hollister, & McGahey, 2001). A basic marketing principle is that the institution needs to know the advantages and disadvantages of offering a program online. To attract students, the institution needs to reduce institutional barriers, and the program needs to be flexible. The DE program should meet adult learners' professional and personal needs, so the institution should identify those needs and market the program to that target population. Students who enroll in DE programs have different characteristics from the general student. They are goal oriented, highly motivated, focused, and risk-takers; they thrive when guided and encouraged by their instructors. Students in DE courses manage their own learning, are more assertive, and participate actively in the instructional process (Mehrotra, Hollister, & McGahey, 2001).
SPECIFIC CHALLENGES TO NURSING EDUCATION In the survey of NLNAC accredited institutions done by the authors, faculty identified challenges of DE in nursing. These challenges included workload, support, technology, student attitudes, and course quality issues. Workload issues focused on the lack of faculty time to develop online courses and the additional time needed to conduct them. Another
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challenge was the lack of infrastructure to support their DE courses and program. Faculty commented on the need for 24/7 student support services and other services for students such as advising and counseling. Other challenges identified by faculty related to technological issues such as "equipment breakdowns" and problems with connectivity. Students' attitudes were challenges for faculty. For example, faculty commented that some of their students hated using the computer. Students believed that distance courses would be easier and were surprised at the rigor even though this was explained upfront. Faculty also emphasized the need for students to feel connected to the institution and their education. Other challenges for faculty related to quality issues such as ensuring that testing online is secure and reliable, and issues with proctoring examinations at distance sites.
IMPLEMENTING CLINICAL PRACTICE COURSES AT A DISTANCE Another challenge for DE nursing programs is how to implement the clinical practice component of a course at a distance. Successful implementation relies on the interaction of the right course structure with the right faculty and the right preceptors. Deciding on the correct course structure must be done first. Nursing faculty have an abundance of technology resources to help deliver a clinical practice course. One approach to delivering the course is the hybrid approach. In this approach the faculty member meets with the students for a number of encounters before placing the student in a clinical site with a mentor or preceptor. The student then uses a course management system (CMS) to enter logs and have discussions with their faculty of record and other students. The student returns to the on campus class for a certain number of meetings throughout the academic term. A second approach is to have a totally distant program. The faculty member designs the course with lectures and activities using a CMS. Each week the student attends class online asynchronously. The student also has a clinical experience with a mentor or preceptor each week. Logs and assignments regarding the clinical experience are a part of the class. One credit of a clinical course is generally converted into three or four hours of clinical practice.
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Faculty Role High quality clinical education offered at a distance requires an understanding of the faculty role. The expertise of the faculty member lies in the instruction. It is the faculty who meets with the student and assists the student in achieving the learning objectives and outcomes, who knows the preceptors and matches the right student with the right preceptor, and who monitors the student's learning by way of the CMS. The faculty makes the initial contact with the clinical agency and explains the goals and objectives of the course to the preceptor. Similar to other clinical courses involving preceptors, there should be a fit between the student and preceptor. In addition, the faculty should help set the pace of the experience, motivate the student, monitor the progress of the student, and assist with the evaluation. Development of a strong partnership among the faculty, preceptor, and student is essential if distance clinical experiences are to be successful (Close, Koshar, & DelCarlo, 2000). In some states, the use of preceptors is regulated by the state board of nursing. An example of this from the State of Kentucky can be found at: http://www.kbn.state.ky.us/documents/ponprecp.pdf
Preceptor Role The goal of the preceptorship in a DE course is no different than other clinical courses in nursing—to establish a one-on-one relationship between an experienced nurse and a student to learn the roles and responsibilities of the nurse and to achieve the clinical objectives. The critical element of distance clinical teaching is the selection of the preceptor who will mentor the student. Criteria for selecting preceptors and strategies for developing an effective preceptorship experience are presented in a later chapter. Once the preceptor is selected, access to some parts or all of the online course is made available. The preceptor then has access to information such as the course syllabus, clinical practice expectations, evaluation form, liability forms, and other documents, which are online. Placing these documents in a digital form decreases the amount of mailing that needs to be done; having e-mail access to preceptors facilitates contacting them about the course and clinical experiences.
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PRACTICUM EXPERIENCES The last part of a successful clinical DE course is the selection of practicum experiences for students and how these experiences should be sequenced. The clinical experiences should build progressively across the curriculum. Having access to the syllabus and learning outcomes helps the preceptor structure the daily experience for the student. Some institutions rely on a database to assist in planning the clinical experiences for students (Lears, Olsen, Morrision, & Vessey, 1998). The access to quality preceptors and less competition with other learners for experiences is a distinct advantage for students in distance sites. Students have reported that in DE courses they had more practicum time, gained confidence and independence in their clinical practice, and improved their time management skills compared with traditional clinical courses. In addition, they feel connected to the university by DE technologies (Yonge, 1997).
FUTURE DIRECTIONS FOR DISTANCE EDUCATION IN NURSING Respondents from the survey of NLNAC accredited institutions discussed earlier indicated a variety of institutional plans for future direction of DE in nursing. Institutions varied widely in the DE programs they provide, yet nearly all respondents indicated plans to expand their current offerings to distance learning. Most of those currently involved in DE are planning to add additional courses, programs, or DE media. A number of the institutions that currently do not offer distance education plan to develop and implement online course and programs in the future. Emerging technologies can assist nurse educators and nurses in overcoming some of the challenges of distance. The use of virtual labs and simulators for nurse education can provide interactivity. Furthermore, the use of telenursing and telemedicine, in which the patient and health care provider are physically separated, is promising. Linking of preceptors and faculty at remote locations via methods such teleconferencing can improve collaboration among preceptors, faculty, students, and clients. The future also will demand greater accountability for DE as the different parameters have become more sophisticated and comprehen-
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sive. This demand for accountability is due in part to the increased national assessment of distance education and the growing fear from some segments that distance education can, in fact, lead to mediocrity and the eventual destruction of higher education (Noble, 2001). The expansion of DE will likely require more emphasis on quality assessment, and educators will advocate for the inclusion of a theoretical basis in assessing DE quality (Thurmond, 2002). We also look toward increased partnerships among multidisciplinary stakeholders in the private and public sector. There will be contin,ued movement of commercial companies into the "educational business" realm and increases in mergers and consortia that provide distance education in nursing. These mergers will likely result in new marketing strategies to reach potential distance students previously overlooked. This may well result in increased globalization, which leads to greater diversity. There will likely be continued improvement in digital libraries and interconnectedness among local, regional, national, and international digital libraries. Distance education now spans an ever broadening range of technologies. From a phenomenon largely limited to correspondence/independent studies and video delivery (both one- and two-way video and audio) in the 1970s and early 1980s, there is now an entire continuum of DE formats from e-mail, to hypertext with compressed video, to videoconferencing. As broadened bandwidth becomes more commonplace and economically feasible, there will be continued new developments. One also can anticipate systems and software, such as described in a 2002 http:// www.ecollege.com press release, which meet Section 508 federal accessibility guidelines. These guidelines require that an institution's electronic and information technology be accessible to the disabled (Kane, 2002). There likely will be further exploration and use of an entire range of asynchronous and synchronous digital technology for distance learning. For example, it is reasonable to anticipate increased quality and use of videoconferencing along with desktop videoconferencing. Engagement and the complexity of learning activities in a heavily textbased online DE offering of today may be increased with the addition of multimedia elements. Innovative technologies for DE promise students more freedom, flexibility, readily available resources, and diversity (Westera & Sloep, 2001). As institutions evaluate access to DE, "new and emerging technologies will open access to populations that have enjoyed only peripheral
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participation in higher education" (Van Dusen, 2000, p. 21). The future of distance education in nursing is optimistic, with numerous technologies yet to be fully explored.
REFERENCES American Association of Colleges of Nursing. (1999). AACN white paper: Distance technology in nursing education. Washington, DC: Author. Retrieved March 16, 2002, from www.aacn.nche.edu/Publications/positions/whitepaper.htm American Association of Colleges of Nursing. (2000). Distance learning is changing and challenging nursing education. AACN Issue Bulletin. Washington, DC: Author. Retrieved March 16, 2002, from www.aacn.nche.edu/Publications/ issues/j an2000.htm American Council on Education. (1996). Guiding principles for distance learning in a learning society. Washington, DC: Author. Billings, D. (2000). A framework for assessing outcomes and practices in Web-based courses in nursing. Journal of Nursing Education, 39, 60-67. Billings, D., Connors, H., & Skiba, D. (2001). Benchmarking best practices in Webbased nursing courses. Advances in Nursing Practice, 23(3), 41-52. Close, L., Koshar, J., & DelCarlo, T. (2000). Clinical collaborative model: A new twist on an old challenge. Nurse Educator, 25(1), 25-27. Commission on Institutions of Higher Education. (2000). Statement of the Regional Accrediting Commissions on the evaluation of electronically offered degree and certificate programs and guidelines for the evaluation of electronically offered degree and certificate programs [On-line]. Retrieved March 16 2002, from http:// www.neasc.org/cihe/evaluation_electronically_offered_degree.htm Digital Libraries Initiatives. (1998). Retrieved April 16, 2002, from http://dli. grainger.uiuc.edu/national.htm Eaton, J. S. (2001). Distance learning: Academic and political challenges for higher education (accreditation). CJEA Monographs Series 2001, 1, 1-21. Flowers, J. (2001). Online learning needs in technology education. Journal of Technology Education, 13(1), 17-30. Retrieved March 16, 2002, from http://scholar.lib. vt.edu/ejournals/JTE/vl3nl/flowers.html Gerson, S. (2000). E-CLASS: Creating a guide to online course development for distance learning faculty. Online Journal of Distance Learning Administration, 3(4). Retrieved April 16, 2002, from http://www.westga.edu/~distance/ summer32.html Gladieux, L. E., & Swail, W. S. (1999). The Virtual University and educational opportunity: Panacea or false hope? Higher Education Management, 11(2), 43-56. Innovations in Distance Education. (1998). An emerging set of guiding principles and practices for the design and development of distance education. University Park,
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PA: The Pennsylvania State University. Retrieved March 25, 2002, from http:// www. worldcampus .psu. edu/ide/docs/guiding_principles .pdf Institute for Higher Education Policy (IHEP). (2000). Quality on the line: Benchmarks for success in Internet-based distance education. Washington, DC: Author. Retrieved March 16, 2002, from http://www.ihep.com/Pubs/PDF/Quality.pdf Jacob, S. M. (2001). The pros and cons of Web-based distance education in nursing. In M. G. Moore & J. T. Savrock (Eds.), Distance education in the health sciences (pp. 71-77). University Park, PA: The Pennsylvania State University. Kane, K. (personal communication, March 25, 2002). King, F. B., Young, M. F., Drivere-Richmond, K., & Schrader, P. G. (2001). Defining distance learning and distance education. Educational Technology Review, 9(1). Retrieved March 17, 2002, from http://www.aace.org/pubs/etr/king2.cfm Kuramoto, A. M., & Lambrecht, J. (1997). Audiographics teleconferencing: A method of distance learning.Journal of Nursing Staff Development, 13(1), 13-17. Lears, M. K., Olsen, S. J., Morrison, C., & Vessey, J. A. (1998). A centralized, computerized, and relational data base for student clinical placements. Journal of Professional Nursing, 14(2), 97-101. Leasure, A. R., Davis, L., & Thievon, S. L. (2000). Comparison of student outcomes and preferences in a traditional vs. World Wide Web-based baccalaureate nursing research course. Journal of Nursing Education, 39, 149-154. Mclsaac, M. S., & Gunawardena, C. N. (1996). Distance education. In D. H. Johanssen (Ed.), Handbook of research for educational communications and technology (pp. 403-437). New York: Simon & Schuster. Mehrotra, C. M., Hollister, C. D., & McGahey, L. (2001). Distance learning. Thousand Oaks, CA: Sage. MERLOT. Retrieved April 16, 2002, from www.MERLOT.org Milstead, J. A., & Nelson, R. (1998). Preparation for an online asynchronous university doctoral course: Lessons learned. Computers in Nursing, 16, 247-258. National Advisory Council on Nurse Education and Practice. (1996). Report to the Secretary of the Department of Health and Human Services on the basic registered nurse workforce. Rockville, MD: U.S. Department of Health & Human Services, Health Resources & Services Administration, Bureau of Health Professions, Division of Nursing. National Education Association (NEA). (2001). Focus on distance education, 7(2), 1-6. Publication of the Office of Higher Education. Washington, DC: Author. Retrieved March 16, 2002, from http://www.nea.org/he/heupdate/vol7no2.pdf National League for Nursing Accrediting Commission. (2000). Accreditation manual: Monitoring. North Central Association of Colleges and Schools Commission on Institutions of Higher Education and Southern Association of Colleges and Schools Commission on Colleges (pp. 74-75). New York: Author. Nelson, L. (2002). Teaching with e-mail and the Web. Retrieved March 25, 2002, from http://www.acusd.edu/theo/cts/web-teach.html Niemi, J. A., & Cooler, D. D. (Eds.). (1987). Technologies for learning outside the classroom: New directions for continuing education. San Francisco: Jossey-Bass.
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Noble, D. (2001). The future of the faculty in the digital diploma mill. Academe, 87(5), 27-32. Nolan, T. (2002). Introduction to online teaching and learning. Retrieved April 18, 2002, from http://www.sonoma.edu/users/ri/nolan/501/ Rahman, M. (2001). Faculty recruitment strategies for online programs. Online Journal of Distance Learning Administration, 4(4). Retrieved April 24, 2002, from http://www.westga.edu/~distance/ojdla/winter44/rahman44.html Reinert, B., & Fryback, P. (1997). Distance learning and nursing education. Journal of Nursing Education, 36, 421. Resick, L. K. (2002). Guidelines for distance learning in nurse practitioner education. National Organization of Nurse Practitioner Faculties, Distance Learning Special Interest Group, Washington, DC. Rockwell, K., Schauer, J., Fritz, S. M., & Marx, D. B. (2000). Faculty education, assistance and support needed to deliver education via distance. Online journal of Distance Learning Administration, 3(2). Retrieved April 16, 2002, from http:// www.westga.edu/~distance/summer32.html Swan, K., Shea, P., Fredericksen, E., Pickett, A., Pelz, W., & Maher, G. (2000). Building knowledge building communities: Consistency, contact and communication in the virtual classroom. Journal of Educational Computing Research, 23(4), 389-413, Retrieved February 10, 2002, from http://www.albany.edu/ etap/swan/knowledgebldg.htm Thurmond, V. A. (2002). Considering theory in assessing quality of Web-based courses. Nurse Educator, 27, 20-24. Van Dusen, G. C. (2000). Digital dilemma: Issues of access, cost, and quality in mediaenhanced and distance education. San Francisco: Jossey-Bass. Westera, W., & Sloep, P. B. (2001). The future of education in cyberspace. In L. R. Vandervert, L. V. Shavinina, & R. A. Cornell (Eds.), Cybereducation (pp. 115-136). Larchmont, NY: Mary Ann Liebert. Wiley, D. A. (2000). Connecting learning objects to instructional design theory: A definition, a metaphor, and a taxonomy. In D. A. Wiley (Ed.), The instructional use of learning objects: Online version. Retrieved March 18, 2002, from http:// reusability.org/read/chapters/wiley.doc Yonge, O. (1997). Assessing and preparing students for distance preceptorship placements. Journal of Advanced Nursing, 26, 812-816.
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Chapter 10 Teaching Creativity Online Peggy L. Chinn
or the past 10 years, I have used some form of online application as an enhancement to courses that I teach or as the only platform for teaching and learning. My own experience is consistent with findings that are emerging in the literature concerning the uses and limitations of online approaches for teaching. What I have not found sufficiently addressed in the literature is the key emphasis that I believe underlies the effective use of online approaches—creativity. Creativity is the key to developing and using effective online teaching and learning experiences (Ryan, Carlton, & Ali, 1999). If creativity is not at the center of a teacher's concern in developing teaching and learning materials, the materials and the resources can be as boring as a 2-hour monotone lecture. By contrast, well-developed course materials and experiences that reflect the teacher's own creativity stimulate and inspire students in their creative expression and potential. Creativity is a phenomenon that characterizes the best of teaching and learning. The best teachers are known to be creative in their classroom approaches whether they use traditional or nontraditional methods. For example, an engaging lecture is one that is creative—it presents new or familiar material in a manner that draws students into actually experiencing the lecture, not merely listening to the words and taking notes. Such a lecture often draws on other methods to aid the experience such as demonstrations or critical discussions, but even without these methods, a lecture that is creative makes the hour (or more) fly by. The Internet and World Wide Web are relatively recent technological tools that can be used to design creative teaching resources and also
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provide important avenues that can facilitate the student's own creativity and engagement with creative learning activities. Like lectures, Webbased teaching modalities are only as effective as the teacher makes them. Like any other modality, a mechanical and technical Web-based experience encourages conformity, passivity, and subordination, not creativity (Espeland & Shanta, 2001). Not all teachers will be readily drawn to using Web-based modalities just as some teachers cannot or choose not to use lectures, discussions, demonstrations, or any other modality. Electronic modalities should never be used just because they are there. Effective use of the Web for creative teaching and learning requires a vision of what is possible, knowledge of Web tools available, and most important, a philosophically grounded understanding of Web-based applications that can enhance creativity. The purpose of this chapter is to present a philosophic grounding for creative teaching and learning using online resources. Examples are provided to illustrate Web-based applications with WebCT to promote envisioning what is possible using other Web tools as well.
CREATIVITY Personal creativity, as defined and studied by one of the foremost scholars on creativity, is the experience of the world in novel and original ways; the hallmark of creativity is a change in a symbolic domain in the culture (Csikszentmihalyi, 1996) (pronounced cheek-sent-me-highyee). Csikszentmihalyi's research has verified one of the most important reasons that creativity is so essential. When people are involved in something they experience as creative, they reach a state of consciousness that is not typical of most of the rest of life—excitement, fulfillment, richness in life, and a profound sense of being part of something greater than oneself. Creativity is also vitally important for society because without it, there would be no way to find solutions to persistent problems. If students are to face their future and find both joy and satisfaction in their personal and professional lives, and if they are to contribute meaningfully to addressing difficult issues and problems, they must be educated to be creative as well as competent. Creative experience is, or can be, embedded in everyday life (Csikszentmihalyi, 1997). The creative experience moves the person into
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"flow," which is a state in which consciousness is harmoniously ordered. This in turn produces happiness because there is control over one's inner life, and external stimuli fade for that period in time. Awareness of the passage of time vanishes, and the person's awareness is transported into a "space" on which the creative activity is focused. The person enters a mind/body/spirit reality of openness to the extent possible, free from constraints and inhibitions. The accomplished artist draws on finely tuned skills and techniques specific to the medium at hand. The novice, or learner, immerses in the medium (words, movements, paints, instrument) to explore what is possible without judgment. Natalie Rogers (1993) identified both internal and external conditions that foster creativity. Internal conditions are the interrelated conditions of openness to experience and an internal locus of evaluation. Openness to experience requires setting aside expectations, defensiveness, or skepticism. It requires the ability to take risks and to stretch beyond that which is familiar. Internal locus of evaluation means taking in the responses of others while remaining free to choose whether or not to incorporate their responses into the experience. The person's own sense of what is pleasing, satisfying, and rewarding remains at the center. The internal conditions for creativity are not typical of most people's daily experience nor are they sufficient for creativity. In fact, according to Csikszentmihalyi (1996), genuinely creative accomplishments are less dependent on individual will or talent than they are on environmental conditions and the synergy of many sources. External conditions that foster one's ability to move into a creative experience are necessary and like the internal conditions contrast dramatically with the conditions of everyday experience. External conditions for creativity are psychological safety, psychological freedom, and stimulating and challenging experiences (Rogers, 1993). The first two conditions—psychological safety and psychological freedom—are interrelated and are characterized by an environment in which the person experiences unconditional worth and acceptance (safety) to the extent that they are free to experiment, even to make mistakes (freedom) (Rogers, 1993). Such an environment can be set up in a laboratory or a studio, and is the ideal environment in which creative capability is nurtured. An atmosphere of unconditional acceptance does not mean that "anything goes" or that everything that the novice produces is compli-
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mented. Rather, each person is valued in their experience, whatever that experience is, while at the same time receiving honest and constructive responses concerning their accomplishments relative to their ends-insight. For example, in a learning situation, students who are struggling to write are given sincere and constructive feedback and assistance to improve their writing skills in a context that recognizes and acknowledges the nature of their struggles, and encouragement for each step toward their writing goals. The gifted teacher does not punish or diminish the student in efforts that are less than ideal, but rather continues to search for that which inspires the next step or guides the novice in a direction that might be more congruent with the student's native capacity. Students who cannot meet writing standards of a course, for example, are encouraged to take the risks involved in getting started even though the outcome may not yet be acceptable. Rather than being penalized for their early attempts, they are encouraged and guided toward the next step, even though the step may be small. The third condition—challenging and stimulating experiences—is provided by a master coach, teacher, or therapist who sees the potential that a person can reach, and while maintaining psychological safety and freedom, encourages others to reach for that which is possible (Rogers, 1993). The master coach or teacher provides materials, instruments, tools, and models or examples of a vision of what might be possible, but at the same time encourages the student or novice to explore novel and creative possibilities that reach beyond that which would otherwise be predicted. An environment that offers stimulating and challenging experiences is at the heart of good teaching and applies particularly to teaching and learning online since many traditional on-site teaching modalities that offer stimulating and challenging experiences are not accessible online. However, key elements that are found in any stimulating and challenging learning opportunity apply as well to stimulating and challenging experiences online. Teaching modalities that foster creativity reflect the following key elements: • • • • •
Encourage critical thinking Foster autonomy Call forth students' unique abilities and interests Reward novel responses Provide opportunities for solitude that nurtures depth
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• Provide opportunities for interactions that expand horizons (Espeland & Shanta, 2001; Pinch & Graves, 2000; Rogers, 1993). Any teaching and learning modality that provides the conditions of psychological safety and psychological freedom and that offers stimulating and challenging experiences will foster creativity, but online modalities actually have some advantages in doing so. For example, online teaching is recognized to be a valuable avenue for enhancing students' writing and critical thinking abilities, and for integrating diverse and minority views (Pinch & Graves, 2000). The sections that follow describe approaches that foster creativity in online learning by developing the external context in which creativity can flourish. Each section is organized around a Web-based tool that is available or that can be developed, but the focus of the discussion is how the tool can be used to create key elements required to provide a context for creativity.
DISCUSSION BOARDS Discussion boards can be among the most useful tools for online learning, and they offer the opportunity for a context that incorporates all of the key elements that foster creativity. E-mail discussions can be equally useful in a small class, but in a large class the volume of e-mail becomes unmanageable. Discussion boards provide the advantage of organizing entries by threads, which makes it possible for participants to read them selectively. Discussion board threads can be organized by topic and content, so that the flow of a discussion, even though it occurs asynchronously, can emerge more or less logically. Discussion boards have a number of drawbacks and challenges that are worth keeping in mind while considering their creative potential. Discussion boards easily become overwhelming in a large class or in a class that has a number of very active participants. They require a considerable amount of online time, which is a major consideration for students who do not have affordable and reliable Internet connections. The advantages generally have been shown to outweigh the disadvantages in that the discussion board facilitates diversity of participation and can be used in a way that promotes depth of participation (Cartwright, 2000; Pinch & Graves, 2000; Teikmanis & Armstrong, 2001). The key elements for creativity reside not in the electronic discussion itself, but in how it is used. When a discussion board is simply
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made available to students with the general instruction to "use it," it rarely serves a useful purpose. In order for online discussions to be useful and to promote creativity, they need to be carefully organized and planned with specific learning activities incorporated into the discussion, and with the teacher as an active participant. The kind of writing that discussion calls for needs to be clearly defined as informal, where the rules of grammar and spelling take a back seat. Effective discussions use all of the conventions that convey feeling and emotion, creating the explicit context for experimentation, safety, and freedom to make mistakes, to move "outside the box." The teacher can model this kind of writing, inserting expletives, smiley faces, and unique expressions that convey a more intimate interaction than typically occurs in written form. For example, when someone points out that I forgot the attachment to a message, I respond with something like "Arrrgghhh . . . I hate when I do this!" For discussion boards to be useful, they need to be carefully designed with specific purposes identified, and the teacher must be an active participant. The key elements that contribute to an external context for creativity provide insights concerning how to effectively use discussion boards to facilitate creativity.
Encouraging Critical Thinking Critical thinking does not occur in a vacuum, and so in order to provide a context for critical thinking online, the teacher must provide the context from which the discussion flows. The context can start with course materials such as case studies, a book chapter or journal article, or an experience that is shared or accessible to everyone in the class such as a current event or political issue. The teacher then poses questions and challenges to the members of the class and calls for participants to offer their ideas and responses. As the discussion unfolds, the teacher continues to ask probing questions that prompt everyone to think beyond what is on the surface.
Fostering Autonomy, Calling Forth Unique Abilities, and Rewarding Novel Responses Once a discussion begins, the teacher's responses and further questioning and challenges convey a clear message that independent thinking, re-
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fleeting individuality and novel responses, is valued. The teacher does not have to "approve" of every response or idea, but the teacher's feedback cannot convey a negative judgmental attitude. Instead, the teacher withholds judgment and asks probing questions that prompt the students to think again about their ideas and consider the perspectives of others. Indeed, one of the most inhibiting responses that a teacher can offer is either positive or negative approval, which diverts the student's attention away from the substance of the discussion to the opinions of the teacher. It is possible to participate as a teacher sharing authentic responses without offering approval or disapproval. For example, instead of saying something like "Good answer, Jane," the teacher might say, "I can relate to Jane's response, and wonder how others feel. Does anyone in the class see this in a different way? Can you imagine a different kind of response, and who might feel differently about this issue?" Or, instead of saying, "Jane, you have not given this enough thought," the teacher might say, "I think there are other considerations in addition what Jane has pointed out. One issue that I notice is ... What else needs to be considered here?" As another example, rather than saying, "Your message does not make any sense," respond instead "I do not understand what you are saying, Sue. Explain this some more, or if anyone else in the class has some ideas about what Sue is saying, jump in to help clarify."
Providing Opportunities for Solitude That Nurture Depth A major advantage of online learning is that online discussions give students the opportunity to think before speaking, and often the kinds of discussions that students offer have more substance than onsite discussions (Cartwright, 2000). However, because of the time pressures and demands on most students enrolled in online courses, similar to students in onsite courses, the inclination to engage in meaningful solitary reflection does not occur spontaneously. The discussion board provides one avenue through which a teacher can convey the importance of solitude that nurtures depth. The questions and challenges that the teacher poses send clear messages that depth is valued and that thinking about a matter requires time and reflection. Here is an example: "Jim has posed a very difficult
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situation that does not lend itself to easy answers. Everyone, over the next few days, set aside some time to think about the issues involved and to explore your inner sense of the situation if this were indeed your own situation. How would you feel about what is happening? What would worry you the most? How would you find out the information you need to know? Who would you turn to for help? What if you were living in poverty? How would this situation appear to you then? Next week, share your reflections with everyone on the discussion board, and we will continue to explore the possibilities." The teacher also can model how this occurs by telling about personal experience with reflection, by telling a personal reflective story. A personal reflective story gives an account of an unfolding inner awareness about some situation or issue and the events, thoughts, feelings, or realizations that unfolded to influence own growing awareness.
Providing Opportunities for Interactions That Expand Horizons Since everyone who is involved in an online discussion can contribute as much as they wish, all students have the benefit of learning about perspectives that usually do not surface in an onsite classroom (Pinch & Graves, 2000; Teikmanis & Armstrong, 2001). In my own experience, this has been one of the major advantages of online discussion. Students who ordinarily rarely speak up in class will often offer insightful and stimulating discussions online, bringing awareness to everyone in the class that this person has something important to say. Often, for example, in my online courses students of minority ethnic heritage have spoken up in online discussions about issues of racism and experiences of discrimination that the majority culture students have never considered. My own participation in these discussions has been crucial to convey to everyone the value of the minority perspective and to assure that the risk that the student has taken in putting forth a minority viewpoint leads to a constructive and positive outcome for everyone involved. In each of these instances, everyone in the class grew in their awareness of how discrimination persists and began to envision ways to overcome the "isms" that damage everyone in society.
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WRITING-TO-LEARN Because online teaching uses writing as the primary medium for participation, this provides an ideal context for incorporating principles of writing-to-learn (Cowles, Strickland, & Rodgers, 2001). Writing-tolearn is a phrase that describes a wide variety of teaching approaches that incorporate writing activities that are consistent both with the course objectives and with student interests and concerns. The writing activities are designed to stimulate students' curiosity, critical thinking, creativity, and self-directed initiative in seeking novel approaches to course-related issues. Writing-to-learn approaches also require the kinds of teacher coaching and feedback that are consistent with the contexts that facilitate creativity. When writing-to-learn approaches are used, the teacher abandons a role of giving information and prescribing outcomes, and shifts to an educational role of learning context designer, resource provider, and coach. Since online content-oriented material is typically exceedingly boring and difficult to use, the shift to an emphasis on writingto-learn is a welcome relief for both students and teachers and provides an avenue for meaningful teacher-student interaction in an electronic context, one which is often assumed to be devoid of interaction. Writing-to-learn assignments require more planning and designing than the typical writing assignment used in traditional classrooms. They are designed specifically with the idea that the students will gain understanding of course content through the act of writing and will internalize course material because they write about specific applications that hold personal meaning. The teacher's evaluation of the writing requires a general reading with minimal feedback, focusing on the student's accomplishment related to the learning goals that are designed as part of the writing activity (Cowles, Strickland, & Rodgers, 2001). The design of the writing activity includes a rationale for the assignment based on the course content and objectives; the purpose of the assignment in terms of what the student is expected to learn; details concerning the structural expectations of the writing, for example, length, format and style standards, and level of polish; and specific guidelines and suggestions for how to go about preparing the paper. The teacher points the student in the direction of resources that are available and encourages students to use additional resources that are
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pertinent to the assignment (e.g., interviewing key informants and experts, observation, etc.). The following sections illustrate several writing-to-learn activities that lend themselves particularly well to online teaching and learning.
Creative Stories, Poems, Essays Assignments that ask students to write a creative story, poem, or essay are well-suited to learning objectives that address such learning goals as application of complex principles, personal knowing, ethical understanding, and abilities related to empathy, caring, and compassion in nursing (Evans & Severtsen, 2001; Severtsen & Evans, 2000; Smith, 2000). Creative writing draws on the student's unique abilities, encourages solitude that nurtures reflection and depth of understanding, and encourages students to express novel perspectives that may be only possible in fiction. When a teacher calls for "creative" writing, the teacher is in fact moving the student from what might be expected or possible in the "real" world, to that which is only possible in the imagination. The purpose for using creative writing in a writing-to-learn context is not to have students produce highly developed creative works (although this can happen), but rather to have them use free writing to deeply explore a life experience that is related to the course objectives. Students are given guidelines that explain the purposes of the writing in terms of the course objectives and describe how to go about representing depth of feeling and experience in words that draw on metaphor and symbolism. If students share their creative writings with the class, which can be part of the assignment, their stories can then become a focus around which the class has a focused discussion to further explore broader concerns such as cultural, ethical, or political meanings.
Reflective Writing Reflective writing is focused on something that the student has read or experienced. It includes a description of the reading or the experience, but the primary purpose of the writing is to reflect on the personal meanings of the experience (Smith, 2000). It is similar to what many
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teachers use as "journaling" but serves a more focused teaching and learning purpose. I do not recommend the use of the term "journaling" for reflective writing assignments because it confuses the purposes of writing for an audience with the purposes of writing for self-healing, which I also encourage students to do. Journaling is a powerful personal growth and self-care tool, but it is only effective as a personal healing modality if the writing is not shared and is done in a completely private and personal "inner space" that nurtures deep inner experience (Chinn & Kramer, 1999). Reflective writing is much like journaling, but in a teaching and learning context the writing is intended to be shared. No matter how candid the student might be in sharing inner experience, it is written with the intention of sharing with an audience—the teacher and perhaps classmates. Reflective writing assignments may promote personal growth and be helpful to the student, but the purpose from the standpoint of the learning experience is to gain insight into professional experience—to become a reflective practitioner (Schon, 1987). In all of my online courses, I use a weekly "closing" assignment that calls for students to reflect on their learning experience each week. The closing follows the format used in Peace and Power (Chinn, 2001), and calls for students to share what they appreciate or value in their experience, their critical reflections that include what they would like to have experienced differently, and an affirmation that connects their personal journey with that of the group. Students receive credit for completing the closing; the closings are not graded based on the content so that students are free to candidly reflect on the substance and quality of their experience and to suggest avenues for change. I use an assignment or the survey function in WebCT that enables me to respond to their reflections and to address any concerns that they have about their experience. For all students to benefit from the valuable reflections that the closings convey, I extract anonymously selected responses that represent important insights about the learning experience and post the summary for everyone in the class to consider. Critical reflections are particularly beneficial and grow in importance as the course proceeds. Students learn within a week or two that it is indeed safe to share insights that they have about the quality of their learning experiences, and they freely share suggestions for addressing concerns or making shifts in what is happening in the course to enrich or improve the learning experience. As much as possible, I respond to
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the suggestions and everyone benefits, modeling how a group can work together to bring about constructive change and creative solutions.
Content and Principle-Oriented Writing Writing-to-learn assignments that are content and principle-oriented address specific areas of course content with the expectation that students will gain a deep comprehension of underlying substantive principles because they have thought about course content, considered various ways in which the content applies in a situation or a context, formed their own analysis of a situation, and integrated insights from experience. It moves the student to an active learner-as-participant role, rather than the passive role of learning by listening, reading, and memorizing facts. The guidelines for this kind of experience provide students direction so their learning is focused toward the objectives while also encouraging flexible exploration and creativity. For example, I teach a course using WebCT that includes an overview of various wholistic healing modalities. For several class sessions, which are online, students read about general principles of wholistic healing modalities and consider common elements in wholistic healing modalities, such as touch, movement, and rhythm. I provide online Power Point slides with teacher notes that give overviews of some of the most common modalities, such as the use of massage, music, art, and therapeutic touch. At the same time, students complete a writingto-learn assignment that they can pursue alone or in small groups, in which they select a wholistic healing modality and write about their experience as well as background information. The guidelines for this assignment are shown in Table 10.1.
Giving Feedback on Writing That Encourages Creativity Writing-to-learn assignments emphasize the student's own insights and experiences. However, for the final, or summative evaluation, the teacher is specific about the level of polish that is expected for any particular writing experience. In the assignment illustrated in Table 10.1, a moderate level of polish that reflects adequate organization, grammar, spelling, and use of an accepted format for citations and references is expected.
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TABLE 10.1 Guidelines for Writing-to-Learn Assignment on Wholistic Healing Modality Rationale for the Assignment: To encourage students to experience a wholistic healing modality as a client, and to consider how elements from that practice might be integrated into their own nursing practice. Audience and Purpose: This paper is to be written in a way that it can be shared with others in the class to inform them about the modality that you have selected, and to pique their interest in learning more about the modality if they perceive that it may offer an added dimension to their nursing practice. You will provide to the reader some resources that can be used to further explore the modality and resources. Suggestions for Preparing the Paper: Select a wholistic healing modality that you have experienced either as a client or a practitioner, or one that you want to learn more about. If you have not yet had experience with this modality, arrange to interview a practitioner and/or receive a session using the modality. You can work with a group of class participants who share your interest. Whether you work alone or in a group, you will prepare your own paper based on the experiences and information that you share among members of the group. Your paper should be between 6 and 10 pages. You can include the following elements as they relate to your selected modality: • An account of your own experience with this modality • An overview of the history of the modality • An explanation of how one becomes certified to practice the modality, if this is required or preferred • A summary of the claims of benefits of the modality along with key references that support these claims • An explanation of how you might use elements of this modality in your nursing practice Illustrations may be used. Submit your paper as an e-mail attachment no later than May 1. Grading: Your paper will be graded based on the following criteria: • The content is clear, well organized, and grammatically sound • The elements (shown above) suggested for the paper are included to the extent that they apply to your selected modality • The paper conveys your own insights and critical reflections concerning the application of this modality in your nursing practice • APA stvle and format are used, with accurate citation of sources.
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The exact content of the paper is defined by the student's learning experience, and the activity of writing about the experience is part of the learning. Therefore, the evaluation focuses on the student's experience and process of learning that is reflected in the paper. Formative evaluation, provided in drafts or in discussions about the experience, focuses on challenges and questions that give the student a reason to explore further, to consider other alternatives, or to think more about an issue that is suggested. This kind of feedback provides candid responses to the writing without rendering negative judgment. For example, if a student is developing an idea that may be outlandish, perhaps even erroneous, the teacher might say, "My own understanding of this is quite different than what you indicate here. Are you sure about this point?" Or, "I wonder how someone who is in pain might experience what you are describing here. Have you taken this into account?" Feedback that conveys blanket approval without a specific rationale is just as inhibiting to a student's creative expression as is disapproval. If a teacher simply says "Good" in relation to a passage, the student has no specific information to guide further development of the work or from which to build on that which is "good." In addition, blanket approval conveys the inherent right of the teacher to also render blanket disapproval. If you like something that the student is developing, share your feeling about it or something about the passage that gives the student something to build on. For example, say, "I am drawn to your description—it gives me a vivid mental image and makes me smile." Or, "Wow! Your explanation is very clear and leaves no doubt as to your rationale." Refrain from feedback that is so specific that you end up doing the work of revision for the student. Instead, provide guidance and coaching that explains the reasoning behind your feedback. For example, instead of editing a poorly constructed sentence, say, "Your sentence structure leaves your meaning unclear. Edit here to be sure that what you write says what you mean." On the other extreme, one of the most damaging kinds of feedback that you can provide for a student is unexplained question marks, exclamation marks, or single words that convey a general and usually hostile message, for example, writing "what?" in the margin. The student has no idea exactly what feedback you are providing, and the marks convey an attack with no anchor to guide how to proceed to the next level. A question mark could indicate that you do not agree with what
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they wrote, that their meaning is not clear, or that you question whether or not their statement is correct.
COMMUNITY AND ACTION-ORIENTED LEARNING A number of creative activities can be designed that move students away from the computer and into a community setting to accomplish specific learning goals while at the same time investing in a project that holds particular interest for them. Service learning projects involve identifying a need in a community and facilitating activities through which the student participates in addressing that need while at the same time accomplishing specific learning objectives. Cybercases can be built around specific issues within a community, providing issues, challenges, and contexts from which students work in a problem-based type of learning activity (Lunyk-Child, et al., 2001; Niederhauser, Bigley, Hale, & Harper, 1999). One of the most valuable features of online teaching and learning are those activities that encourage students to form small groups that interact together onsite, or if this is not possible in small group online interactions (Ndiwane, 2001; Patterson, Crooks, & Lunyk-Child, 2002; Thiele, Allen, & Stucky, 1999). 1 use the concept of "sojourner groups" to convey the importance of traversing together the new territories covered in the course and providing support, encouragement, and inspiration for one another. Early in the semester students form small sojourner groups of two to four members based on some identified shared interest or context. In a course that focuses on nursing theory or practice, students might form their sojourner groups based on a shared interest in a particular concept or an area of clinical practice. In an online only course, students might form sojourner groups based on close, or relatively close, geographic location to facilitate face-to-face meetings and discussions. Learning activities are then designed to bring sojourner groups together in a way that stimulates creativity and meaningful interaction. For example, in a course on feminism and nursing that was only offered online, I designed a project that asked students to identify within their sojourner group a common issue or situation that affects the daily lives of women in their communities, such as housework or child care. In this course, students were located in different countries and in different
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states within the U.S., and so their sojourner groups were online groups with students located in different kinds of communities. Each student then interviewed women in their community to explore how the issue they identified shaped and influenced women—the struggles they experienced and the ways in which they dealt with the issue. The sojourners brought their insights together to engage in discussion, comparing and contrasting, looking for common ground, and exploring the ways in which the situations in their distinct communities affected the lives of women with respect to the selected issue. Finally, the sojourners presented online to the class the results of their explorations, and everyone participated in discussing how women's health was various influenced by daily concerns worldwide. SUMMARY In this chapter I have provided an overview of what creativity is, why it is important, and various approaches to promoting creativity in online teaching. The guidelines for using standard online Web-based platforms for course delivery contain a number of useful ideas to help teachers make the most of their online resources. The preparation of a course, particularly when you also have to learn a new delivery platform, is a huge undertaking. But in my experience the investment is well worth the effort with rewards and benefits that far outweigh the frustrations and limitations. REFERENCES Cartwright, J. (2000). Lessons learned: Using asynchronous computer-mediated conferencing to facilitate group discussion. Journal of Nursing Education, 39, 87-90. Chinn, P. L. (2001). Peace &> power: Building communities for the future (5th ed.). Sudbury, MA: Jones & Bartlett. Chinn, P. L., & Kramer, M. K. (1999). Theory cV nursing: Integrated knowledge development (5th ed.). St. Louis, MO: Mosby. Cowles, K. V., Strickland, D., & Rodgers, B. L. (2001). Collaboration for teaching innovation: Writing across the curriculum in a school of nursing. Journal of Nursing Education, 40, 363-367. Csikszentmihalyi, M. (1996). Creativity: Flow and the psychology of discovery and invention. New York: HarperCollins.
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Csikszentmihalyi, M. (1997). Finding flow: The psychology of engagement with everyday life. New York: Basic Books. Espeland, K., & Shanta, L. (2001). Empowering versus enabling in academia. Journal of Nursing Education, 40, 343-346. Evans, B. C, & Severtsen, B. M. (2001). Storytelling as cultural assessment. Nursing and Health Care Perspectives, 22, 180-183. Lunyk-Child, O., Crooks, D., Ellis, P., Ofosu, C., O'Mara, L., & Rideout, E. (2001). Self-directed Learning: Faculty and student perceptions. Journal of Nursing Education, 40, 116-123. Ndiwane, A. (2001). Safety net: Student exchange learning and supervision on the World Wide Web. Journal of Nursing Education, 40, 330-333. Niederhauser, V. P., Bigley, M. B., Hale, J., & Harper, D. (1999). Cybercases: An innovation in Internet education. Journal of Nursing Education, 38, 415-418. Patterson, C., Crooks, D., & Lunyk-Child, O. (2002). A new perspective on competencies for self-directed learning. Journal of Nursing Education, 41, 25-31. Pinch, W. J. E., & Graves,]. K. (2000). Using web-based discussion as a teaching strategy: Bioethics as an exemplar. Journal of Advanced Nursing, 32, 704-712. Rogers, N. (1993). The creative connection: Expressive arts as healing. Palo Alto, CA: Science & Behavior Books. Ryan, M., Carlton, K. H., & Ali, N. S. (1999). Evaluation of traditional classroom teaching methods versus course delivery via the World Wide Web. Journal of Nursing Education, 38, 272-277. Schon, D. A. (1987). Educating the reflective practitioner. San Francisco: Jossey-Bass. Severtsen, B. M., & Evans, B. C. (2000). Education for Caring Practice. Nursing and Health Care Perspectives, 21, 172-177. Smith, M. J. (2000). A reflective teaching-learning process to enhance personal knowing. Nursing and Health Care Perspectives, 21, 130-132. Teikmanis, M., & Armstrong,]. (2001). Teaching pathophysiology to diverse students using an online discussion board. Computers in Nursing, 19(2), 75. Thiele, J. E., Allen, C., & Stucky, M. (1999). Effects of web-based instruction on learning behaviors of undergraduate and graduate students. Nursing and Health Care Perspectives, 20, 199-203.
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Chapter 11 Innovation and Quality in Higher Education: An RN-BSN Program Goes Online Joan E. Thicle and Anne M. Hirsch
hat! You are telling me that my course is going to be nline! I don't know how to teach online. I need a lot of help! There is no time for me to convert my course by fall." Faculty responded with these concerns to the announcement by the Associate Dean for Academic Affairs at the Intercollegiate College of Nursing, Washington State University (WSU) College of Nursing that the Registered Nurse Baccalaureate Degree (RN-BSN) courses were going to an online format. She reported that during the summer of 1999, she had obtained a grant from the Washington State Higher Education Coordinating Board (HECB) to convert all of the RN-BSN courses to a totally asynchronous, online format. The Associate Dean attempted to provide her rationale to the faculty who were teaching in the RN-BSN program. She explained that increasing enrollment in the RN-BSN program would contribute additional baccalaureate prepared nurses to the workforce. Providing easier access to the program for registered nurses (RNs) with associate degrees would encourage them to continue their education and attract place-bound individuals who, due to time, work, or geographic distance, cannot attend regularly scheduled traditional classroom courses. In particular, it was hoped that the number of rural and minority nurses, particularly Native American and Hispanic individuals, would increase with an online asynchronous program because of its convenience and accessibility. This chapter describes the process of converting a traditional classroombased RN-BSN program to a totally asynchronous, online offering.
"W
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BACKGROUND At the time, WSU offered the RN-BSN program to five sites across the state, that is, Yakima, Vancouver, Richland, Pullman, and Spokane (Figure 11.1). The classes were transmitted from any one of five sites to the other four using two-way audio and video technologies of the Washington Higher Education Technology System (WHETS). Despite the multiple access points across the states, many RN students could not take advantage of a traditional lecture class due to their work and family requirements. Others lived in rural areas that are a considerable distance from the WHETS sites. Extensive use of the WHETS system presented scheduling problems affecting when classes could be offered; this was another factor contributing to the need for courses in an online format. In addition, the nursing shortage that was beginning to emerge was not only a lack of practicing nurses, but also a shortage of nurses prepared at the baccalaureate level (National Advisory Council on Nurse Education and Practice, 1996). Providing high-quality accessible classes on a flexible schedule convenient to working professionals was essential to increase the level of preparation of the nursing workforce. All of the factors cited above merged at a time when the HECB offered a one-time call for innovative program proposals.
FIGURE 11.1
WHETS locations in the state of Washington.
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The call for proposals was issued during the summer break when faculty with nine-month contracts were unavailable. The Associate Dean had 20 days in which to submit a proposal to take advantage of the opportunity to obtain additional funding for the RN-BSN program. After consulting with the Coordinator of the RN-BSN program, the Associate Dean for Instructional Resources and Extended College Activities, the Information Technology (IT) support staff, and the Dean of the College, the proposal was written. On return from summer break, the RN-BSN faculty were informed of the receipt of the innovative program grant and the specific objectives to be accomplished. The projected outcomes of the two-year project were: 1. An increase of at least 25% (13 FTEs) per year in students enrolled in the RN-BSN program. 2. An increase of 10% (14 FTEs) in the graduate program as a direct result of the project. 3. The production of asynchronous learning materials, including appropriate high-quality graphics. 4. The delivery of all of the theory courses (10 courses, 25 semester credit hours) in the RN-BSN program using asynchronous instructional methodologies. 5. Competency-based measurements of student achievement for each theory course. 6. A high level of satisfaction by students with the course content, instruction, and method of delivery as demonstrated by course evaluations. The faculty knew they had considerable work to do. The grant identified an ambitious timeline for re-engineering each of the 10 courses in the RN-BSN program to an asynchronous online format. The initial online courses would be available to students by the Fall of 2000, with the entire program available online by Spring of 2001. At a subsequent meeting of the RN-BSN faculty, a proposal to ensure smooth implementation and transition to an online environment was presented to the Associate Dean by the RN-BSN faculty.
PLANS FOR IMPLEMENTATION Approximately one month later, the RN-BSN faculty met again. By this time, the reality of the need to re-engineer courses to an online distance
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education environment was apparent. Fortunately, one of the faculty had considerable knowledge in this area and used many online components in her courses. This individual was recognized as the faculty computer "guru" and was often asked by faculty for individual assistance with the technical aspects of computer use. A month or so later, a second meeting of the RN-BSN faculty was held. At this session, the faculty readily admitted their naivete in relation to creating online courses and their hesitancy to do so without additional support. Both the format of presenting class material to an unseen audience and the technicalities of using computer software for online courses were viewed as obstacles to be addressed. The faculty put forth a request to the Associate Dean for an individual who would provide direct assistance to the faculty in converting their courses to an asynchronous format. The Associate Dean consulted with the faculty computer "guru," who was promptly named as coordinator of asynchronous course faculty.
Role of Asynchronous Course Faculty The role of the faculty assigned to teach an asynchronous, or Webbased, course differed from that of regular course faculty because of the intensive development required for the Web courses. It has been estimated that online teaching requires about one-third more faculty time than does a traditional lecture course. In fact, one author (Boettcher, 1998) suggested that it can take an average of 18 hours of faculty time to create one hour of instruction on the Web (p. 58). In recognition of the increased time requirements, faculty were given release time for course conversion the semester prior to implementation of their online course. For Fall implementation, a stipend was given to the faculty to reimburse them for summer preparation time. Although all courses require preparation time prior to their implementation, it was recognized that Web-based courses require significantly more planning and development time than do traditional lecture courses. This tactic proved to be an effective recruitment incentive for reluctant faculty.
Faculty Development One of the first activities of the Asynchronous Coordinator was to meet with the Information Technology (IT) staff and plan a workshop for
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faculty. The workshop presented the software to be used for online course offerings. Blackboard was chosen for the online courses after extensive review of other courseware. In addition, several of the faculty had positive experiences with the publicly available version of this courseware. The program was purchased and placed on the College of Nursing server. Faculty were introduced to the use of this software at the initial workshop. In addition, innovative uses of video streaming, audio, and other multimedia that can be incorporated into online courses were presented. The majority of faculty who would be converting their courses to online offerings attended the session. As might be expected, the more technical the information presented, the more lost and concerned many of the faculty became. In addition to presenting the technical dimensions of course conversion, a theoretical basis was provided. The seven principles of good teaching delineated by Chickering and Ehrmann (1996) served as the underpinnings for the design of online courses. These principles of evidence-based practice focus on application of the following in the construction and implementation of online courses: 1. 2. 3. 4. 5. 6. 7.
Good practice encourages student-faculty contact Good practice encourages cooperation among students Good practice encourages active learning Good practice gives prompt feedback Good practice emphasizes time on task Good practice communicates high expectations Good practice respects diverse talents and ways of learning.
The faculty were introduced to sources of information, such as T.H.E. Journal and Syllabus. Multiple approaches for creating interactive course materials were discussed, as was online evaluation of learning.
BEGINNING COURSE CONVERSION Following the workshop, countless sessions were held between the Asynchronous Coordinator and individual faculty. One room in the College of Nursing became a dedicated "Web development" office. This office contained a high-speed computer workstation with an attached scanner and printer. Software for creating online courses and multimedia presentations was loaded onto the computer. All faculty offices have direct access to the College of Nursing server and a direct fiber optic
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T-l connection to the main campus computers in Pullman, Washington. This connection provides high-speed e-mail and Internet access. The individual sessions enabled the novice faculty to learn the skills needed to convert their courses in a quiet environment with one-onone instruction. The IT staff was always available and provided additional technical expertise as needed. Faculty assigned to the online courses were provided with updated computer hardware and given summer stipends or workload adjustments for course development. By the time Fall 2001 arrived, the first three courses were ready for students. A process for enrolling students into the courseware was established. Directions for self-enrollment were mailed to the students. Faculty were directed by the Asynchronous Coordinator to make contact with the students by postcard or telephone during the first week of the semester. Despite these efforts, some technical snags with getting students enrolled in the courses and able to use the software emerged. Often, students had an identification number (ID) assigned to them on admission to WSU. In some instances, the WSU ID was not one that allowed them access to a course. Self-enrollment in the courses proved to be an easier and more efficient method of getting the students into the courses than did having the IT staff enroll students and inform them of login IDs and passwords. Support from the IT staff resolved each of these difficulties and improved the enrollment process for subsequent semesters.
Meetings with Faculty Once courses were online, the Asynchronous Coordinator continued to meet with the faculty on a regular basis. At these meetings, problems and issues were discussed. One recurring problem was how to deal with the nonparticipating student. Faculty were directed to contact the student via e-mail after the first episode of nonparticipation occurred, such as not submitting an assignment on time, having minimal to no response to discussion items, and similar events or omissions. If the email did not produce a prompt response, the next recommended step was a telephone call. Following this, a notice of unsatisfactory performance was mailed to the student by the faculty. In the majority of situations, the initial e-mail was sufficient to alter the student's performance and participation.
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Guidelines for discussions found in the literature (Knowlton, KnowIton, & Davis, 2000) were addressed during these meetings. A second major item of discussion, and one that continues today was where to find simulations, graphics, and other ready-to-use materials. Information identifying resources such as the Multimedia Educational Resource for Learning and Online Teaching (MERLOT) and other sources were shared. In fact, the sharing of new sites and online materials is an ongoing endeavor for all faculty, in particular by the Asynchronous Coordinator.
PLANS FOR EVALUATION OF LEARNING AND COURSE INSTRUCTION As soon as the first courses were available online, questions arose relating to evaluation of student learning, faculty instruction, and student satisfaction with the course format. Each faculty designed their own evaluation of student learning. Some used essay examinations, others a final project or paper, others online testing. The main criterion was that the evaluation was consistent with the course outcomes.
Evaluation of Instruction Evaluation of instruction presented several issues. The College of Nursing uses a standard evaluation tool that is distributed to students during one of the final course sessions. Since the online courses did not meet as a class, this methodology was not feasible. The questions on the standardized form also were not appropriate for the asynchronous offerings. An online evaluation method had to be designed.
Use of Flashlight Project Evaluation Items Washington State University (WSU) is a participant in the Flashlight Project. The Asynchronous Coordinator made contact with the Center for Teaching and Learning with Technology at WSU. Items that evaluated course presentation and efficient use of the Blackboard technology were selected from the Flashlight inventory of items and placed on an evaluation survey tool (Brown, 1998). After review by the faculty, the
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tool was made available as an online survey of teaching effectiveness and satisfaction with the course conducted at the end of each semester. Directions for student use were created and distributed. At the present time, the template for the evaluation tool is available to the Asynchronous Coordinator. Every semester she creates a copy of the template for each online course and individualizes it with the faculty name and course number. The faculty member is informed of the availability of the survey and the directions to provide to students. The online surveys are activated close to the end of the semester and stopped after the end of the semester. The online survey is automatically tabulated through the Flashlight project software. Printed copies of the tabulated survey are made by the Coordinator and given to the faculty. A separate survey for program completion also has been created and will be implemented with the graduation of the first students from the asynchronous RN-BSN program in May 2002.
PROGRAM OUTCOMES Students who enrolled in the online courses have been excellent recruiters for the program. The first group of students in the initial courses realized that convenience and flexibility, in addition to quality instruction, were primary components of the online offerings. Student enrollment in the online program began to increase. In fact, a number of students who started the RN-BSN program in the WHETS (traditional classroom) version changed to the online program. The increase in student enrollments is shown in Figure 11.2. As displayed, the RN-BSN online program has quadrupled in size since its inception. Students in the initial online course were asked to respond to the question: "Why did you choose to enroll in the online course?" Responses included: • "I am taking this online [course] because it will be a new experience, and it allows me to be flexible with my schedule and not have to change my work schedule very much." • "Part of the appeal is convenience. I also enjoy the self-guided aspect of this course. I usually work best this way and with working full-time while completing this program, it makes it convenient for me."
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FIGURE 11.2 Increase in students in online RN-BSN program.
• "I wanted to be enrolled in an online program mainly because I work full time and wanted the convenience of doing school work when I was free. I have found that I learn so much more online because of the links that provide information at my fingertips. Before I had questions [but] I did not know where to find the answer. Now it is much easier. Thank you for being a pioneer!" • "I am REALLY excited about the asynchronous program . . . although I am still feeling a little shaky, since I am completely in the dark as to how this works!" • "How I got interested in the online program was that I was researching how to go to school and still keep my job. I have tried going to class and it didn't work. So, with a little help and a lot of hard work, I will get used to finding my information on the Internet." Convenience and flexibility are major factors in the appeal of online courses. Working professionals can take courses and still attend to work, home, and family commitments. There is no commuting time, and the flexibility allows place-bound working students to attend class anytime, anyplace. They can even attend in their bathrobe and slippers if they wish.
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Student Satisfaction with Online Program As part of the evaluation of teaching effectiveness, students were asked questions about the technology and how it affected their course participation. While not directly relating to satisfaction with the program, the responses provide an indication of how the online format was viewed by the students. Evaluations of eight different faculty and courses produced a total of 59 responses. Several students were enrolled in more than one online course, so the total number of respondents is actually less than 59 (Table 11.1). As determined from the positive responses, the majority "strongly agree" or "agree," the students believed that use of Blackboard helped
TABLE 11.1 Response of Students to Use of Blackboard Technology Item
Strongly agree
Agree
The technology used in this course was appropriate for performing the tasks required. Because of the way this course uses Blackboard, I am able to learn at my own pace. Because of the way this course uses Blackboard, I am acquiring skills that will be useful in my chosen profession. Because of the way this course uses electronic communication, 1 put in less time traveling to and from the campus/course delivery site. Because of the way this course uses electronic communication, I was able to take this course. Because of the way this course uses electronic communication, I spend more time studying. I would recommend this course to others.
37 (64%) 21 (36%)
Disagree
29 (50%) 26 (44%) 3 (5%)
Strongly disagree
1 (2%)
41 (69%) 17 (29%) 1 (2%)
54 (92%) 4 (7%)
1 (2%)
52 (88%) 7 (12%)
42 (71%) 14 (24%) 3 (5%)
43 (73%) 15 (25%) 1 (2%)
Total responses: 59 (some students were enrolled in more than one online course). Note: Due to rounding, some totals equal more than 100%.
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them attain success in the courses. It also is interesting to note that 56 (95%) of the online students indicated that they spent more time studying than they did in a traditional lecture course.
LESSONS LEARNED Faculty Considerations Fears and concerns of the faculty undertaking a venture such as conversion of an entire program to an asynchronous format are genuine and must be addressed. At WSU, the faculty fears fit into several categories. First, the technical skill of many faculty in relation to computer abilities is often minimal. Many faculty still struggle with e-mail attachments, creating graphics and slide presentations, and other computer technologies. Development of faculty computer skills is both time-consuming and fear invoking. The initial steep learning curve can be quite daunting to many individuals. Concerns about the course materials also are real. Faculty who have not taken online courses wonder what will happen to the quality of their content. In addition, the loss of their personal identity and individualized manner of presenting content is disconcerting. Replacing lecture notes with online materials created by someone else may be viewed as a personal loss by the faculty. Only after students begin to respond positively to the selection of excellent teaching materials and guidance in new directions do faculty begin to view the conversion as rewarding and contributing to the learning of the students. Faculty also must learn the science of online teaching and learning. To an already over-burdened faculty member, additional learning is a time-consuming task. Faculty who are specialists in a clinical area may not have a background of educational theory. In addition, learning educational design, development, and evaluation requires considerable effort. The toll on the time of the faculty can be considerable.
Solution to Faculty Concerns Fortunately, in this situation, faculty were provided time within their assignments to convert their courses to an asynchronous format. The recognition of the time and effort required to convert a course enabled
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faculty to attend computer workshops, read online learning theory, and thoughtfully approach their task. Because of this time allocation, the online courses were relatively complete at their initial offering. This one factor alone enabled faculty to meet the increased time demands of teaching an online course. The highly interactive nature of online courses places additional demands on faculty time. With the courses well developed at the time of offering to the students, attention could be directed toward interactions with students and directing the learning of individual students. The RN-BSN faculty wisely established two policies that directly affect their time. The first is that an online course may have no more than 25 students enrolled. This policy was recommended to enable the faculty to maintain the high level of interactivity, including multiple group and individual e-mails weekly. The second policy was that an individual faculty should teach only one online course at a time. This policy was established to assist the faculty with maintaining a reasonable workload.
Student Considerations and Solutions An early assumption that turned out to be erroneous was that students could be quickly and easily enrolled in courses located on Blackboard. However, simply directing the students to go to the Blackboard site once they were enrolled proved to be problematic. The faculty quickly realized that student readiness for online learning, including possessing the required computer skills, was not a given. Student computer skills and variations in modems rose to the forefront. The IT support staff assisted students with configuration of their modems and working with their browser software to access the courses. Low levels of computer skills among students were recognized by the faculty and were a source of frustration to the students. The faculty teaching the initial online courses spent considerable time encouraging students to become more familiar with their computers. Gradually, a number of online tutorials, such as word processing, PowerPoint, e-mail and attachments, and the American Psychological Association (APA) reference format, were located and placed as links that students were directed to for assistance. An online tutorial for using Blackboard was created and made accessible. Now students are directed to the Blackboard
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tutorial prior to starting an online course. Information about the Nursing Online Basics tutorial and other resources mentioned in this chapter is provided in Table 11.2. Use of the Nursing Online Basics tutorial enables students to begin courses without a tremendous learning curve just to become acquainted with the software. As online learning is new to most students, the time commitment, expectations, and student performance behaviors had to be learned. Many students were surprised that a 3-credit hour course actually required 9 hours of work each and every week. Simply studying for a test every few weeks was not adequate to meet the learning expected on a weekly basis in online courses. To provide students with a better understanding of the differences between traditional course expectations and online expectations, a manual for online students was written. This manual elaborates on the self-discipline, types of student efforts, and amount of effort to be expended to meet the demands of online courses. As many faculty required students to send assignments via e-mail attachment, viruses were often accompanying these materials. The IT
TABLE 11.2
Resources in Chapter
Blackboard URL: http://www.blackboard.com Nursing Online Basics is an online tutorial for using Blackboard created and maintained by the Intercollegiate College of Nursing, Washington State University. Guests may visit this resource at the following URL: http://icneonline.wsu.edu The course ID is NURONLINE, the User name is: nursing and the password is: online. From the list of My Courses, select Nursing Online Basics to access the tutorial. Manual for Online Students was written by Joan Thiele for the Intercollegiate College of Nursing, Washington State University. For additional information, contact the author, (
[email protected]) Multimedia Educational Resource for Learning and Online Teaching (MERLOT): MERLOT is a free and open resource designed primarily for faculty and students in higher education. It provides an expanding collection of online learning materials, peer reviews, and assignments. URL: http://www.merlot.org/Home.po Syllabus (New Dimensions in Education Technology). A monthly publication available free to qualified subscribers. For subscription information, visit their Web site: http://www.syllabus.com T.H.E. Journal (Technological Horizons in Education). A monthly publication available free in the United States and Canada on a limited basis. To subscribe, visit their Web site: www.thejournal.com/
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staff works with individual students via telephone, e-mail, and in-person contact to resolve individualized computer difficulties. In addition to working with students in relation to software access and e-mail, the IT staff found that they learned more about detecting and eliminating a wide variety of computer viruses than they wished to know. The IT staff assists students with use of virus protection programs and virus removal. Today, the College of Nursing has installed a virus protection software program that screens each piece of mail entering and leaving the system to protect faculty and staff computers. Accessing the university library also presented difficulties. The library gateway requires use of a WSU student identification number and a self-generated password. Often student browser software and Internet Service Provider settings were either incompatible with the library software or not configured to enable access. The library staff provides individual assistance to every student and faculty member who requests it. DIFFUSION INTO BSN PROGRAM Many of the faculty teaching in the RN-BSN program also teach in the traditional baccalaureate degree program (BSN). It was only natural for these same faculty to place course materials on Blackboard for the BSN students. Quickly the undergraduate students began to rely on the placement of notes from lectures or outlines of PowerPoint slides to accompany each class. Recently, the undergraduate students put forth a request to have the syllabi, individual gradebooks, and related materials for all courses made available to them via placement on Blackboard. To date, none of the BSN courses is offered in a totally asynchronous mode. However, online testing is used in several of the BSN courses. In addition, a few faculty are replacing selected class lectures with online assignments. These assignments range from use of clinical simulations to virtual field trips to use of online tutorials. Gradually, use of the Internet and its tremendous array of materials are being integrated into the BSN program as an adjunct to traditional classroom lectures. DIFFUSION INTO MASTER'S PROGRAM At this writing, two of the Master's in Nursing (MN) courses are offered in a primarily asynchronous mode; the Asynchronous Coordinator
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teaches both. The two courses each meet 3 times over the course of a semester; all other class activities are conducted asynchronously via Blackboard. Students in the graduate program, particularly those who entered after completing the online RN-BSN program, are asking for additional courses to be placed online. High-quality instruction coupled with convenience and flexibility are major considerations for these graduate students.
INCREASES IN STUDENT ENROLLMENT Currently, eight students who are completing the online RN-BSN program are enrolled in the RN-MN program as a direct result of the RN-BSN course conversion. Three additional students will begin the MN program in the Fall of 2002, two will begin in 2003, and another two in 2004. Another six students have received approval from the Graduate Program Committee of the College of Nursing to substitute MN courses for two of the RN-BSN courses. This action is often a first step toward admission into the MN program. Best of all, the total number of students in the online RN-BSN program has more than quadrupled. While we would like to attribute this increase directly to the inception of the online program, other factors must be acknowledged. No doubt, the nursing shortage, particularly of individuals prepared for leadership positions in education and administration, is a contributor to this increase. The inception of a RN-MN option offers an additional incentive, as the RN-BSN student can enter the MN program more quickly than was the case previously. Students, however, remain the best recruiters as they tell others about the quality, convenience, and flexibility of the program and encourage interested individuals to enroll.
THE FUTURE Online courses open educational opportunities to students who could not otherwise take college courses due to time and distance constraints. For the working professional, the convenience and flexibility of online courses make them appealing. As Internet access becomes universal, students are no longer restricted from advanced education by distance
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or geographic location. Increased Internet access is enabling faculty to use innovative technologies to present live sessions to a number of students simultaneously in multiple sites using videostreaming technology, as we are currently doing in the Psychiatric-Mental Health Advanced Nurse Practitioner program. The technology itself is expanding the view of what constitutes higher education. Sophisticated simulations and a tremendous array of mediated instructional materials are being placed on the Web and used in instruction. Virtual field trips, procedural demonstrations, and clinical case studies are being developed to replace the traditional lecture. These developments enable greater attention to be placed on development of critical thinking and diagnostic reasoning. What does the future hold? In today's digital world, the future holds more, not less, online learning and teaching. In fact, one prediction is that "online teaching will constitute 50% of all teaching by 2010" (Draves, 2000, p. 7). A recent report from the Department of Education (2000) states that "the Internet is bringing learning to students, instead of bringing students to learning" (p. 25). Online learning enables the use of highly interactive teaching simulations and real events captured as they occur by the transformed educators who were reluctantly dragged into an online environment.
REFERENCES Boettcher, J. V. (1998). How much does it cost to develop a distance learning course? It all depends Syllabus, 11(9), 56-58. Brown, G. (1998). Flashlight at Washington State University. Retrieved February 26, 1998, from Washington State University, Center for Teaching, Learning, and Technology from http://www.ctlt.wsu.edu/publications/flcases.htm Chickering, A., & Ehrmann, E. C. (1996). Implementing the seven principles: Technology as lever. American Association for Higher Education (AAHE) Journal. Retrieved February 26, 1998, from http://www.tltgroup.org/programs/ seven.html Department of Education (DOE). (December 19, 2000). The power of the Internet for learning: Movingfrom promise to practice. Report of the Web-based Education Commission to the President and the Congress of the United States. Retrieved March 15, 2001, from http://www.ed.gov/ Draves, W. A. (2000). Teaching online. River Falls, WI: Learning Resources Network. Knowlton, D. S., Knowlton, H. M., & Davis, C. (2000). The whys and hows of online discussion. Syllabus, 13(10), 54-58.
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National Advisory Council on Nurse Education and Practice. (1996). Report to the Secretary of the Department of Health and Human Services on the basic registered nurse workforce. Rockville, MD: U.S. Department of Health & Human Services, Health Resources & Services Administration, Bureau of Health Professions, Division of Nursing.
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Chapter 12 Community-Based Model of Distance Education for Nurse-Midwives
and Nurse Practitioners
Susan E. Stone
he Frontier School of Midwifery and Family Nursing (FSMFN) is a leader in distance education for nurse-midwives and nurse practitioners. The School has been offering education to nursemidwives via the Community-Based Nurse-Midwifery Education Program (CNEP) since 1990 and to Family Nurse Practitioners (FNP) since 1999. The curricula are designed to offer flexibility in graduate education for mature, self-directed, adult learners who prefer independent study or who are unable to relocate to existing programs. The foundational concept of a community-based education program is that students learn best in their home environment. Students do not leave the community they plan to serve in order to gain nurse-midwifery or FNP education. Over 900 nurse-midwives have graduated from the CNEP, representing every state in the nation as well as Canada. The first graduate of the Community-Based Family Nurse Practitioner Program (CFNP) was in January 2002. This chapter describes the history and development of the FSMFN including how the need for distance education was identified and evolved. A description of the programs and the process of educating students as nurse-midwives and nurse practitioners using distance education are included.
T
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HISTORY Frontier Graduate School of Midwifery The Frontier Graduate School of Midwifery was started in 1939 by the Frontier Nursing Service (FNS), established by Mary Breckinridge, as a part of its demonstration project in the care of the mother and child in rural areas of Kentucky. Mary Breckinridge had traveled through the United States and Europe observing different models of health care. She became convinced that the British nurse-midwives who received training in both nursing and midwifery were ideally qualified to care for the families in the Appalachian region of Kentucky that she had targeted for her demonstration project. When the FNS began the project in the United States in 1925, there were only two ways to secure qualified nurse-midwives: by sending American nurses to Great Britain for graduate training, or by enlisting British nurses already qualified as midwives. In the early years, the FNS offered scholarships to American nurses to go to Great Britain for training in nurse-midwifery and recruited British nurse-midwives. When World War II started in 1939, most of the British members of the FNS staff wished to return to their homes. Under war conditions, it was not possible to continue to send American nurses to Great Britain. The Frontier Graduate School of Midwifery enrolled its first class on November 1, 1939 (Breckinridge, 1981). The Frontier School has graduated nurse-midwives on a continuous basis since that time.
Development of Community-Based Nurse-Midwifery Education Program The development of the CNEP was originally a cooperative effort of the Maternity Center Association, the National Association of Childbearing Centers, Frances Payne Bolton School of Nursing of Case Western Reserve University (FPB/CWRU), and the FNS. The purpose was to develop a nurse-midwifery education program that would increase the numbers of practicing nurse-midwives to meet a growing demand and prepare them to practice in freestanding birth centers. The target market was the hundreds of nurses who had expressed a desire to be midwives but
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because of commitments to family or work could not relocate to the few university settings where the education was offered. The first groups of students were admitted in April and October of 1989. In 1990, two more groups were admitted for a total of 95 students in the pilot program. The program orientation, Midwifery Bound, was facilitated by Outward Bound instructors given the charge to build a community of students that would carry them through the unknowns of distance learning. The curriculum was delivered to students via a modular format in large binders. Students communicated with faculty via telephone, mail, and fax machines. Obtaining a clinical site was a barrier for all midwifery students in the country. To prepare for this, two new initiatives were taken. Just as there were nurses across the nation who could not relocate to study midwifery, there were nurse-midwifery teachers who could not relocate to teach midwifery students. A mailing to all nurse-midwifery practices listed by the American College of Nurse-Midwives brought a response from 150 clinical sites willing to consider taking students. The potential teachers would be trained as preceptors and would be paid a percentage of the student's tuition for their work. The second initiative was to require that students identify a preceptor in or near their home community who would interview them and make a commitment to be trained to serve as their preceptor. The Outward Bound experience, combined with hands-on instruction on clinical teaching, was replicated to prepare the clinical preceptors of the first students (Ernst, 1999). The CNEP pilot project was successful, graduating 19 nurse-midwives in 1991, and 31 in 1992. In the meantime, the 1980s brought a gradual but significant decline in the number of births occurring at Mary Breckinridge Hospital. There were not enough births to continue offering the FSMFN residential nurse-midwifery education program at Hyden to the increasing number of nurses seeking midwifery education. In 1990, FSMFN recognized that the CNEP model of education matched its goals and mission. The President of the School and the Board of Directors voted in 1991 to adopt the CNEP model as its nurse-midwifery education program.
Addition of Nurse Practitioner Education Mary Breckenridge always envisioned family nurse-midwives as the primary care givers for the rural family. In the late 1960s, the FNS Board
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recognized that health care options had become more complex and a broader based education was necessary for nurses to provide comprehensive primary care to all family members. At that time the Frontier Graduate School of Midwifery developed the first certificate program to prepare FNPs. In 1970, the name of the school was changed to Frontier School of Midwifery and Family Nursing (FSMFN) to reflect the addition of the FNP program. This program was suspended in 1989, but was reestablished in 1999 using the CNEP distance education model and affiliation with FPB/CWRU for the master's degree (Stone, Ernst, & Schaffer, 2000). The program is now called the Community-Based Family Nurse Practitioner Program (CFNP). Modeled after the CNEP, nurse practitioner students complete the two year curriculum in their communities except for the initial five-day orientation on campus and the two-week residential session at the end of the first year. All course work is delivered via the World Wide Web. Clinical site arrangements occur in or near the student's community. Many of the FSMFN graduates and students are located in medically underserved and/or rural areas and either do not wish or are unable to attend a traditional school to gain a master's degree in nursing. Through the affiliation agreement with FPB/CWRU, we have been able to offer a MSN via concurrent enrollment at the FSMFN and FPB/CWRU. Case Western accepts all credits of the FSMFN program and requires nine credits of graduate work offered in one-week intensive classes on the Cleveland campus to complete the requirements for the MSN.
CURRICULUM The curriculum was redesigned in 2000, to meet the recommendations of the American Association of Colleges of Nursing's (AACN) Essentials of Master's Education in Nursing as well as the specialty organizations (AACN, 1996). Faculty chose an integrated curriculum in which content common to both nurse-midwives and nurse practitioners is offered in core courses. Course coordinators develop content for the courses based on the core competencies and the task analysis of the American College of Nurse Midwives and the National Organization of Nurse Practitioner Faculties. The didactic and clinical components of the program are achieved through demonstrated mastery of the objectives.
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The program of study is divided into four levels. Students progress sequentially through each level, completing one before starting the next. All courses, except Level Three residential courses, are available at all times allowing students to begin a course whenever they are ready. Level One is designed to present the scientific and conceptual basis for advanced practice. Many of the foundational courses are shared between the nurse-midwifery and family nurse practitioner programs. Level Two begins the foundational management courses with an emphasis on developing critical thinking skills through the use of the management process. The case study is heavily relied on as a teaching strategy. Students also learn to use the Internet to access professional information. In line with the philosophy of community-based education, student assignments include learning the practice laws of their state or country, doing a community assessment of the health care needs of their region, and observational experiences in their field of study. An important curricular thread focuses on the business of having a practice as a nurse-midwife or nurse practitioner. The nurse-midwifery students develop a proposal to start a free-standing birth center including community assessment, construction planning, state rules and regulations, billing and payment schemes, and operations. The nurse practitioner students do the same for the development of a clinic. These skills are essential for students who plan to work in rural and underserved areas where services are not developed. Students are required to contract with a proctor, preferably an advanced practice nurse in their specialty area, to proctor their examinations. Proctors complete an application process in which they are informed of the rules regarding the examinations, and they sign a form stating that they will ensure that the exams are kept secure. When a student is ready for an examination, the proctor orders it through the FSMFN Web site. The examination is mailed to the proctor who provides the student with a quiet room, devoid of reference materials and computers, where a closed book exam may be completed. The proctor then secures the examination for grading by the course faculty by signing a sealed envelope and mailing it. On completion of Levels One and Two, students are scheduled to return to the main campus for Level Three, a two-week intensive educational session. The focus is on the development and measurement of critical psychomotor skills and group process. The classes in Level Three promote the development of basic clinical skills and evaluate
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readiness to enter the clinical setting. Students in the nurse-midwifery and family nurse practitioner programs participate in many activities together such as physical assessment, practicing clinical skills on models and each other, analyzing case studies, developing curriculum vitaes, attending workshops on coding and billing, and discussing ethical dilemmas. Students must successfully complete the Level Three courses to be eligible to enter Level Four and start their clinical experience. Level Four starts immediately after Level Three. In this level, students integrate theoretical concepts with didactic and clinical coursework. The academic coursework in Level Four builds on the theoretical foundation created in Levels One and Two. Students begin their clinical experience in Level Four by attending sessions with their preceptor in their own community.
FACULTY The Frontier School of Midwifery and Family Nursing employs 32 faculty members. Faculty are certified nurse-midwives (CNM) or nurse practitioners holding doctoral or master's degrees; there also is one master's prepared librarian. Six faculty members hold certifications as both a CNM and FNP. All faculty have practiced or are currently practicing in their field. The Dean is responsible for the overall administration of the school. The chairs of the Department of Family Nursing and Department of Midwifery and Women's Health are responsible for the overall management of their specialty programs. This includes ensuring the quality of the curriculum, budget management, teaching and working with students in the department, and advising faculty. Course coordinators assume responsibility for an individual course or a sequence of courses. They develop the course objectives, learning activities, and evaluation measures. The course coordinators teach by structuring the learning and evaluation experiences, acting as a facilitator and contributor to the course forum, answering students' questions, and grading learning activities, papers, and examinations. Course coordinators also may teach face to face at orientation or during the onsite intensives at the FSMFN campus in Hyden, Kentucky. All course coordinators serve on the curriculum committee and provide quality assurance for the courses.
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Course faculty serve as assistants to the coordinator. They participate in development, implementation, and evaluation of the course and may teach at Level Three. They also assist with student counseling. Course coordinators and faculty grade all papers and tests and provide written evaluations to the students by e-mail, fax, or regular mail. To maintain continuity and a personalized program for each student, three faculty in the Department of Student Affairs have primarily advising functions. These faculty serve as Directors of Student Affairs (DSA), each with responsibility for applicants and students in a region of the country. The DSAs are responsible for student advising throughout the program, the overall clinical education of the students, and the quality of the FSMFN clinical sites. The DSAs monitor the student experiences in the clinical courses in Level Four, with input from the regional clinical coordinators, department chairs, and course coordinators. The DSAs also work closely with the chairs, course faculty, regional clinical coordinators, and preceptors on the resolution of student academic or clinical problems. The regional clinical coordinators (RCC) are experienced nurse midwives or nurse practitioners residing in the region that they coordinate. The RCC and the potential clinical preceptor interview the student for admission. Students are assigned to an RCC during the application process. The regional coordinator serves as the liaison among the clinical site, preceptor, student, and faculty. The RCC evaluates each clinical site before and during the student's clinical practicum. The RCC guides students through the clinical practicum and Level Four, fostering the networking of students in their area. The regional coordinators visit sites to assess student progress and ensure a positive learning environment. They also evaluate clinical performance and assign the clinical grades with input from the preceptor. Preceptors are clinical faculty who are responsible for student education at the clinical site. All preceptors are master's prepared, experienced nurse-midwives or nurse practitioners who are certified in their specialty. Preceptors guide and supervise students to meet the clinical objectives and become safe, beginning level practitioners. The FSMFN received a Rural Health Grant in 1994 that allowed the school to hold preceptor training workshops across the United States for three years. Over 1000 practitioners attended these workshops to learn the skills necessary to provide effective clinical guidance for students. After the grant ended, the preceptor curriculum was redesigned into a modular
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workbook that preceptors can complete at their own pace and can gain CEUs. All preceptors are strongly encouraged to complete this or a similar training course. Preceptors are paid an honorarium at the completion of each student's clinical experience. Six faculty members including the Dean, the librarian, the Chair of the Department of Family Nursing, and three course coordinators live in Kentucky and work from offices at the school. Others are located in many different states working in home offices. All faculty are available to students through regularly scheduled office hours and other appointment times during which they may "meet" with students via phone or Internet chat rooms. The FSMFN provides faculty with a basic phone line and covers charges for long distance phone calls to promote close contact with students. Faculty hold regularly scheduled meetings via conference calls and faculty meeting forums on the Banyan Tree bulletin board system. Every fall semester the entire faculty meets in Hyden, Kentucky for a threeday retreat. At that meeting faculty evaluate the programs, develop the annual strategic plan, and participate in educational sessions on distance learning. Course coordinators have a retreat each spring to deal with curricular issues.
STUDENTS The student body is 99% female with an average age of 35 and representation from across the United States and Canada. Most students have several years of nursing experience, and many have a wide variety of experiences. Almost all have families and plan to work at least parttime during the program. Admission criteria require that students enter the program as a registered nurse with a bachelor's degree from a regionally accredited institution. If the bachelor's degree is not in nursing, students are required to submit a portfolio detailing their nursing experience and relating their experience to nursing theory. On approval of the portfolio by the admission committee, the student may be admitted. The past GPA must be 3.0 or above. Therefore, these are experienced adult learners with a history of success in educational endeavors. Most students lack experience in learning via distance modalities and in an environment where they must structure their own schedule. All classes are delivered in an asynchronous mode. Therefore, students must develop a realistic schedule of study that works with their own lifestyle. Some will study every day in a set pattern, while others will
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spend their entire weekend and some evenings studying. The benefit of the asynchronous delivery is that they can do the school work on a schedule that best fits their lifestyle. This also can be a challenge as they seek the schedule that works for them.
TECHNOLOGY Gone are the large folders; the curriculum now resides on the Web. The school employs a multimedia team of four Web designers who are responsible for the Web site that hosts the FSMFN program. Located at www.midwives.org, this site is used to deliver the course materials, Student Handbook, Faculty Handbook, application materials, school catalog, and online library, as well as a wide variety of information about the school. Each course has its own Web site within the Members Only section of the school site. The Web designers work closely with course coordinators to develop each course site. Courses are delivered asynchronously via a secure Web site. Students can access the courses online at any time of the day or night and submit assignments as they complete them. Communication occurs on the school bulletin board system, called the Banyan Tree. The Banyan Tree is accessed via the Internet and is the hub of communication for the FSMFN community, processing approximately 2000 messages daily. There is an online tutorial for the Banyan Tree that students complete before coming for the initial orientation. This allows them ready access to the faculty, students, and staff of the school as soon as they are admitted. Every course has a forum at which students and instructors can interact, faculty can post announcements, students can post assignments, and faculty can schedule online chats. The system also supports threaded chat discussions and private e-mail. Forums also are available for student groups, faculty committees, and announcements. All members of the FSMFN community are required to check their forums a minimum of two or three times a week.
LIBRARY SERVICES The FSMFN maintains a small on-site library collection with books and journals related specifically to midwifery and primary care. The collection is supported by extensive electronic resources accessible via
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the Internet. Most of the library use is by individuals who are off site; therefore the school is interested in expanding these library resources and providing efficient electronic access. Many resources are available to students and faculty though the FSMFN virtual library. Through a contract with Kentucky Virtual Library, all students and faculty have direct (24 hour/7 day a week) access to a large number of databases and full-text electronic collections. These include EbscoHost databases such as MEDLINE®, CINAHL®, PsycINFO, the Cochrane Collaboration, and full-text journal collections in nursing, sociology, and psychology, and a number of OCLC FirstSearch and ProQuest® databases. The School also contracts with netLibrary© for 16,000 full-text volumes. In addition to direct access to electronic full-text articles, FSMFN provides materials to library users through the traditional mechanisms of document delivery and interlibrary loan. Arrangements with other libraries, such as the Bluegrass Medical Libraries, provide the library with free interlibrary loan access to other collections, reducing the cost of interlibrary loans to students and faculty. Lonesome Doc delivers requested articles to the School, and the library assistant sends them to the student or faculty making the request. STUDENTS' PATHS THROUGH THE PROGRAM Orientation—Frontier Bound All students are required to attend an orientation program called Frontier Bound. A new class is admitted three times each year, with groups ranging in size from 25 to 40. The orientation consists of five days on the small, historic campus in Hyden, Kentucky. All Level One course instructors, student advisors, department chairs, and the Dean attend Frontier Bound. The orientation is designed to introduce the students to their initial course work and faculty as well as begin building a community of learners. Students attend introductory classes for each of their Level One courses, the online library services, use of the Banyan Tree bulletin board system, and navigating their courses via the school Web site. Many activities are designed to assist the students in taking on the role of adult learner. Students complete a learning styles inventory and
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then discuss their own experiences as learners. Discussion topics include developing a weekly schedule to accommodate their studies, how their lives will change while being in school, and development of a timeline to assist them in measuring their progress. Storytelling is used as a teaching strategy during orientation. Experienced nurse midwives and FNPs attend sessions to share with students their stories about their practices, how they began, and their greatest triumphs. Students tell their stories regarding why they want to become nurse midwives or FNPs. Student representatives currently in Level Four of the program attend to guide students in electing their own representative and to connect them with a student mentor. During the orientation, students visit with their assigned faculty advisor. Course coordinators introduce the Level One courses, answer questions, and assist students in planning how to be a distance learning student on their return home. Students stay in Haggin Dormitory, the historic place where the nurses on horseback lived. Classes are held in the modernized Mardi Cottage, a classroom built in 1942 for nurse-midwifery students, and in the Barn, the renovated building that once housed the nurse-midwives' horses. One evening is reserved for students and faculty to have dinner together at the historic, log home fondly named the "Big House," where Mary Breckinridge lived and worked from 1925 to 1965. The last evening together is called "Follies Night." Students are assigned to small groups to develop a skit to present to the group; faculty also develops a skit. Many innovative songs, poems, and memories have evolved from this time when all can relax and have fun together. On the last morning the students and faculty "circle together" to share their thoughts. Each student then rings the bell located in the small chapel, signaling the beginning of his/her journey. The orientation is carefully designed to not only provide the information necessary for the students to get started, but also to build a community of learners who feel a sense of belonging to the school and to their future profession.
Levels One and Two Students complete at-a-distance course work in Levels One and Two. Completion of these two levels takes an average of 15 to 18 months. The course work is designed to be self-paced so students may take a
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shorter or longer period of time to complete, depending how much time is spent on their schoolwork. As adult learners, many students are working and raising families while they are in school so the time they can devote to their schoolwork varies with these other responsibilities. Each course has an assigned faculty member who is responsible for course content and for guiding the students through the course. Students and faculty interact using the Banyan Tree via course forums and informal meeting rooms.
Level Three Level Three, a two-week intensive educational session focusing on the development and measurement of critical psychomotor skills and group process, is scheduled five times a year, approximately every 10 weeks, to meet student needs. Generally 15 students attend a session. They live in Haggin Dormitory for the two weeks, providing an opportunity for networking with other students. Students often reflect on the Level Three as a time of making friendships that last for a lifetime.
Level Four and the Clinical Experience The student's focus during Level Four is gaining clinical experience. Under the preceptor's tutelage, students spend 6 to 12 months in the clinical setting. In addition, they are completing the more complex clinical courses. Students must enter the program with an arrangement in place for the clinical experience. Applicants begin by arranging an interview with the RCC. The students may already know of a potential preceptor or may get referrals from the RCC. Once a preceptor is located, the preceptor interviews the student seeking a good fit between the student's needs and the preceptor's site. All preceptor sites have a preclinical site visit from the RCC to evaluate the learning environment. Once the preceptor agrees to work with the student, a contract is signed between the FSMFN and the clinical site detailing the preceptor arrangement. The CNEP and CFNP options require 675 clinical hours and, to maintain quality, both options have a specific list of types of experiences that students in that specialty must have to graduate. For either option, if the student does not accomplish the list of experiences in the allotted hours, clinical practice will be extended until all essential learning expe-
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riences are accomplished. Students may choose, or be required, to use more than one clinical site to receive a variety of clinical experiences. During the clinical practicum the student is continuously evaluated by the preceptor and is in close contact with the RCC, who calls both students and preceptors at least every other week to assess progress. Students and preceptors complete daily evaluation logs and monitor clinical hours and numbers of experiences. These are collated and mailed to the RCC at the end of each month. After the student has completed at least half of the clinical practice hours, the RCC schedules a site visit. During this visit, the RCC observes the student's interactions with the preceptor, clients, and other members of the team at the site. The RCC also completes chart reviews and ends the visit with a conference with both the preceptor and student, providing feedback and suggestions when necessary. In summary, to meet the clinical practice requirements, the student must spend a minimum of 16 weeks at the clinical site, complete 675 hours of clinical practice, and complete the required number of specific clinical experiences. In addition, the preceptor signs a statement indicating that the student is a safe, beginning level practitioner. After completion of all required courses, students take a comprehensive examination. Their graduation date is the date when a passing score is documented to the registrar. They are then eligible to take the national certifying examination. The graduation ceremony is held every October in Hyden, Kentucky for all students who completed their certification within the past year. It is a wonderful celebration at which families finally come to see the historic sites. Students receive their diplomas and again ring the bell in the chapel to signal completion of their educational goal and the beginning of a new career. Graduation is held in conjunction with the annual faculty meeting so that all faculty can attend. The students are finally able to see the entire faculty together in one place.
STUDENT SUPPORT Student Advisors The DSAs provide guidance and support to students throughout the program. Students discuss with their DSA their academic progress, performance problems, and barriers to timely progression through the
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program. The DSAs assist students in setting academic goals, make sure that students are achieving those goals, and help them revise the goals if needed. They also work closely with students who are not keeping their commitments to help them develop the necessary study habits required for success. The DSAs have access to all course faculty, administrators, and students through the Banyan Tree and by phone.
Mi Amiga Mentorship Program The Mi Amiga Mentorship Program was developed by students, for students. Students believed that they could reach out to other students because they had "been there, done that." The Mi Amiga Program, coordinated by a student volunteer, matches any new student seeking a mentor with an experienced student. When the student volunteer "retires," usually near graduation, the responsibilities are passed to the next student volunteer leader.
Study Groups Students form study groups at various times throughout the program. Some groups get together for one content session and do not meet again because the goals have been achieved. Other groups meet on a regular basis as an ongoing educational tool. During Frontier Bound Orientation, regional groups are formed. These bonds established during Frontier Bound are strong and nurturing. During the Level Three experience in Hyden, Kentucky, the students form tight knit support groups that endure for the duration of the Frontier School experience and beyond. Students are encouraged to network with fellow students, faculty, staff, and other nurse-midwives and nurse practitioners. Guidance and support also are provided by the student advisors as students balance the educational program with life circumstances and commitments.
FACULTY SUPPORT Faculty are committed to supporting students as they progress through the program. Faculty do this through their teaching, ongoing forum
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discussions, and phone calls. As each class is admitted, the class is assigned a faculty mentor called the Class Mom. There is a forum opened for that class that is primarily a social place. Class Moms and students share stories, quotes, recipes, jokes, bad days, and good days. These forums are frequently busy with many students and faculty checking in as a mean to connect with one another.
FINANCIAL AID OFFICER The FSMFN financial aid officer is readily available to students to assist in their applications for financial aid, explore funding opportunities with them, and assist in seeking scholarships and loans. The FSMFN offers several scholarships to students every year.
STUDENT COUNCIL The Student Council is composed of elected student members from each CNEP and CFNP class who agree to act as class representatives. The election occurs at Frontier Bound. The primary role of the student council representative is to serve as a liaison among students, faculty, and administrators to facilitate active communication. The mission of the Student Council is to help make each student's experience as positive as possible (FSMFN, 2001). Student representatives are active on the Banyan Tree and available for students in their class to ask questions, relay comments, and address concerns. Representatives are responsible for being aware of student issues or concerns as they arise in the Banyan Tree forums. They also promote dialogue among students to explore these matters further and follow up on issues. Representatives communicate these concerns and the information gathered from discussion with students to the rest of the Student Council. Communication among the Student Council representatives takes place in the Student Council Forum, which is accessible only to the representatives. The Student Council also communicates via a Banyan Tree distribution e-mail list. In some instances a representative may contact an individual faculty or staff with a concern. Representatives also assist students in this circumstance by maintaining confidentiality when communicating sensitive individual issues.
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The Student Council surveys the student body biannually to solicit concerns, feedback, and ideas. The information is collated and given to the FSMFN administration. Discussion of results occurs via a conference call between administration and the Student Council. This survey is an important contribution to the planning and evaluation process. Student representatives also coordinate selection for the annual faculty award, serve on the Honor Code Council as needed, and assure student representation on various committees such as the curriculum committee.
EVALUATION The FSMFN has a systematic method of program planning and evaluation. All course evaluations are entered online by students at the completion of the courses. Instructors have immediate access to course evaluation data to provide ongoing assessment of the curriculum. All students complete an end-of-program survey after taking their comprehensive examination. Graduates complete a survey 1 year after graduation and again at their 5th year anniversary. They are surveyed on their satisfaction with the program, strengths and weaknesses in their skills, and their current employment. Additionally, their employers are surveyed at the same time. In the last survey, completed in 2000, 90% of the graduates were employed as certified nurse-midwives, 47% reported working in rural areas, and 50% reported that 70%-100% of the clients they served were either on Medicaid or self-pay. This supports the fact that the FSMFN is fulfilling its mission to provide education to nurse-midwives and nurse practitioners to provide primary care to women and families with a focus on underserved populations. Data from these surveys are used in developing the annual strategic plan each year. One tool for evaluation is how well students perform on their national certification examination. We only have data on the nursemidwives at this point in time since none of the NP graduates have taken the examination yet. The results for CNEP graduates taking the American College of Nurse Midwives National Certification Council examination in 2001 revealed a 98.7% first-time pass rate. In 2000, the first time pass rate was 97%, and in 1999 it was 96.7%. The CNEP program consistently scores above the national average for pass rates on this examination.
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THE FUTURE The FSMFN has recently obtained licensure from the Kentucky Council on Higher Education to grant an MSN degree, and we are currently seeking regional accreditation for the MSN program. The MSN through the CFPB/CWRU pathway is an excellent option for some students but for those who live far from Cleveland, the onsite intensives have become a barrier to completing the MSN. The FSMFN is committed to continuing to provide quality education for nurse-midwives and nurse practitioners using distance methods with a focus on community-based learning.
REFERENCES American Association of Colleges of Nursing (1996). The essentials of master's education for advanced practice nursing. Washington, DC: Author. Breckinridge, M. (1981). Wide neighborhoods—a story of the Frontier Nursing Service. Lexington, KY: The University Press of Kentucky. Ernst, E. (1999). An evaluation of the Community-Based Nurse-Midwifery Education Program of the Frontier School of Midwifery and Family Nursing. Hyden, KY: Unpublished document. Frontier School of Midwifery and Family Nursing. (2001). Frontier School of Midwifery and Family Nursing Student Council Handbook. Hyden, KY: Unpublished document. Stone, S., Ernst, E., & Shaffer, S. (2000). Distance education at the Frontier School of Midwifery and Family Nursing: From midwives on horseback to midwives on the World Wide Web. In J. Novotny (Ed.), Distance education in nursing (pp. 180-198). New York: Springer Publishing Co.
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Chapter 13 Issues in Rural Health: Model for a Web-Based Course Angeline Bushy
n the past decade educators of health professionals have made a dedicated effort to expose students to practice in rural environments. Their educational goals have been to prepare professionals to practice in more remote and austere environments, ultimately improve access to care for consumers living in regions described as underserved. While there has been a proliferation of articles related to online learning, little has been written specific to rural offerings. This chapter presents an overview of an online (Web-based) rural health issues course entitled Issues in Rural Health, and discusses lessons learned from that experience. The course, comprising twelve learning modules, was designed to create greater awareness of rural practice among undergraduate and graduate students in the health professions. The information provided herein could be used as a model to develop a similar course, be it Webbased or in the classroom setting, focusing on rural-related concerns across health disciplines. Historically, the main constituents of the teaching-learning situation have been the teacher, learner, content, and context. The context in which teaching-learning traditionally occurred has been a group of learners meeting face-to-face with a teacher in a classroom setting. Traditionally, the teacher has been expected to disseminate content while the learner passively absorbs it. Computers and network technologies, however, are modifying the context in which learning takes place as well as what we know about how students learn (Bielema, 1997; Burge & Carter, 1997; Graveley & Fullerton, 2000). Metaphorically, an Internet-
In
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based course can be described as a place (context) without physical boundaries (i.e., cyberspace), having a wealth of information (content) waiting to be actively sought by the teacher and learners as partners. In turn, from an environment filled with experts waiting to be accessed, the learners create in-depth and meaningful knowledge. In this instance, to complement and enhance the course textbook, Web resources provided access to in-depth and timely information on a range of ruralrelated topics. In addition to the potential for greater student diversity, a benefit of online courses is that they can reduce or even eliminate commuting time to teach or attend classes. Conversely, enrolling in an online course may require a greater degree of self-direction and motivation on the part of the learner, while the teacher may feel less in control of the learning environment. Likewise, technology and Internet accessibility can expand educational opportunities for consumers and health care providers alike in rural areas. Along with technology, some new terms have become evident in educators' lexicon. For example, distributive learning is a recently coined term used in lieu of the more traditional descriptor outreach or distance education. Of the two, distributive learning has a broader connotation in respect to the time when a class is offered (scheduled) and the site at which it is delivered. Compared to the traditional classroom confined within a bricks-and-mortar structure, community of learners also assumes a wider contextual dimension in reference to a virtual classroom that is located in cyberspace. A course can be fully Web-based, offered entirely online, or Web-enhanced, offering supplementary materials online to augment classroom content. Logging on refers to the action of accessing the course on the Internet via a computer. In the virtual classroom, discussions can be synchronous (real time) or asynchronous (one can log onto the Internet-based classroom at any time within a 24-hour time frame). Posting is the action of responding, in writing, to an online assignment or to a peer's comment; subsequently, the posted comments become apparent in the browser window (screen/page). When developing the online rural course, the author integrated the preceding concepts in its design. GETTING STARTED In many ways designing an online course is similar to developing one for the traditional classroom context (Peterson, Hennig, Dow, & Sole, 2000; Zalon, 2000). It requires the following activities:
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Planning the course Setting the stage Guiding and managing the discussion Problem solving and trouble shooting Evaluating the process and outcomes
Developing a course is not a linear process. Rather, one moves back and forth among the activities based on new insights or additional information that occurs in the process. To successfully integrate online teaching-learning in a course, the teacher must have an open mind, along with the willingness to assess the appropriateness of the technology for the unique course content, goals, and students' learning preferences and needs (Buchanan, 2000; Knowlton, Knowlton, & Davis, 2000). The kind of technology and software for teaching Web-based courses varies from one institution to another and from one student to another. The lack of standardization can pose the greatest challenge to both the instructor and students enrolled in a course. It is of utmost importance when developing a Web-based course to first become familiar with the technology that is in use at the employing institution. Table 13.1 suggests minimum requirements for access, capability, and usage for faculty teaching Web-based courses at a mainstream institution (Gilbert, 2002). There is a need for similar guidelines for students, and some universities have recommendations regarding minimum technology requirements and computer proficiencies for students enrolled in a Web course. At first, teaching an online course can be daunting. Often, though, the instructor has previously taught the course in a traditional (faceto-face) classroom as was the case with the rural issues course. It can be reassuring to know that rarely is there a need for a teacher to develop an online course, Web-based or Web-enhanced, without having access to software specifically designed for this purpose. Although a number of products are widely available, WebCT is the software used by the university in which this course was taught. Hence, it will be used in the reference to discussions about the rural issues course (Buhmann, 2000; Frizler, 1999; Presby, 2001; Zalon, 2000). Essentially, software provides a template that facilitates transition of course content from the traditional classroom to an online format. It allows for instructor creativity while controlling the layout, colors, texts, and graphics for the course. Course design software allows for the creation of lesson plans, i.e., learning modules, that include student discussion, specific assignments, e-mail capabilities, online testing, and
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TABLE 13.1 Minimum Technology Needs and Skill Proficiency for Faculty Teaching Web Course Equipment Desktop/laptop computer less than four years old Accessible color printer Compatible suite of software products (at least word processing, e-mail, presentation tool, Web browser, spreadsheet, Webbased course management tool), latest version from same publisher Fastest commonly available modem, ethernet or other connection for Internet access with greater bandwidth than provided by telephone modem No personal usage fees for accessing basic data bases and related services recommended by professional library association Help desk capacity sufficient to respond to phone or e-mail messages with answers or referral within one hour Some type of almost immediate support for those teaching in a smart classroom
Skills Operate basic computing and printing functions Perform most basic operations required by word processing software, e-mail, and Web browser Recognize when telecommunications are down/slow Know when and whom to contact about problems Open, read, and send email attachments Know when and how to ask librarian for assistance Identify and use online information services and databases Know when, how, and whom to ask for help (e.g., help desk personnel, student assistants, faculty peer mentors, or at least one colleague)
Behaviors Check for new e-mail messages at least once a day Decide which messages are important and respond to those within 24 hours Have flexible attitude about teaching and learning Be open to new ideas regarding education
Adapted from Gilbert, S. (2002). Technology implementation: Achieving the embarrassment level. Syllabus, 15(6), 24-25.
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chat room capabilities. Metaphorically, course design software is comparable to the architectural structure of a school building. The software provides consistency for students enrolled in a particular Web course.
COURSE FORMAT The author was asked to offer the rural issues course as a Web-based course, as part of the university and School of Nursing initiative to make advanced education more accessible to students in outlying catchment areas (Bushy, 2000, 2001). The School of Nursing has a standard format for all of its courses. The home pages (screens) of courses have the same colors, logo, and organization. Buttons located on the right side of the screen link to other course materials, specifically, the schedule, syllabus, tests, evaluation forms, learning modules, reading assignments, and discussion sites in which to post responses to specific assignments. This format was used for the Web-based rural issues course. The course was organized into twelve learning modules. Each had a corresponding discussion site in which students posted assignments, responded to peers' comments, and discussed current issues (Table 13.2). Two additional modules were dedicated to testing during the semester and one focused on international perspectives.
BUILDING COMMUNITY OF LEARNERS Establishing rapport is critical to building a learning community be it in the traditional or virtual classroom. Regardless of the delivery modality, one of the responsibilities of an instructor is to stay in contact with students and respond to individual needs. Achieving these outcomes can be difficult when meeting face-to-face and pose an even greater challenge in the virtual classroom. E-mail, bulletin boards, and chat rooms are useful electronic tools to connect with and monitor students' progress. To expedite accessing information for subsequent course assignments, two dedicated discussion sites were created. Two additional sites, that is, bulletin boards, were developed, specifically for the instructor to disseminate information in a timely manner to students and for students' notes to the instructor. The site for the teacher served as a way to communicate with students about technology problems, course
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TABLE 13.2
Learning Modules: Content and Assignments
Module content
Assignments
Module #1 Course Overview - Orientation to Web software - Assignments - Instructor's/Web protocols Historical perspectives of rural nursing Characteristics of rural lifestyle
Discussion #1 1. Introduce yourself to classmates in Discussion #1 2. Search/list two (2) Internet sites that provide information related to rural health that can be of use to others in this course. Post in Web resources discussion 3. Read one article related to the content in this module; prepare/ post in Discussion #1
Module #2 Defining rural and urban - Official definitions - Subjective perceptions - Socioeconomic structures - Rural-urban continuum Interview a rural resident
Discussion #2 1. Read one article related to the content in this module; prepare/ post in Discussion #2. 2. Answer these questions: - How do you define ruralness? (For this course, rural refers to areas having fewer than 99 persons per square mile and communities having a population of 20,000 or fewer). - Describe rural populations for whom you care. - How is rural (as opposed to urban) defined in your state? - How does the agency in which you work define rural? — Describe frontier areas (if any) in your geographical region. - Describe Health Professional Shortage Areas (HPSAs) in your state? - Summarize your comments in Discussion #2.
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(continued)
Module content
Assignments
Module #3 Theories for rural nursing Nursing concepts (application to rural health) - Person - Environment - Health - Nursing - Proposed relational statements Borrowed theories relative to rural nursing
Discussion #3 1. Interview a person who lives in a small town, farm or ranch. The interviewee can be someone on campus who comes from a rural community. 2. Inquire about the following:
Module #4 Health status of rural populations - Healthy People: 2010 - Overall health status - Groups at-risk; with special needs - Cultural and linguistic competence
Discussion #4 1. Read two articles related to the content in this module; prepare/ post in Discussion #4. 2. How did your outside readings support or refute the information in your textbook?
- Briefly describe the person's background and/or the rural community in which they live (age, gender, and position in the community) - What does being rural mean for your health (or your family's health)? - What are the main health problems encountered by people in your community/area? - What health services do you think are most urgently needed? - In what ways do you think rural folk are different from (or like) city folk? - How do this individual's comments fit with content in the instructor's notes and your peer's comments? - Reflect on, then summarize the interview in Discussion #3
(continued)
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TABLE 13.2
(continued)
Module content
Assignments 3. Describe the at-risk/vulnerable group that you read about. Comment in Discussion #4
Module #5 Community Health Assessment In community health nursing textbook(s) of your choice, review purposes and process for completing community assessment. If you have completed community assessment in the past, reflect on the data sources and data collection methods were used to complete that project
Discussion #5 1. Organize your group for the community assessment project. 2. As a group, identify from the instructor's list a rural community that you want to learn more about. - Identify data sources on Internet that will enable you to complete assignment - Implement the group community assessment - Use chat room to complete your work 3. Complete and post your group's community assessment in discussion #5 - Read, reflect on, then provide feedback to other group reports - Identify similarities and differences from your group's report - Comment on any other themes/ patterns you identify related to rural life, economic systems, social structures, health care resources, and health status - Post comments in Discussion #5
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(continued)
Module content
Assignments
Module #6 Rural Professional/Nursing Practice: - Scope - Roles/skills - Current issues - Opportunities - Challenges/rewards Interview a rural-based health professional
Discussion #6 1. Read one article related to the content in this module; prepare/ post in Discussion #6 2. Interview a nurse (health professional) who works, or has worked, in rural setting. Ask about the following: - Describe his/her professional roles and responsibilities - What are the greatest rewards and satisfaction? - What are the most significant work-related challenges? - Discuss his/her perspectives on the recruitment, retention and education needs of health professionals who want to work in that setting in a rural community - How is telehealth and technology used in the facility? What are the outcomes, benefits, and drawbacks? - How do his/her comments support or refute the information in the textbook? - Reflect on and post comments in Discussion #6 (continued)
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TABLE 13.2
(continued)
Module content
Assignments
Module #7 Rural nursing research - State-of-the-science - Needs/topics - Dissemination of research findings - Individual student interests
Discussion #7 1. Read one article related to the content in this module; prepare/ post in Discussion #7 2. Discuss: Do you think rural nursing is a specialty area of practice? Should it be? Post comments in Discussion #7 3. Describe research problem related to a rural nursing phenomenon that you would be interested in pursuing. 4. Provide constructive feedback to peers on their interest area. Post comments in Discussion #7
Module #8 International perspectives related to rural health care/practice
Discussion #8 1. Read one article related to the content in this module; prepare/ post in Discussion #8. Reflect on information provided in the article. - Briefly describe the nation and author(s) background - How did your outside reading support or refute what is happening in rural US? - Discuss/debate common themes/ issues that emerge in postings with your classmates in Discussion #8
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(continued)
Module content
Assignments
Module #9 Current rural health issues (Presentation of scholarly papers) - Regional perspectives - National perspectives - International perspectives
Discussion #9: Presentations 1. Post Issues papers
Module #10 Rural health practice issues (continued)
Discussion #10: Presentations 1. Respond to instructor initiated discussion items
- Read/reflect on papers - Provide feedback to peers on their issue/topic N Pose questions/comments in Discussion #8
- Focus on ethical, legal, and financial concerns Module #11 Wrap-up and course evaluations
Discussion #11 1. Complete university and school of nursing evaluation protocols 2. Complete self-evaluations to meet course requirements for contracted grade
Module #12 Final examination
Discussion #12 Access and complete final examination; Send as attachment to instructor
logistics, and assignments. The designated site for learners was used to post questions of a general nature to the instructor such as ones related to assignments and technical problems. Notices about rural conferences and other newsworthy items such as policy related issues could be posted in either of these sites. Another site, the Web resources discussion site, was for listing and easy access to relevant URL-links found by students or the instructor.
GRADING AND ASSIGNMENTS Evaluation and grading in an online course need to be considered in light of the technology that is used. Specific assignments along with
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evaluation criteria were delineated for each letter grade, that is, A, B, and C. Course assignments included participating in class discussions; reading and posting annotated bibliographies; searching for and posting relevant Web resources; completing a Web-based community assessment, which was a group project; interviewing a rural resident and a health professional in the student's discipline who worked in a rural practice setting; and completing an essay-type examination. Students contracting for the grade of "A" prepared a scholarly paper on a current rural health issue. All students were expected to complete a self-evaluation along with other university, college, and School of Nursing evaluation forms. The evaluation forms were available online for ready access. Participation, in the form of attentiveness and discussion, are features of most courses taught in a traditional classroom or broadcast as an outreach offering. However, facilitating meaningful participation among students in an online course is an art in itself. In brief, the course must be constructed so students have opportunities to share and defend their positions. At the outset of the course, expectations must be clearly communicated by the instructor to the learners. For example: What are the university and course protocols for Web courses? How should students conduct themselves online and in front of the world? What topics are to be included in the discussion for a particular learning module? Should students only post original contributions or are replies necessary? If replies are the expectation, how many must a student make for each module? Where and when are replies to be posted? How will the quality of student responses be evaluated? For the rural course students were directed to actively participate in seminar discussions by sharing insights gleaned from outside readings coupled with personal and professional experiences related to rural health. A student was expected to post responses a designated number of times for the various modules, by a specified date and time. Specific details were included within the instructor-generated scenarios to encourage class discussion for each learning module. Generally, students were given at least three weeks to complete assignments in consideration of the multiple responsibilities of adult learners. When the deadline arrived, the discussion site was locked by the instructor, thereby restricting further assignment postings by a student. Online management tools can assist the instructor in monitoring, evaluating, and responding to individual students. WebCT, for instance,
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progressively tracks the first, last, and total number of times an individual logged on to the course. Progressive tracking, though, does not indicate the quality or appropriateness of a response or even if an individual read the course materials. Rather, it merely indicates that a student logged on to the course and can be an indicator if individual follow-up is needed by the instructor. Posted responses and questions can offer insights about the quality of students' comments and their understanding of course materials. It is imperative, therefore, that the instructor read these, then intersperse questions to individual students and the group as a whole. This strategy can be used to reinforce or redirect the discussion, or enhance the quality of the content in students' messages.
PREPARING ANNOTATED BIBLIOGRAPHIC CITATIONS To expose learners to rural-related literature, students were required to post annotated bibliographic citations from nursing and health-related journals. Each citation was to include from 6 to 12 summary sentences with the reference written in the format of the American Psychological Association (APA) Publication Manual. Because of limitations in the software, on posting the document the reference format often became misaligned. This problem was extremely frustrating for students who made great efforts to "get it right." Consequently, the expectation of using APA format was modified because of these technology limitations.
COMPLETING WEB-BASED COMMUNITY ASSESSMENT The Web-based community assessment was a group project with most, if not all, of the information about a particular community found on the Internet. To begin, a list of rural communities, that is, towns, was developed by the instructor. The list represented various regions and ethnic groups across the United States. Some examples of communities from which students could select were a small rural community: • located in an intermountain state, with historical roots based on agriculture, precious metal mining, and the railroad • situated in a less publicized Hawaiian Island • having a large Latino migrant farm worker population
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• in the South having a predominantly black population • along the seacoast having fishing as its predominant economic base • on a Native American reservation Subsequently, the class self-organized into groups comprising four to six members. Then the group selected a community from the list that they wanted to learn more about. Logistical details for the group assignment were resolved in virtual chat rooms provided within WebCT, via e-mail, and by telephone. Adapting the traditional community assessment format, the following information was to be sought on the Internet and included in the final group report: • Geographic, climactic, and environmental features • Demographic data, for example, age, ethnicity, cultural background, race, religion, education, etc. • Socioeconomic data, for example, unemployment rates, new jobs, per capita income, poverty rate, etc. • Public utilities, safety, transportation, communication, and educational infrastructures • Health care resources and needs, for example, services, providers, access issues, etc. • Health status, for example, morbidity, mortality, immunizations, occupational risks, etc. • Health benefits/risks, for example, socioeconomic, climate, age, gender, racial-related, etc. • Health professional practice-related information One of the greatest challenges in determining the health status of rural communities is the lack of, or conflicting data about, populations living there. The deficit is attributable partly to national health data sets not being analyzed by smaller geographical areas or by racial/ethnic subsets. Consequently, in most instances, data for the communities in this course had to be extrapolated from state, county, and other types of public domain documents. Specific information about the practices of health professionals in a small geographic area also tends not to be readily available on the Internet. In most instances students interviewed a health professional
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via e-mail and/or telephone to learn more about the health status of their particular community. Individuals to be interviewed were identified from social service listings provided on the Internet or by calling a particular health care agency. After introducing themselves and stating the purpose of the call, students asked to interview a health professional in the agency about the attributes and challenges facing the community. Group reports were posted and peers provided feedback on them. Primarily, these consisted of written reports and student-designed community Web sites. Most included digital imaging, action graphics, and sound effects. In several instances, issues related to community privacy emerged. In these cases, the reports integrated hypertext links to existing Internet sites to describe the lifestyle and belief systems of the people living there. In total, the Web-based community assessment reports presented a cross section snapshot of America's diverse rural communities, highlighting similarities and differences among them. Students indicated this was a rich learning experience, and they gleaned much from it.
WRITING A SCHOLARLY PAPER The scholarly paper required students to examine in-depth a particular rural health topic. The objective was to create awareness among the community of learners about a variety of health care delivery and practice related issues. Examples of topics included advanced practice professional roles, provider isolation and burnout, mental health services, reimbursement patterns, concerns of the elderly, disparities in maternal and infant health, challenges in caring for persons with HIV/AIDS, trends in health policy, various ethical issues, and managed care. Individual scholarly papers were posted in a dedicated discussion site to which peers provided feedback.
EVALUATION METHODS Evaluation focused on process and outcomes of the course along with an assessment of student learning and course effectiveness. Ultimately, the instructor is responsible for determining students' final grade. Timely and objective evaluation can be awkward especially after students are encouraged to generate and elaborate on ideas. Self-evaluation coupled
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with peer feedback can create an atmosphere that encourages a high level of learning among a community of learners. Self-evaluation infers that an individual critically examines and re-examines his or her contributions to online discussions. It involves students' knowing, understanding, and being allowed to apply criteria put forth by the instructor. With respect to peer evaluation, the informal dynamics among the community of learners was one way to achieve this goal. Through their online postings, a student received feedback about his or her ideas. The instructor also encouraged peer feedback by posing questions to an individual or the class as a whole. As part of the contracting for a grade, students completed a self-evaluation to assess whether or not they met the course requirements relative to the grade for which they contracted. They also completed university, college, and School of Nursing evaluations as dictated by policy. All of the evaluation forms were available online for students' convenience. An essay-type examination required that students analyze and synthesize rural content learned in the course. The goal was to reinforce course content and made it relevant to their practice. Word limits were specified for each question (Table 13.3). The completed test was sent as an e-mail attachment to the instructor. Based on student generated data, the course was rated as highly successful. In particular, students found the interviews of a resident and a health professional in a rural community, the community assessment project, the scholarly issues paper, and the examinations to be valuable learning experiences. Most students found the textbook appropriate for the course, but the Web resources and links proved to be the best source for current information relative to regional, national, and international contexts. LESSONS LEARNED By evaluating the process and outcomes of the course, a number of lessons were learned that could be useful to others who are developing a similar Web-based course.
Delineate Student-Instructor Roles and Responsibilities Understanding the roles of the instructor and students is critical to successfully building a community of learners. Optimum learning is
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TABLE 13.3 Exemplar: Examination Questions 1. Define the term "rural." How has your definition been impacted, if at all, by this course? 2. Briefly describe the health care system in a rural area that is located near(est) to your home or workplace. What are the similarities and differences in this community from what you have learned in this course about rural communities in general? 3. The following question could be a real or hypothetical situation. You are working in an urban-based medical center and caring for Mr. John Farmer. He lives in the rural community that you described in the previous question. Using information gleaned in this course, list strategies that you would use to implement an appropriate and effective discharge plan for this patient. 4. As a case manager, how would you link formal with informal community resources to coordinate a seamless continuum of services? Give examples. 5. Should rural nursing be designated as a specialty area of practice? Defend your position. Note: This question may or may not be appropriate for students in other health disciplines. 6. Identify specific information about rural health care that you learned in this course and how it can be used in your current practice.
associated with the instructor allowing students to set the tone and pace of the discussion. Students, on the one hand, must understand that they are responsible for generating and elaborating on ideas related to the assigned topic and course materials. The instructor, on the other hand, is responsible for guiding and facilitating student interactions about the course content.
Model Appropriate Behaviors Instructor modeling of appropriate class participation can show students how to express ideas appropriately, critically, and effectively online. An opportune time for the instructor to join in and perhaps lead the discussion is in the beginning of the course. By the second or third assignment, the instructor's role should evolve from active participant to a less obtrusive facilitator. Supportive modeling can motivate a reserved student or guide a student with minimal computer experience. It also can be used to improve the overall quality of the online student discussions.
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Facilitate Active Student Participation Student participation, in the form of assignments and class discussions, is a critical component in building a community of learners. Through online discussions, students learn vicariously from each other as they share experiences, build consensus, and learn the course content. A carefully worded question can facilitate in-depth analysis of the topic being studied. Questions posed by students, as well as the instructor, can be used to validate, amplify, clarify, and, in some cases, refute an idea. Sometimes, there is a common understanding among a segment of the class that conflicts with one or more students' viewpoint. In turn, the processes of reflecting, discussing, and debating can lead to better understanding of the course material.
Modify Strategies to Fit the Technology When adapting a course to a Web-based model, established teachinglearning practices may need to be modified. For example, both synchronous and asynchronous classroom discussions have benefits and trade offs. One advantage of synchronous discussion is that it occurs in real time. In other words, at a specified time and place, students and perhaps the instructor log into a virtual classroom to discuss a particular topic or complete an assignment. However, considering the multiple personal and work-related schedules of adult learners, a drawback of synchronous discussion is coordinating a meeting time. Similar problems arise when organizing a group in the traditional classroom. Likewise, technological problems may arise at the most inconvenient times, and Murphy's Law seems to go into effect during a synchronous discussion. For example, one or more participants may have problems logging on to the course, computers may crash, and the university's or Internet Service Provider's (ISP) server may not be operating at that particular time. In the rural course, synchronous (written) discussions were difficult for individuals to follow when more than three students chatted in one classroom at the same time. Obviously, technological glitches create stress, more so for some than for others, which can hinder building a learning community. As mentioned earlier, asynchronous discussions do not occur in real time. Hence, they could be a disadvantage or benefit depending on
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the instructor's goals and objectives for the course. The student completes assignments and posts responses at a time that is personally convenient, be it late at night, very early morning, or weekends when classes are not traditionally held in a university setting. Likewise, if technological glitches occur, the student can complete the assignment after these are resolved. Instructor flexibility goes a long way to reduce the stress among the learning community in an online course.
Clearly Define Course Expectations Most students are quite interested and highly motivated in their educational pursuits. However, there always will be a few students who complete only the minimum expectations while still expecting a high grade for those efforts. Willingness to participate actively in discussion tends to be directly related to the grade allocated to it. For this reason standards for participation should be clearly articulated. If not, students will revert to previous practices and define their own level of performance. For example, the teacher can clarify expectations for participation by: • Specifying the minimum number of postings for each module • Explaining how posted comments will be evaluated and by whom, that is, the instructor, a teaching assistant, or peers • Being explicit regarding the format, spelling, grammar, and length of the message, the forum in which it should be posted, and the assignment deadlines Sometimes the instructor's criteria are vague, for instance, "for an 'A' grade your posted messages should have substance." Needless to say, a student's perception of substance often is not congruent with the instructor's. The teacher should develop questions that require analysis, synthesis, and critical thinking focusing on the learning objectives and should define clearly the criteria for grading the discussion.
Address Issues Related to Security, Confidentiality, and Privacy Internet security is of utmost concern for all. Therefore, the teacher should emphasize the need for current and reliable antivirus protection.
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The teacher can reinforce this requirement with a penalty of some sort should a virus be attached to a student's document that is distributed through cyberspace. Every instructor teaching an online course should be knowledgeable about the virus protection provided by the university for its information system along with recommendations for student users. At the outset of the course, students should demonstrate their ability to maintain security, specifically installing and updating antivirus software and scanning files. Privacy and confidentiality are two other important considerations when designing an online course and establishing rapport among the learners. Prior to sharing personal ideas, a student must have a certain level of rapport with the teacher and classmates. For this reason class discussions should be restricted to enrolled students and the instructor or, on occasion, a guest speaker. Without respect for privacy, the quality and quantity of individuals' participation will also suffer. For the rural course, confidentiality issues extended to the group project. For example, one group selected a community located in an intermountain state with a controversial fundamentalist group in its midst. The telephone interview with a key informant was quite revealing. Near the end of it, the student had second thoughts about the interview and was concerned that the mass media might learn what he told in confidence. Students took his apprehension into consideration. Prior to that interview the group had planned to create a Web site to display their community assessments. After the interview concerns were raised about that approach. To maintain confidentiality and insure privacy, the group reports were posted within a discussion site and included hypertext links to existing Internet sites. The links allowed peers to access public information on the lifestyle and belief system of that particular group. SUMMARY In conclusion, this chapter summarized the process for developing a Web-based rural issues course. Content areas, along with corresponding student assignments, were outlined. This model course could be adapted for other purposes and to other settings, for example, including a more extensive clinical component or focusing on a particular region, population, health problem, or practice issue. Likewise, the international perspective could be expanded.
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In brief, technology is here to stay. To that end, technology can help expose students to less accessible practice environments, in this case the rural setting. Technology also can help make education more available and accessible to health professionals and consumers in more remote rural settings.
REFERENCES Bielema, C. (1997). How computer-mediated communication (CMC) can work to enhance distance delivery of courses. Journal of Applied Communication, 81(4), 3-17, Buchanan, E. (2000). Getting the extra mile: Serving distance education students with resources and services. Syllabus, 13(9), 44-48. Buhmann, J. (2000). Electronic education: Authoring software for courses delivered on the Web, Part 2: WebCT. Nurse Educator, 25(2), 61-64. Burge, E., & Carter, N. (1997). It's building, but is it designing? Constructing Internetbased learning environments. Paper for the 18th World Conference of the International Council for Distance Education. Washington, DC: U.S. Department of Education. Bushy, A. (2000). Orientation to nursing in the rural community. Thousand Oaks, CA: Sage. Bushy, A. (2001). Nursing in the rural community: Concepts & practice issues. Computer Assisted Instruction (CAI) course. St. Louis, MO: ASK Data Systems, Inc. Frizler,K. (1999). Designing successful Internet assignments. Syllabus, 12(2), 51-53. Gilbert, S. (2002). Technology implementation: Achieving the embarrassment level. Syllabus, 15(6), 24-25. Graveley, E., & Fullerton, J. (2000). Incorporating electronic-based and computerbased strategies: Graduate nursing courses in administration. Journal of Nursing Education, 7, 186-188. Knowlton, D., Knowlton, H., & Davis, C. (2000). The ways and how's of online discussion. Syllabus, 13(10), 54-59. Peterson, J., Hennig, L., Dow, K., & Sole, M. (2000). Designing and facilitating class discussion in an Internet class. Nurse Educator, 26(1), 28-32. Presby, L. (2001). Seven tips for highly effective online courses. Syllabus. Retrieved December 10, 2001, from www.syllabus.com. Zalon, M. (2000). A prime-time primer for distance education. Nurse Educator, 25(1), 28-33.
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Chapter 14 International Distance Learning Collaboration to Prepare
Nurse Educators in Malaysia Diane M. Billings, Linda Kolandai, Ida Chin Meng Li, Sheela Devi, Getpin Rudie, Maria Mazani, and Shareena Paramasuvarum
t a time when health care is becoming increasingly complex and the need for nurses has escalated, there is a worldwide shortage of nurse educators (Hinshaw, 2001; Kelly, 2002). As countries begin to develop plans for recruiting nurses into the profession and preparing graduate nurses for advanced practice, there is a need for more nurse educators/tutors to serve in schools of nursing and health care institutions. Given limited resources, and the immediacy of the need to recruit and educate nurses, collaboration for preparing nurse educators is one way to leverage scant resources. Additionally, the increasing availability of the Internet worldwide makes distance learning a viable option for resource sharing. Thus, educators in schools of nursing and continuing education programs in the United States will be increasingly called upon to collaborate with their counterparts in other countries to develop and offer nurse educator preparation programs. The purpose of this chapter is to describe a collaboration between a school of nursing in the United States and an institute of health sciences and nursing in Malaysia to offer a Web-based certificate course to prepare nurses for faculty and staff development positions in Malaysia.
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THE CHALLENGE The development of a program to prepare tutors for schools of nursing in Malaysia was precipitated by several factors. First, there is an increase in the need for nurses in the country and in the numbers of students enrolling in nursing programs. Second, in Malaysia, nurses who seek employment as tutors must have completed course work or a certificate program to be eligible to teach in the classroom and, therefore, there is a need for specific courses for tutor role preparation. Finally, the course to prepare nurses as tutors previously offered by the Ministry of Health was being discontinued. Thus, the preparation of nurse tutors was met by conversion (diploma to degree) programs and certificate programs for postdiploma nurses, and the nurses in Malaysia were exploring the possibility of collaborating with a school of nursing in the United States to provide the certificate program. International collaborative projects require an understanding of the needs and capabilities of the parties involved as well as an appreciation of each other's cultural background. Face-to-face visits are essential for establishing the foundation of collaboration. To explore the possibility of offering a tutor's preparation course in Malaysia, the director of the Institute in Malaysia visited a school of nursing in the United States that has a series of online courses to prepare nurse educators. Next, the faculty member from the United States who would teach the courses visited the institute in Malaysia to assess participant readiness and the availability of resources including the library, computer support, a course coordinator, and preceptors for the teaching practicum. This visit also served to establish the credibility of the school of nursing and the capabilities of the course faculty. Because of the distance and the fiscal impracticality of having a full-time faculty member on site, the potential collaborators discussed the possibility of using the Internet for part of the course. While the use of the Internet for fostering global communities has been shown to increase cultural awareness, develop cultural competence, and make experiences available that otherwise would not be (Anderson, 1995; Kirkpatrick, Brown, & Atkins, 1998), it was important to anticipate the likely problems and impact of providing part of the educational experience in this new and relatively untested way. Because both schools had access to computer resources and the ability to provide support to the participants, we decided to use the Internet to offer a part of the course.
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PLANNING Detailed planning began after feasibility was assured. Planning took approximately one year and included developing a certificate course, identifying personnel for course implementation, and signing a memo of understanding. All planning efforts occurred by sharing drafts of documents using e-mail.
Development of Certificate Course The primary goal was that the course meet local needs for nurse educators based on internationally recognized competencies that could result in awarding a professional certificate. The collaborators first developed a course description, course competencies and objectives, and a sequence for the course content. The final course had 10 modules and a teaching practicum, occurring over nine months. Each module was designed with objectives, course content (some for the Web and some on site), learning experiences, and evaluation activities. The course had a total of 10 days of on-site visits, which were to occur at the beginning, middle, and end of the course. The collaborators also defined the teaching practicum, which included 30 hours of on-site practice teaching. The Institute would provide preceptors and access to curriculum, students, and course materials for the practicum component of the course. The teaching practicum was to involve preparation and implementation of two lesson plans, one in Bahasa Malaysia and one in English. Subsequently we decided to use videotape as way for course faculty to evaluate the participants' teaching as it would be difficult to coordinate an on-site evaluation with the natural flow of when the tutor would be teaching content in the ongoing courses in Malaysia.
Course Coordination International collaboration requires careful coordination and ongoing communication as the course is implemented. The Institute employed a course coordinator to facilitate the on-site activities and recruit precep-
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tors. The role of this coordinator is described in Table 14.1. The university in the United States also employed a course coordinator who in this particular course was also the course developer and course faculty. This role is described in Table 14.2. E-mail, both inside and outside of the course, proved invaluable in coordinating the course, on-site visits, and practicum. Since participating in online courses is initially a bit "disorienting" and "isolating" (Billings, Connors, & Skiba, 2001; Ryan, Hodson-Carlton, & Ali, 1999), course coordination also included using a technical facilitator and learning facilitator in the Web component of the course to provide additional support for the participants. The technical facilitator assisted participants with problems in accessing the course and using the TABLE 14.1 Role of Coordinator at Host Institution Qualifications • • • •
Must be a graduate, preferably in the same discipline as the course Good organizing and management skills Good communication skills Must be familiar with the local course curriculum and be able to do comparative studies with the course from the foreign university • Must be able to adopt the foreign university's mission statements and philosophies to the local program
Responsibilities • • • • • • • • • • • • • •
Be a full-time coordinator Be responsible for students' enrollment Conduct students' orientation Be responsible for the local course accreditation and registration Process students' complaints Assist foreign university to make changes to the course methodology and other changes to meet the needs of the students Coordinate a number of part-time preceptors throughout Malaysia Conduct a 1-day training session for preceptors Work closely with the foreign university to maintain standards Plan students' teaching practicums and their supervision Allocate preceptors to the students on commencing the course Be willing to travel to supervise on-site preceptors and their students Conduct periodic evaluation/appraisals of the preceptors Conduct course evaluation at the end of each course
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Role of Course Coordinator at Collaborating Institution
Qualifications • • • • • •
Advanced degree in nursing and experience as an educator Effective communication skills Ability to respect diversity Flexibility Skilled in developing and teaching in Web-based courses Availability to travel
Responsibilities • Assess learning needs • Establish competencies for certificate course • Coordinate with Continuing Education (CE) office to meet CE accreditation requirements and standards • Coordinate with technical team (instructional designer, director of information technologies, and Web master) developing the technical aspects of the course • Appoint advisory committee to review course content and teaching/learning activities • Direct pilot test of course • Assess availability of resources at both sites • Facilitate development of contract/memo of understanding • Contract with faculty and learning facilitator to develop and teach course • Coordinate technical development of course • Coordinate course with on-site course coordinator • Help select preceptors and assist with orientation and evaluation of preceptors • Collaborate in establishing an evaluation plan, evaluate course and teaching effectiveness, and plan for continuous quality improvement • Participate in course planning with course coordinator at host institution • Meet and communicate with administrators at host institution
course software. The learning facilitator answered participants' questions about the course assignments, facilitated access to online learning resources through the library, and interacted with participants to overcome the isolation that can occur in Web courses.
Preceptors Preceptors were selected based on their educational experience and willingness to assist participants in the course. The role of the preceptor
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is explained in Table 14.3. Preceptors were paid a small stipend. At the conclusion of the course, we suggested that preceptors also should be computer literate, should understand the process of Web learning, and should not have supervisory responsibilities for the participants. TABLE 14.3 Role of Preceptors for Nurse Tutors Certificate Program Qualifications • • • • • •
Be a qualified Nursing Tutor Have a nursing degree Have advanced academic preparation Be competent as a tutor Be computer literate or at least be familiar with word processing, e-mail, etc. Be familiar with the Nurse Tutor Certificate Web-based course.
Roles of preceptor • Collaborator between students and course faculty Be a significant member of the faculty Provide support to faculty and students • Motivator Guide students through a process of self-discovery Enable students to understand, value, and respect their future nursing students Develop a relationship of mutual respect with students • Facilitator of Learning Build on experiences Provide opportunities for students to practice teaching skills Use adult learning theory when working with students Responsibilities of preceptor • • • • •
Provide students with teaching practice schedule Guide students with their lesson plans Allow students to participate at Structured Clinical Exams Allow students to be invigilators (i.e., examiners) for end-of-semester exams Provide opportunities for students to write multiple-choice questions and multiple-essay questions for semester exams • Provide opportunities for students to mark test papers and attend "markers" meetings • Do students' assessment checklist as feedback for students to improve
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Participant Qualifications The collaborators established entry qualifications for participants. Since potential participants could speak English, the course could be offered in English. Other qualifications included being a graduate from a nursing program and practicing nursing, preferably working as a clinical instructor in a school of nursing or hospital. Although not a selection criteria, a sense of adventure also is important, as the participants in this course have been pioneers in new ways of learning.
Learning Resources A certificate course such as this requires adequate learning and audiovisual resources. The institute provided a library and subscribed to several nursing education journals. The institute also developed a computer laboratory and provided multimedia support staff during the on-site visit and throughout the course. The institute subsequently purchased a digital videocamera for participants' use during the teaching practicum. The library at the university in the United States provided limited use to its online collection of full-text nursing journals for the duration of the course. A course packet of readings would have been ideal but costly to assemble; however, the Internet provided substantive resources that could be accessed by the course participants.
Memo of Understanding A memo of understanding (MOU) served as the collaboration agreement. The MOU was drafted by legal counsel and approved by the respective chief officers. The content of the memo included a description of the course, number of site visits, employment and supervision of the preceptors, provisions for on-site coordination at schools, tuition, and revenue sharing.
IMPLEMENTATION Although planning occurred throughout the course, the implementation stage began with the first day of the course. Implementation included
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orientation to computer software and the actual teaching and learning throughout the course.
Orientation to Web Course Software The first activity for implementing the course involved orienting participants to using the Web course software. As a preliminary step, the course coordinator participated in a Web-based course that prepares educators for teaching in online learning courses. Having the course coordinator understand the principles of teaching and learning online and the use of the software was invaluable in her ability to assist the participants as they learned to use the course tools.
Face-to-Face Sessions Because this was the first course of this type for both collaborators, it was important to have sufficient time for face-to-face orientation to the course to assess learning needs, have an exchange of ideas, and develop relationships. The on-site sessions were used to apply content from the Web component of the course, demonstrate active learning strategies, and present content that is difficult to learn on the Web. We used debate, role-play, simulations, concept maps, and discussion as strategies for learning both content and teaching methods. We integrated audiovisual media (computer presentations, slides, and transparencies) into the sessions as a way to develop comfort with these learning resources. We also practiced writing multiple choice and essay test questions and developing course grading scales. Our time together presented opportunities for clarification of content and for socialization to new roles.
Getting to Know Each Other It was important that we spend time getting to know each other as individuals. We needed to be able to communicate what each one expected from the other. Communicating expectations is always important in teaching and learning, and even more so in this course because the tutor role and methods of teaching and of evaluation are different in each culture.
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We learned about each other during face-to-face class sessions, during lunch breaks, and at "high tea." We also created a "tutors' lounge" as a discussion forum within the Web course. In the "lounge" we told each other about our various holidays, shared photos digitally, sent each other electronic greeting cards, and even announced the birth of one of the participant's baby girl!
Teaching Practicum The practicum experience occurred on site and with the support of the preceptors. Each participant developed a lesson plan, taught a clinical learning laboratory session, and conducted a one-hour classroom session. Preceptors used pre-established evaluation instruments and gave feedback to the participants. The teaching that was offered in English was videotaped. The course faculty reviewed the videotapes at the last onsite visit and gave feedback to each participant using the same evaluation instrument used by the preceptor. Participants also critiqued their own teaching.
EVALUATION Because this was the first time to offer this course, it was important to communicate frequently and evaluate on an ongoing basis. Evaluation used informal and formal strategies.
Informal Evaluation Informal evaluation occurred both on site and within the Web course. At each on-site visit, the course faculty and participants reviewed how the course was going. We asked ourselves, what is working well? What needs improvement? Are there technical problems? Is there enough time to do the work?
Formal Evaluation Formal evaluation occurred at the end of the course. Participant learning outcomes were evaluated using evaluation rubrics identified at the outset
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of the course. The participants evaluated anonymously the course itself using a Likert-type course and faculty evaluation form.
FINDINGS AND RECOMMENDATIONS Six of the eight participants completed the course. One participant worked in a nursing service setting; the others were employed at schools of nursing in Kuala Lumpur. Two participants did not complete the course for personal reasons. Participants completing the course attained all of the course competencies and developed a teaching portfolio, wrote a philosophy of teaching, developed lesson plans, and taught several sessions in the classroom and learning laboratory. The Web component of the course for the most part was a success. Participants learned to use the rather complicated course management software and adapted easily to using threaded discussion, course e-mail, and quizzes. As is typical in Web courses, the participant's computer skills improved, and the Internet has now become a resource for the tutors' own students. Learners in Web courses must be self-directed and motivated to keep up with assignments. This also was true in this course, and we noted that the Web participation increased and lessons were completed close to the time the faculty member was due to make a site visit. We recommended setting tighter deadlines for module completion, providing more structure to assignments, and connecting timely course participation to the end of the program "grade." We also suggested removing each module and discussion from the general discussion board at the conclusion of the module. Then participants who are completing the module after the deadline would not distract the following module discussion. We found that the course could be completed in six months, thus compressing the time commitment and keeping the course momentum more focused. Finally, potential students should be aware of what Web courses involve and the commitment of time and effort they are making if they enroll in the course. The course was designed to meet needs for tutors who were working in both nursing service and schools of nursing. The course experiences and opportunities, therefore, must be developed in a way that each participant can have similar opportunities to apply course concepts. Orientation of the preceptors is critical to course success. Establishing clear understandings of the role is important from the outset, as
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there will be inevitable role confusion that is difficult to clarify at a distance. In the future, preceptor orientation could explain more fully the preceptor's role in evaluating the participant's teaching practicum and establish "interrater reliability" between the preceptors and the course faculty. Mentoring is an important role particularly after the course, and this role could be further developed for the preceptors. Giving preceptors access to Web course training prior to serving as a preceptor is one way of recognizing their significant contribution to the certificate program. Students from this course will be ideal preceptors for subsequent Web-based courses. We found that the course structure and content could be modified in several ways. For example, there could be more practice with specific content areas such as writing objectives and developing lesson plans. Some participants preferred more structure and more clearly defined course expectations. Although learning resources were adequate, and the course was designed to be somewhat resource independent, the participants suggested having a printed book of readings and a required textbook. At the end of the course, we became "reflective practitioners" and reflected on the course and our experiences (Brookfield, 1995). At this time we came to understand that there are differences in teaching and evaluation strategies and in the roles of the nurse and tutor in both countries. For example, "lecture" is a common teaching strategy in Malaysia, while in the United States there is a shift from teaching to learning and an emphasis on more active learning. Preparation of detailed lesson plans prior to teaching holds greater significance in schools of nursing in Malaysia than it does in the United States. Finally, we discovered that in Malaysia evaluation tends to focus primarily on negative aspects as opposed to noting what went well or commenting on those elements that need improving. These understandings can be used to guide course revisions.
CONCLUSIONS AND FUTURE DIRECTIONS Offering a certificate program in a collaborative way took advantage of the strengths and resources of both institutions and was a beginning for meeting the needs for nurse educators in Malaysia. Using the Internet was a solution to the barrier of distance and was critical to making resources available to course participants.
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Developing a certificate program that has both on-site and Web components is a major investment of resources for both parties. It is particularly difficult to offset program development costs, faculty salaries, and travel based on the United States economy against what can be recovered in tuition from nurses whose salaries are not comparable. Thus, collaborative planning and implementation must have goals of becoming self-sustaining and realistic for the local wage structures. Courses with heavy front-end costs must be designed for long-term use, and collaborators can seek additional audiences, such as from allied health or related professions with similar educational needs, or course development grants from international development agencies. The long-term effects of a certificate program such as this will not be known soon, but we speculated about the future. For example, it will be important to consider the impact of tutors prepared this way. How will the tutors integrate the new methods into the current educational system? To what extent will Web education become commonplace and barriers of distance more easily overcome? How well will a certificate from a university in the United States be accepted in Malaysia? How will the expertise acquired as a result of this course be recognized and remunerated? What mechanisms can be put in place to convert the certificate to academic credit? Participants still need mentoring in their new roles—will these resources be available? In summary, participating in what is likely the first Web program for nurse tutors was an extraordinary experience for all involved. We learned from each other, and our lives as individuals, nurses, and tutors have been forever changed.
ACKNOWLEDGMENT The authors wish to acknowledge Madam Asmarani Siddik who had the vision for the certificate program and initiated the planning process.
REFERENCES Anderson, D. G. (1995). Electronic education: E-mail links students and faculty. Nurse Educator, 20(4), 8-11. Billings, D., Connors, H., & Skiba, D. (2001). Benchmarking best practices in Webbased nursing courses. Advances in Nursing Sciences, 23(3), 41-52.
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Brookfield, S. (1995). Becoming a critically reflective teacher. San Francisco, CA: Jossey-Bass. Hinshaw, A. (2001). A continuing challenge: The shortage of educationally prepared nursing faculty. Online Journal of Issues in Nursing, 6(1) [Internet]. Retrieved March 14, 2002, from http://www.ana.org/ojin/topicl4/tpc!4_3.html Kelly, C. (2002). Investing in the future of nursing education: A cry for action. Nursing Education Perspectives, 23(1), 24-29. Kirkpatrick, M, K., Brown, S., & Atkins, T. (1998). Electronic education: Using the Internet to integrate cultural diversity and global awareness. Nurse Educator, 23(2), 15-17. Ryan, M., Hodson-Carlton, K., & AH, N. (1999). Evaluation of traditional classroom teaching methods verses course delivery via the World Wide Web. Nurse Educator, 38(6), 1-6.
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Chapter 15 Videoconferencing Innovations in Nursing Education Kay Sackett and Suzanne Steffan Dickerson
his chapter describes videoconferencing innovations at The University at Buffalo School of Nursing, The State University of New York. The University at Buffalo (UB) is located in an urban area surrounded by rural settings where there is a need to provide quality nursing education from a research university to registered nurses (RNs) at the baccalaureate and master's levels. Faculty who were interested in using technology initiated use of videoconferencing as a viable mechanism to reduce geographic barriers to nursing education. These efforts were supported by federally funded grants that complimented Healthy People 2000/2010 initiatives (U.S. Department of Health and Human Services, 1990, 2000). Using the broad goals outlined in Healthy People 2000/2010, several advanced practice training grants were funded at UB. The foci of each grant recognized the need to reduce health disparities and to narrow the health care provider gap between the total populations living in identified Health Professional Shortage Areas (HPSAs) in western New York State (Brewer & Kovner, 1999; Western New York [WNY] Rural Area Health Education Center [AHEC], 1999). The use of real-time videoconferencing initiatives extends the UB School of Nursing to the rural areas of western New York State. This increases opportunities for advanced practice education, addressing issues of nursing image and the nursing shortage, recruitment of minorities, and education of culturally competent nurses.
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These funded grant initiatives using videoconferencing provided access to educational opportunities at any time and place for targeted populations of students in rural and urban areas. The use of real-time videoconferencing affords the students exposure to potential telehealth technology. The challenge becomes, then, for nurse educators to drive the use of videoconferencing in a manner that is appropriate for teaching health care to students. The videoconferencing technology becomes the delivery platform for educators, which leverages the capabilities of the technology to achieve selected student outcomes. Videoconferencing is the use of two-way audio and video communication devices that allow interaction between students and faculty via phone lines, integrated service digital networks (ISDN), Digital Subscriber Lines (DSL), or Internet connections.
LITERATURE REVIEW Innovation in communication technology from the telephone to television, cable and fiber optic, to satellite, wireless and Internet modalities are encouraging members of the health professions to identify the potential benefits of videoconferencing as a mechanism to extend access to care for consumers as well as education for learners and professionals. Barrett and Brecht (1998) described three generations of telemedicine (telehealth) that illustrate the progressive use and inclusion of videoconferencing capacity as a mechanism to provide health care any time and any place. This framework is used to outline the historical review of the literature. Clinical care and feasibility studies were the focus of the first generation. From the late 1960s to the early 1980s, many successful telemedicine sites operated using early interactive video systems based on analog television. When federal funding for these demonstration projects was cut, one factor stood out—the use of real-time videoconferencing technology extended scarce health care resources any time and any place (Barrett & Brecht, 1998). The second generation was affected most profoundly by the digital revolution. Digitization of computer components, smaller and faster desktop computers, compression technology, the adoption of wide area networks (WANs), the increased speed of transmission, clarity of the audio and visual presentation of information, and a decrease in the cost
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of equipment are well documented (Sackett & Erdley, 2002). Two other significant factors also impacted the extension of and provision of health care, the rise of managed care organizations and the use of the Internet. Telehealth initiatives were demonstrated as sustainable in the health care arenas of medicine, nursing, home health, and a myriad of other health related disciplines (Barrett & Brecht, 1998). The American Association of Colleges of Nursing (AACN) also recognized the importance of expanding access to nursing education beyond traditional boundaries as evidenced by a "white paper" titled "Distance Technology in Nursing Education" (AACN, 1999), which supported the use of technology to improve access to and the quality of nursing education. Distance education can provide access to nursing education for nursing students in remote sites whether nationally or internationally. Examples of distance learning education in nursing include: (a) programs at The University of Texas Medical Branch in which the conceptual model includes partnerships with the rural host organization, the sending site, and the community (Hartshorn, 1998); (b) Ball State University where the BSN Completion Program used interactive television to reach students in multiple locations (Hanson, Brigham, & Carlton, 1998); and (c) UB initiatives (Sackett, Dickerson, McCartney, & Erdley, 2001) to name a few. In the mid-1990s, advances in technology and the need to meet expanding health care needs encouraged a resurgence of distance learning technologies for educational purposes. The current tertiary stage is focused on the evaluation of teleconferencing technology. Areas identified for evaluation include, but are not limited to: (a) the cost of using advanced technology applications; (b) the need for standards; (c) issues of multistate licensure; (d) liability; (e) compliance with Health Insurance Portability and Accountability Act (HIPAA) requirements that include issues of confidentiality, security, transmission, and sharing of sensitive health care information; (f) reimbursement; (g) the creation of a new field of inquiry focused on health care informatics; (h) the use of electronic information databases; (i) the need for community-based practice guidelines; (j) the use of an electronic patient medical record; (k) videostreaming; and (1) the use of the Internet and intranets to deliver patient data, images, and real-time videoconferencing any time and any place. It becomes readily apparent that real-time video transmission has a tremendous impact on health care, business, and education (Barrett & Brecht, 1998; Dixon, 2000;
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Elfrink, 2001; Roine, Ohinmaa, & Hailey, 2001; Schlachta-Fairchild, 2001). In a glimpse at the future, Elfrink (2001) linked information about the Health Care Infocosm (HCI) identified by the Anderson Consulting Group in 1996, and forecasts made by the Robert Wood Johnson Foundation Institute of the Future in 1999. What becomes readily apparent is that all facets of information technology will change the health care delivery system, the business of health care, and the delivery of distance education. The use of videoconferencing technology is one example that can be used to enhance nursing education by linking faculty, students, preceptors, and patients to each other and to health care information. Schlachta-Fairchild (2001) corroborated Elfrink's perspective on the use of videoconferencing. This face-to-face interaction replicates face-toface interactions in a traditional educational experience. Essentially, the technology becomes ubiquitous providing students, consumers, preceptors, faculty, and other health care providers with practical, clinically focused learning experiences.
PLANNING AND IMPLEMENTATION Planning for videoconferencing initiatives includes identifying educational needs, developing partnerships, and establishing technical interfaces. Three examples will be used to illustrate the implementation of videoconferencing in nursing education.
Identify Educational Needs Faculty recognized the necessity for expanding the educational program to reach rural settings based on needs assessments produced by local WNY rural AHEC studies. Faculty wrote grants to support the initial cost outlay for technical equipment.
Develop Partnerships It was essential for faculty to develop partnerships with rural community college satellite sites and medical facilities. The university and remote
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sites negotiated a contract that required an on-site liaison person to coordinate library and technical equipment, and a technical person to set up and maintain the equipment. The contract also included the need for recruitment of cohorts of students in sufficient numbers to balance financial considerations.
Establish Technical Interfaces The systems for videoconferencing used an integrated service digital network (ISDN) connection. Each ISDN line consists of two D channels capable of 64kbps transmission speeds, which combined make our connection rate 128kbps. The ISDN connection time was under one minute. Use of identical teleconferencing systems at the remote site enhanced connectivity. Videoconferencing activities were conducted using a WinTel Desktop Videoconferencing system utilizing Zydacron Z-350 CODEC technology, which facilitated real-time audio and video transmission between an off-site facility and the school of nursing's teleconferencing center. Both test sites were equipped with identical videoconferencing technology and staff familiar with using this modality for educational purposes.
Three Videoconferencing Examples RN/BS Cohort A series of classes were held remotely for RN students in the BS program using videoconferencing. At one point the videoconferencing technology was used to conduct a mock trial debate (Dickerson, Jones, & Sackett, 2002). Students debated the question of the liability of an insurance company in the death of a patient when treatment was denied. Students in Jamestown and Buffalo, New York read an article in the paper on this case and were encouraged to access the actual legal briefs. Students in Jamestown represented the insurance company (defendant) while the Buffalo students represented the family (plaintiff). Each group had approximately 20 minutes for presenting their side over the span of 3 hours. The presentation was conducted using questions, answers, and rebuttals from both sides.
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The excitement of the mock trial format sparked student creativity and excitement. It increased the opportunities for socialization between two groups of students that would not normally have occurred without the technology. Master's Student Cohort Videoconferencing technology was used to conduct clinical evaluations of Family Nurse Practitioner (FNP) students in an emergency department (ED) urgent care setting to effectively replace on-site faculty clinical evaluations (Sackett, Campbell-Heider, Donahue, Woodard, & Ellis, 1999). An examination room in the ED was set up for patient assessments by students with an ED-based preceptor and remote UB nursing faculty via a videoconferencing unit. The unit included a mobile cart, camera, microphone, computer, and monitor connected to an ISDN line (Figure 15.1). The technical interfaces (connectivity, audio, and visual) with the clinical site posed a few problems that were resolved by faculty and technicians. The effectiveness of videoconferencing to evaluate a student's clinical performance in remote sites, similar to the evaluation of students on site, is most related to the quality of the interpersonal interface. The phrase "interpersonal interface," in this instance, means the ability of all the members (student, preceptor, remote faculty, and patient) to actively communicate. In addition, using technology for clinical evaluation increases the need for sensitive human interactions, both verbal and nonverbal, which can illuminate rather than diminish the role modeling of professional behaviors with patients. Videoconferencing of student clinical evaluations offered a viable mechanism to reduce geographic barriers to clinical evaluation and also offered increased opportunities for collaboration between the university-based FNP faculty and the clinical preceptors. Buffalo-Tortola
Cohort
As part of a distance RN/BS program, a cross-cultural videoconference debate was used to bring 63 Buffalo, New York baccalaureate nursing students and 16 Tortola, British Virgin Islands students together for exposure to cross cultural differences in providing health care. The concepts and principles of health care delivery in a managed care system were taught to two different populations of nursing students using ISDN videoconferencing and Web-based technologies.
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FIGURE 15.1 Videoconferencing unit.
Students debated the question "Should we save this hospital?" based on the novel Code Blue (McDermott, 2000). The novel provided the context for the debate, which was a small, financially stricken rural hospital in the United States. Students recognized cross-cultural differences in values of health care and attitudes toward free market and socialized systems.
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LESSONS LEARNED The use of videoconferencing involves an acknowledgement that technical glitches can and do occur, often in spite of all the advanced planning. Laughter or a humorous quip can often break the tension of dealing with a frustrating situation such as establishing connectivity between the school of nursing teleconferencing center and the off-site facilities. Three examples describe the lessons learned.
RN/BS Cohort The initial challenges of technical glitches were worked out by site-tosite communications. Troubles included maintaining audio and video connections on phone lines. There was a need to have a computer technician on site at all times to initiate and maintain connections. At one point there was a snow day at the remote site so the learning session was videotaped and sent to the remote site for later viewing. There was a need for technical savvy by faculty in understanding the different dynamics in the classroom. The local students had to deal with the interruptions when technical problems arose such as when the audio or video connections were lost. Faculty became adept at using PowerPoint to project outlines, electronic overhead visualizers, and teaching strategies that promoted interactions such as debates and presentations. A good sense of humor by faculty and students helped alleviate the tensions that occurred by the techno-glitches. Hand signs and signs also assisted when the audio signals failed. Many faculty took time to spend at least one day at the remote site to foster person-to-person contacts that are dampened when interacting via videoconferencing.
Master's Cohort Problems with cross-platform connectivity were addressed by using the Zydacron Z-350 and the consultation room's PicTel Concord System during the FNP clinical evaluation pilot project. During clinical evaluations, audio capture of patients' dialogue proved difficult to accomplish. Patients who told their stories to providers were not "playing to the
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camera" and were frequently difficult to hear and understand. Patients' accents, slang expressions, and level of education, which are factors that interfere with dialogue in any setting, further complicated this situation. Positioning of the microphone in relation to the dynamics of the evaluation room also was critical. Placement of the microphone on the examination light immediately over the stretcher was most effective in picking up patients' dialogue. Establishment of camera angles to view physical aspects of examinations also was problematic. The teleconferencing system uses a Sony Pan Tilt and Zoom (PTZ) camera with 12X zoom capabilities allowing remote repositioning through the Z-350 interface. Initially, the videoconferencing technology specialist assumed this role. However, it proved more expedient to allow the faculty observer to control the camera angles (Wetzel, Radtke, & Stern, 1994). Using a moveable cart to allow repositioning of the teleconferencing system as well as the patient examination table also required experimentation to provide the best viewing angle. The teleconferencing system was moved to the left of the examiner and the camera elevated to a higher plane, facilitating unobstructed faculty viewing of the camera transmission. Figures 15.1 and 15.2 demonstrate the videoconferencing unit and positioning of the gurney. The interpersonal interface also presented challenges such as students' increased anxiety from being "on camera." These apprehensions quickly subsided, though, as the focus became the clinical experience of examining the patient. The effectiveness of videoconferencing to enhance students' educational experiences in remote sites is mostly related to the quality of the interpersonal interface. The technical barriers to proper audio and visual reception are easier to solve than factors that inhibit interactions among students, patients, and faculty. However, technical factors can distract observers and clinicians from their focus.
Buffalo-T ortola Cohort Facilitating domestic and international connections requires different considerations such as crossing time zones, cost, compatibility, availability, access to equipment, and the need for consistent electrical power. These barriers were overcome by scheduling the debate at a time when both parties could participate. While the connections were somewhat
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FIGURE 15.2 Positioning of gurney and videoconferencing unit.
different, this was overcome by one of the local businesses that had the only ISDN line on the island and was willing to allow us to use it for this occasion. The videoconferencing was accomplished at the local business site, which could accommodate the number of students at a reduced cost since the equipment was already available. The UB videoconferencing crew "dialed up" the business and made a 128kbps connection to a Pic-Tel Live PC based system for transmission. The transmission lasted three hours. There was only one Pic-Tel Live PC camera system on Tortola, British Virgin Islands. Students stood in front of the PC and presented their facts to the UB students. The UB
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students and faculty could view everything at one time, contrary to the students in Tortola who could only see portions of the UB students' presentations. Both sides, however, could hear each other clearly. The connection failed one time midway through the presentation but was reestablished at the first dial-up attempt. Audio and video transmissions, considering the speed of connection (128kbps), were acceptable for this type of demonstration. The approximate cost for this endeavor was 28 cents/minute plus international long-distance charges. University of Buffalo absorbed the cost for this transmission, while the business in Tortola provided the room gratis. The ability to ask questions of one another, which was made possible by videoconferencing, stimulated some interesting interactions among the students. At one point, a student from Tortola stepped in front of the camera, straightened her shoulders, pulled her suit jacket closed, and said, "If you would so kindly tell us how you might provide care if the hospital were closed?" These pointed questions focused both groups of students on the health care delivery issues. Students truly enjoyed the interactions.
IMPLICATIONS FOR NURSE EDUCATORS It is essential for today's professionals to connect across cultural divides and develop networking communities that empower nurses and their patients. This can be facilitated through applications of technology. Although technology can "stretch" faculty and institutional resources, it can link groups of students and faculty in distant places and facilitate active engagement of culturally different groups of nursing students in learning. Using videoconferencing allows interaction in a synchronous modality, where "real-time" communication can occur. The visualization via videoconferencing provides the addition of nonverbal cues that are important in communication processes. Faculty and students gain an understanding of the issues and challenges presented by the technology.
SUGGESTIONS FOR USING VIDEOCONFERENCING IN NURSING EDUCATION The first step in planning to use videoconferencing for distance education is to define the needs of the community, outline existing resources,
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and plan with remote partners to meet these needs. Expected expenses and revenues to support the development or use of existing infrastructures should be outlined early on. Grant money is useful to support the hiring of technical personnel who can set up and maintain the videoconferencing system. The administrators of the school of nursing should negotiate with the remote partners for sufficient cohorts of students to maintain financial viability. As part of the planning process, there also is a need to consider ownership issues of content developed by faculty, as well as consent for videotaping of others. The HIPAA regulations need to be met in patient care situations. Technical support is essential during videoconference sessions, and the support person should assist faculty during switching from various mediums to avoid the "talking head." Use of overheads, video clips, and interaction with students require changing camera angles and microphones. For clinical evaluations completed with videoconferencing, faculty should control camera angles to facilitate observation and interactions with students and patients. Faculty should be trained for camera presence, noting how various clothing, eye contact, voice, and body language, impact projection of a professional image. The symbolism of professional clothing, such as white lab coats, is a well known factor in establishing patient-provider relationships (Campbell-Heider & Hart, 1993). Visual materials need to be varied and with sufficient font for clarity during transmission. Examples include using shades of blue for the background of a PowerPoint presentation; the inclusion of no more than six lines of text using a font that is easily readable; judicious use of sound, music, and animation; and use of video clips and videostreaming that can hold students' interest. One of the problems faculty and students encounter with videoconferencing is the lack of physical presence of the teacher at the remote sites (Diekelmann, 2000). Strategies for dealing with this are: • Begin the relationships with a personal visit to the remote site, which allows for face-to-face introductions by faculty, students, and others involved in the videoconferencing. • Maintain frequent interactions with both sites (remote and local) by asking questions and leaving time for discussions. • Select a faculty liaison person at the remote site who has personal contact with students and contact with the faculty in the school
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of nursing. Frequent interactions between faculty (remote and local) assure that students are on track. • Be available by e-mail or phone for student advisement and questions. Videoconferencing requires faculty who are flexible and willing to adapt creatively to challenges such as down phone lines, lack of audio transmission, or snowstorms closing remote sites. At times creating a videotape to be shown later or using hand signals or signs to communicate will allow the class to "go on." A good sense of humor can help relieve tension. There is a need for continued evaluation of this teaching strategy since there are few research studies that indicate how students learn best with videoconferencing. This is readily apparent when one considers the variety of learning styles particular to students at all levels of undergraduate and graduate education. Likewise, issues of confidentiality and security of patient information for clinical evaluation of/by students, patients and preceptors must be evaluated in light of potentially sensitive transmission of health information. This is especially relevant with the advent of the HIPAA regulations. Videoconferencing also requires cultural sensitivity to interpersonal issues and differences in communication styles, verbal and nonverbal cues, and verbiage. This is particularly important when using videoconferencing with students from other countries and cultural groups.
SUMMARY This chapter described the inclusion of videoconferencing technology in teaching at the UB School of Nursing. Technology compliments an arsenal of teaching-learning approaches for both faculty and students. Videoconferencing interaction replicates face-to-face interactions in a traditional learning experience. It enhances clinical and nonclinical nursing education by linking faculty, students, preceptors, and patients to each other and to health care information potentially at any time and place in a seamless fashion.
REFERENCES American Association of Colleges of Nursing. (1999). White paper: Distance technology in nursing education. Washington, DC: Author.
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Barrett, J., & Brecht, R. (1998). Historical context of telemedicine. In S. Viegas & K. Dunn (Eds.), Telemedicine: Practicing in the information age (pp. 9-15). Philadelphia: Lippincott-Raven. Brewer, C., & Kovner, C. (1999). Supply and demand for registered nurses in New York State. Latham, NY: New York State Nurses Association. Campbell-Heider, N., & Hart, C. (1993). Updating the nurses bedside manner. Image: Journal of Nursing Scholarship, 25, 133-139. Dixon, R. (2000). Internet videoconferencing: Coming to your campus soon. EDL7CAUSE Quarterly, Number 4, 22-27. Diekelmann, N. (2000). Technology-based education: Distance education and the absence of physical presence. Journal of Nursing Education, 39, 51-52. Dickerson, S., Jones, J., & Sackett, K. (2002). Bang the gavel: Using mock trial debate to teach health care delivery perspectives. Nurse Educator, 27. Elfrink, V. (2001). A look to the future: How emerging information technology will impact operations and practice. Home Healthcare Nurse, 19, 751-757. Hanson, A., Brigham, C., & Carlton, K. (1998). Using computer technology to provide distance education. In M. Armstrong (Ed.), Telecommunications for health professionals: Providing successful distance education and telehealth (pp. 91-106). New York: Springer Publishing Co. Hartshorn,]. (1998). Distance education in nursing: Strategies, successes and challenges. In S. Viegas & K. Dunn (Eds.), Telemedicine: Practicing in the information age. Philadelphia, PA: Lippincott-Raven. McDermott, R. (2000). Code Blue. Syracuse, UT: Traemus Books. Roine, R., Ohinmaa, A., & Hailey, D. (2001). Assessing telemedicine: A systematic review of the literature. Canadian Medical Association Journal, 165, 765-771. Sackett, K., Campbell-Heider, N., Donahue, R., Woodard, M., & Ellis, D. (1999). The use of synchronous video conferencing technology to conduct a clinical evaluation of a family nurse practitioner student. Retrieved March 19, 2002, from SyllabusWeb web site: www.syllabus.com/syll99_proceedings Sackett, K., Dickerson, S., McCartney, P., & Erdley, W. (2001, Spring/Summer). Interactive connections: Technologies used in nursing education. The Journal of the New York State Nurses Association, 32(1), 7-10. Sackett, K., & Erdley, S. (2002). The history of health care informatics. In S. Englebardt & R. Nelson (Eds.), Health care informatics: An interdisciplinary approach. St. Louis: Mosby. Schlachta-Fairchild, L. (2001). Telehealth: A new venue for health care delivery. Seminars in Oncology Nursing, 17(1), 34-40. U.S. Department of Health and Human Services. (1990). Healthy People 2000 national health promotion and disease prevention objectives. Washington, DC: U.S. Government Printing Office. U.S. Department of Health and Human Services. (2000). Tracking Healthy People 2010. Washington, DC: U.S. Government Printing Office.
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Western New York Rural Area Health Education Center (AHEC). (1999). Community assessment: Understanding the health and health care training needs of our local communities. Batavia, NY: Author. Wetzel, C. D., Radtke, P. H., & Stern, H. W. (1994). Instructional effectiveness of video media. Hillsdale, NJ: Lawrence Erlbaum.
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Chapter 16 Distance Technology in Nursing Education on a Taxpayer's Budget: Lessons Learned from 22 Years of Experience Pamela E. Hugie
he American Association of Colleges of Nursing (AACN) issued a white paper entitled "Distance Technology in Nursing Education" (AACN, 1999). Weber State University began delivering distance education more than 22 years ago. Since that time WSU has made significant progress toward the National Advisory Council on Nurse Education and Practice's (1996) goal of using technology to improve access to education. Because we are pioneers in distance education, we have negotiated many challenges over the years. Perhaps the most significant challenge is that WSU is a state-sponsored school, with no additional funding for the distance education (DE) program in nursing since 1989. As a statesponsored school, the mandate of meeting the needs of the state is paramount, and budgetary constraints are a fact of life. This chapter addresses ways that WSU met the recommendations of the white paper while also remaining true to the needs of the state and fiscally sound. The chapter also includes recommendations, based on lessons learned, for nurse educators who are interested in initiating or expanding DE programs in their institutions.
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NEEDS OF THE STATE As a state-sponsored school, with funding primarily from taxpayers, the nursing program must meet the needs of the state. These needs are to: 297
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(a) prepare more qualified registered nurses (RNs) statewide, (b) increase the number of nurses prepared and willing to serve in rural areas of the state, and (c) use funds wisely in a fiscally labile environment. Utah is experiencing a nursing shortage as it has for the last 30 years. Currently, there is a 20% vacancy rate in nursing positions statewide. Given the low cost of living, Utah has lower nursing salaries compared with other states. Nurses from outside the state are not drawn to work in Utah, and many nurses educated in Utah migrate to other states because of salary and other reasons. Therefore, the need for qualified RNs in Utah is already great and is anticipated to get worse. Although WSU has 3 to 4 applicants for each available student opening on the main campus, and 2 to 3 applicants for each available opening on the cooperative campuses in Logan and Cedar City, Utah, we cannot increase our student enrollment due to funding restrictions. Funding is not available for increasing faculty to support higher student enrollment. Increasing main campus student admissions also is not an option because of the limited availability of clinical placements in acute care facilities. Therefore, we continue to turn away qualified students who would make good nurses, creating an ethical dilemma given the current nursing shortage. The rural areas of the state are particularly affected by the nursing shortage. The majority of Utah's population lives along the Wasatch Front Corridor between Ogden to the north and Provo to the south. Five state-sponsored nursing programs in addition to WSU are situated along this corridor. The implication of this geographic configuration is that rural hospitals must draw nurses educated in urban areas to their settings to work. Distance education offers a way of preparing health professionals who have no access to higher education where they live. When we started our distance nursing education program, there was no other institution providing education for nurses outside of the Wasatch Front corridor. Students who wanted to be nurses had to leave home to complete that education. Our experience indicates that when students must relocate to the Wasatch Front for nursing education, and are educated in tertiary and higher level facilities, the likelihood of their returning to their rural settings to practice is small. Therefore, educating students where they live and work is important. Distance education meets the needs of adult learners in rural areas, enabling them to stay in their own communities and maintain family relationships while obtaining their nursing degree.
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Distance education also meets the needs of generation-X learners in the rural areas more readily than traditional instructional methods. These learners are technologically literate, independent problem solvers, and self-starters (Ochs, 2002), all of which are important in distance learning. Generation-X learners also are focused on their individual learning needs and goals, and they expect meaningful assignments and learning experiences. We have found that the learning needs of Generation-X and other students are met readily through DE. In terms of funding, DE at WSU has always required resourcefulness. Considering the current economic status of most state-sponsored institutions, it is unlikely that funding will be available to hire more faculty to increase student admissions. In our DE program, we rely heavily on the use of on-site adjunct faculty. Adjunct faculty spare the program the cost of fringe benefits and provide good return for the financial investment. Additionally, some rural areas severely affected by the nursing shortage formed a consortium and offered to pay a portion of the program's expenses if our DE program was made available to students in their immediate area. These types of partnerships have enhanced our ability to meet the health care needs of rural communities. Through the DE nursing program, WSU has successfully met the challenge of remaining fiscally viable while preparing nurses for practice in rural areas. Distance learning provides the opportunity for students to study and to work after graduation in their rural settings.
NURSING PROGRAM Weber State University is a 1 + 1 + 2-year nursing program with multiple entry and exit options. On completion of the first year, students are eligible to take the Licensed Practical Nurse (LPN) board examination and receive an Institutional Certificate. On completion of the second year, students can take the National Council of Licensing Examination for RNs and receive either an Associate of Applied Science or an Associate of Science degree, depending on the general education requirements completed in the program. At the end of the fourth year, students receive a bachelor's of science degree in nursing. This "stepladder" approach is conducive to DE. Students who have already completed LPN training at an accredited college or technical school and are licensed as LPNs can enter the second year of the nursing
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program to complete an associate degree (AD). Similarly, RNs who are graduates of an accredited AD program can complete the last two years of the WSU program and receive a baccalaureate degree. Given the need for baccalaureate prepared nurses, we typically offer both years of the program at a specific site so RNs can complete their bachelor's degree. If there is enough interest, we also offer the second year of the program so LPNs can progress to the RN level. Once a distance site has been adequately prepared with RNs, assessment of the area is completed to determine need and interest for the final two years of the program.
DELIVERY OF THEORY COURSES AT DISTANCE Since 1998, theory courses have been delivered online to students using the Internet (Rosenlund, Damask-Bembenek, Hugie, & Matsumura, 1999). This means that students with Internet access in their home can "log on" any time to complete their nursing courses. They can submit assignments any time, which are then saved in a designated file (that is dated and timed) for faculty to evaluate. With improved Internet service to all parts of the country, even rural Utah, increased speed of delivery, and the prevalence of personal computers, delivery of nursing theory courses to distant sites has improved dramatically over the years. Students who are accepted into the university and nursing program and are registered for classes, with their tuition paid, have access to these courses from the first day of the semester. Each course includes a specific schedule so students can allocate their time; a calendar with deadlines; reference sources (printed, online, and library); assignments (individual and group); grading criteria; and instructor expectations. Some instructors require proctored tests, while others use nonproctored testing. Faculty also use evaluation methods other than testing.
DELIVERY OF CLINICAL COURSES AT A DISTANCE Clinical courses are the most critical component of any nursing program. From the inception of our DE program, we have been committed to obtaining quality clinical opportunities for distance students that are as close to home as possible. In most cases, local facilities are used for clinical education during the first two years of the program.
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Clinical course syllabi are available online to the students enrolled in the course. These syllabi explain the requirements for completion of the clinical course, direct students to their clinical instructor, and identify sites where clinical experiences will be completed. Skills lists, explaining specific skill requirements for the clinical course, and related references are available online. The clinical evaluation form that is used to evaluate student performance is available for students to print off and take to the clinical setting. Written clinical assignments also are listed, with deadlines, criteria for grading, and reference sources. Grading criteria for the course are carefully explained. In cases where an adequate clinical placement is not available locally, consolidated clinical experiences are scheduled for the students at another location in an effort to minimize expense, travel, and time away from home. One example of a consolidated clinical experience is in the mental health nursing course, taken in the second year of the program. Inpatient psychiatric units are sometimes not available in rural areas, and mental health patients with acute problems are often in facilities along the Wasatch Front. To provide experience in caring for these patients, students have a 1-week clinical practicum at an inpatient psychiatric setting. Students are notified at the beginning of the semester of the dates they are scheduled for this consolidated clinical practicum. They can then arrange babysitters, get time off from work, and drive in carpools to the clinical site. Students spend five consecutive 8-, 10-, or 12-hour days in the clinical setting and return home. If the consolidated clinical practicum is completed after students have learned most of the theory in the course, they are well prepared for it. Clinical instructors are adjunct faculty who reside in or close to the rural areas where the students are located. Frequently they are parttime employees of the local facilities. Clinical instructors assess the clinical agencies, meet with students to discuss scheduling needs, plan clinical experiences and times in the setting, teach students in the practice setting, proctor clinical hours, and conduct post-conferences for assessment, evaluation, and sharing. During the first two years of the program, students are taught by the clinical instructor, who is physically present during the experience. In some specialty courses, students are informed of the number of hours required in the clinical setting to meet the objectives, and they can "sign up" for those hours. This process provides flexibility for students. Clinical instructors are interviewed, hired, and trained by WSU's distance program administrators. The instructors may have part of their
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salaries paid by the community or facility in a collaborative effort to support the outreach program in meeting their nursing needs. Quality clinical instruction is a key factor to the success of the DE program. Students interact in the clinical setting with the instructor, model the instructor's behaviors, and frequently clarify confusing points in theory with this instructor. It has been our experience that the quality of the clinical instructor can "make or break" the quality of the outreach program. Clinical nursing faculty act as liaisons to connect students with meaningful and diverse clinical experiences (DeBorough, 2001). DELIVERY OF TESTING AT A DISTANCE Proctored tests are offered on the Internet during specified time frames, usually over a one- to 3-day period, at sites where there is an established testing center and proctors. Generally these sites are close to the clinical facilities so that students can complete the examination prior to or immediately following clinical practice, thereby decreasing travel time. Nonproctored tests are available to the student online 24 hours a day, seven days a week, until the deadline is reached. These tests are usually written at the higher cognitive levels of Bloom's taxonomy, requiring application of concepts and analytical thinking. Each student receives a password when prerequisite work has been completed, which then allows them access to the examination at a specific site or at any computer. CURRICULUM PATTERN FOR WEBER STATE UNIVERSITY DISTANCE EDUCATION The curriculum pattern for the DE program at WSU is identical in content to the on-campus program. Occasionally the pattern is changed to accommodate differences in the availability of support courses and general education courses at specific sites. Many of these courses are offered for distance education by WSU. The same criteria and expectations are held for distance learners as for on-campus students. All online courses are equivalent to face-to-face on-campus courses in objectives, content, and expectations. When course or curriculum changes are made in the on-campus program, the same changes are made in the online courses.
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EVALUATION OF DISTANCE NURSING EDUCATION PROGRAM Evaluation of DE is an important part of the WSU Nursing Program. Students evaluate all courses, all instructors, all facilities where they had clinical experiences, and the process of online learning. Faculty evaluate students, clinical facilities, and the process of delivery of DE. Other data such as licensure examination results also are used in the evaluation of the program.
Student Evaluation Student evaluations of online theory courses are consistently positive and comparable to face-to-face courses (WSU, 2001). Student evaluations of clinical experiences also are positive in both face-to-face and distance clinical courses. However, students at a distance often have more favorable evaluation comments about their clinical instructors. Although most clinical facilities are evaluated positively by students, the evaluations of agencies in the distance education sites are frequently rated higher than those on the crowded Wasatch Front. In the evaluations, students identify many advantages of online distance education. These include increased: • • • • •
Accessibility Student-instructor interaction Student-centered learning opportunities Individual feedback Student-student interaction.
These advantages are consistent with other studies of online education (Andrusyszn, Craig, & Humbert, 2001; Rushlow, 1999; Thiele, Allen, & Stucky, 1999). Distance education is becoming so desirable that requests are increasing from on-campus students for online nursing courses. To meet the needs of rural communities, the nursing program has mandated who is eligible to enroll in the online courses. If this mandate were not established, many on-campus students would take the online courses, and they would be unavailable for the rural students the program is
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attempting to educate. However, this year some online courses are offered for students in the on-campus program in an attempt to meet their requests.
FACULTY EXPERIENCE WITH DISTANCE EDUCATION Faculty teaching in online courses were initially self-selected. Interested faculty adapted their courses for online delivery. One notable exception was a faculty member who was adamant in her beliefs that nursing could not be taught online; so she set out to prove it. She carefully prepared an online course on basic pharmacology. She taught one group of students in the traditional face-to-face method and one group of students online. She administered the same tests to both groups of students. She was quick to report that on the first test the traditional students scored higher than the online students. However, on the next examination the scores of the two groups were almost identical. When the results of the third test were examined, the online group scored higher than the traditional group. The faculty member recalculated the test scores but was unable to discount the fact that the online delivery of content was as good as the traditional course. This person has become a strong advocate for DE ever since. As DE courses have proliferated, other faculty have become involved in online teaching. Once technological barriers are overcome, faculty consistently evaluate DE positively.
OTHER EVALUATION DATA The results of licensure examinations also are compared regularly between graduates of the on-campus and DE programs. While state board examination pass rates for the WSU on-campus graduates remain consistently high (96.4% on the NCLEX-PN and 88.4% on the NCLEX-RN), pass rates for the distance students are also high (95% on the NCLEXPN and 88% on the NCLEX-RN) (Utah State Board of Nursing, 2001). These findings are consistent with the literature that indicates there is no significant difference in learning outcomes of students taught by traditional classroom methods versus DE methods (Russell, 1998). In addition to state board pass rates, anecdotal evidence increases our confidence in the benefits of DE in nursing. A hospital in Richfield,
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Utah reported that 85% of their nursing staff were graduates of the WSU distance learning program in that area. The hospital also reported that because of WSU's DE program, the hospital has been somewhat "insulated" from the woes of the nursing shortage (Willardson, 2002). This is but one of many such testimonies that tell us that the program is meeting the needs of the state.
APPLYING THE LESSONS LEARNED FROM WEBER STATE UNIVERSITY'S DISTANCE EDUCATION PROGRAM In this time of limited funding for nursing education, it behooves every faculty and program to reassess its values and goals. State-sponsored schools must balance the expectations and goals of the profession with the needs of the state they serve. Challenges such as these present educators with an opportunity to look beyond their ivory towers to find new ways to deliver educational services. Like programs across the country, nursing programs that seek to meet the needs of rural populations should consider online nursing education. In today's world, nurses must possess at least some computer literacy to practice in most settings. Given this context, nurse educators are doing students a disservice by not using technology to enhance their educational process. If your faculty is considering incorporating distance technology in their program, keep in mind the most important lesson we learned: there is no substitute for good teaching. "Anybody has the potential to teach well or poorly in any medium. Knowing and honoring one's students and their desires or needs, and having invested the time to master the instructional material and the means of instruction are still the best guarantors of quality instruction . . . and that was true when people were scribbling in the dirt with a mastodon bone around the fire" (Rushlow, 1999). Good teachers do not need a "crash course" in online education to be effective. They can start by incorporating available technology into their traditional courses, for example, using e-mail to students to clarify difficult concepts, developing Web pages for their courses with links to Internet resources, and giving one or more examinations online. While there are many Web sites for student learning, students need to be
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taught how to evaluate the sites and the information provided. The teacher can experiment with virtual flower bouquets for class rewards, virtual vacations for class breaks, and others. Listservs are beneficial if used correctly; students can subscribe to a listserv and participate in the discussion. Although the DE program at WSU started with the entire program being offered at a distance, the technology of today allows for a more gradual integration of DE into the curriculum. Programs might consider offering one course in an online format. Faculty and students can then assess the outcomes and whether more offerings are feasible. Schools of nursing experiencing decreased enrollment might develop an online course for high school students on opportunities in nursing. SUMMARY This chapter discussed ways that the WSU nursing program addressed the current nursing shortage, difficulties in meeting the need for nurses in rural areas, and current fiscal restraints. However, a 22-year history of success does not grant the option of remaining stagnant in nursing education. Indeed, it mandates that the program continue to be innovative and assume a leadership role in meeting the changing needs of the health care environment and the state. Rural applied technology centers in Utah have begun to offer practical nurse programs. We anticipate a decreased need for the first year of the WSU distance program. As more associate degree programs become available in the rural areas of the state, there will be a decreased need for the second year of the program. With these changes, it is anticipated that more funds and resources will be available to use in the third and fourth years of the program. More emphasis can be placed on baccalaureate level preparation. The AACN white paper recommends increasing nurses' access to education through technology, creating plans by schools and institutions for implementation of new distance education programs, and using technology to promote quality nursing education through collaboration (AACN, 1999, p. 7). We have lived that plan for 22 years and find it rewarding and beneficial to all involved. REFERENCES American Association of Colleges of Nursing. (1999). AACN white paper: Distance technology in nursing education. Retrieved January 31, 2002, from http:// www.aacn.nche.edu/Publications/positions/whitepaper.htm
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Andrusyszn, M., Craig, C. E., & Humbert, J. (2001). Nurse practitioner preferences for distance education methods related to learning styles, course content, and achievement. Journal of Nursing Education, 40, 163-170. DeBorough, G. (2001). Using web technology in a clinical nursing course. Nurse Educator, 26, 227-232. National Advisory Council in Nurse Education and Practice. (1996). Report to the Secretary of the Department of Health and Human Services on the basic registered nurse workforce. Rockville, MD: U.S. Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Professions, Division of Nursing. Ochs, G. (2002, January). Educating today's generation-X. Presentation at Faculty Development Institute, Scottsdale, AZ. Rosenlund, C., Damask-Bembenek, B., Hugie, P., & Matsumura, G. (1999). The development of on-line course for undergraduate nursing education: A faculty perspective. Nursing and Health Care Perspectives, 20, 194-198. Rushlow, K. (1999). Factors that influence student or faculty satisfaction with Internet online courses; Multimedia, motivation, interaction and accessibility. Doctoral Dissertation, Northwestern State University, Natchitoches, LA. Russell, T. L. (1998). The no significant difference phenomenon [Online]. Retrieved January 31, 2002, from http://cuda.teleeducation.nb.ca/nosignificantdifference/ Thiele, J., Allen, C., & Stucky, M. (1999). Effects of web-based instruction on learning behaviors of undergraduate and graduate students. Nursing and Health Care Perspectives, 20, 199-203. Utah State Board of Nursing. (2001, November 21). NCLEX results for Weber State University. Salt Lake City, UT: Department of Commerce, Division of Occupational and Professional Licensing. Weber State University. (2001). Evaluation forms. Unpublished document. Willardson, K. (personal communication, February 27, 2002).
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Chapter 17 Ethics of Web-Based Learning Roy Ann Sherrod and Mitch Shelton
he positive and negative aspects of Web-based courses are becoming more challenging to nurse educators with an increasing number of faculty offering courses through this medium. As institutions struggle to gain their share of students in the competitive market of distance education, they may face ethical issues by requiring faculty to offer courses online. Making courses available on the Web also has required educators to consider a new realm of ethical issues. Many of these ethical issues occur when a faculty member is faced with the decision to offer a course over the Internet as opposed to the traditional classroom setting. Issues related to beneficence, accountability, and responsibility may occur. Because of the limitations in offering Web based courses, there are often trade-offs that faculty must make. These trade-offs can create a whole new set of ethical issues. Efforts to balance or resolve these ethical issues and the nature of Web-based courses may require additional commitments from faculty. Thus, the decision to offer and efforts to improve Web-based courses require careful consideration by faculty. This chapter is a description of ethical issues to be considered when offering Web-based courses. The goal of the chapter is to assist faculty in making more informed choices and exercising more informed options related to Web-based courses in nursing education.
T
ETHICAL ISSUES Faculty There are a number of ethical issues to be addressed by faculty when making the decision to offer a course on the Web. Several ethical theories 309
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may be used to examine faculty-related issues. Ethical theories guide actions and provide an overall framework for ethical decision making (Sullivan & Decker, 2001, p. 72). The theories of utilitarianism and deontology are useful to faculty when considering Web-based courses. Other ethical principles such as distributive justice, beneficence, and fidelity also provide a framework for faculty to consider in relation to teaching on the Web. With regard to utilitarianism, faculty must consider what methodology would offer the greatest good for the greatest number of students (Marquis & Houston, 2000). The fact that placing a course on the Web might make it more accessible to students who cannot travel or take time off from work to attend on-site classes has been well documented (Billings, 2000; Cobb, Billings, Mays, & Canty-Mitchell, 2001; Thede, 1999; Thurmond, 2002). However, using this medium for course delivery also can limit access to students who do not have the technology, and the ethical principle of distributive justice must then be considered. Inherent in this principle of distributive justice is the notion that benefits and burdens should be shared equally regardless of race, socioeconomic status, and similar factors (Sullivan & Decker, 2001). Not everyone can afford a computer and Internet access (Marchessou, 2000; Yeaman, 2000). The cost of the hardware and Internet connection adds to the educational expense for the student. These costs are in addition to tuition that in some institutions is higher for Web-based courses. Another ethical consideration related to the principle of distributive justice is the cost to the university for teaching with technology. Keeping up with technology can be a drain on finances and can affect other programs such as the arts that may not use extensive technology in teaching. Students learn in varying ways, and not every student is computer literate. Many students lack the discipline and initiative required by a Web course. Some students learn best in an environment with face-toface contact with the instructor (Anderson, 2001; Wolfe, 2001). Carr and Bromley (1997) suggested that adequate attention has not been given to how technology affects students' learning, faculty, and the teaching process. Too many Web-based courses mirror the old information transmission method. What is needed goes beyond mastery of basic technology skills by faculty. Teachers developing Web-based courses need to understand that technology is a tool that can offer solutions to some teaching and
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learning problems. Teaching on the Web is more than knowing how to automate past practices; it should be viewed as a means to approach old problems in a new way (Fwlton, 2001; Wolfe, 2001). Consideration of what is best for the greatest number of students is a critical component of that view. Considering the theory of deontology, the faculty member should examine the intent behind the decision to offer the course on the Web. If the basic principles of the intent are good, for example, delivering distance education to students who otherwise could not complete a nursing education program, then the act is deemed good regardless of the outcome such as students not being successful in the course because the medium does not meet their learning needs (Sullivan & Decker, 2001). The ethical principle of beneficence, doing good for others, also is relevant to faculty decisions about offering Web courses. The question for faculty is "for whose benefit will the course be offered?" Are the benefits to the student, such as ease of access, self-paced learning, and flexibility in scheduling, the motivating factors to offer a Web-based course, or is it a belief that a course on the Web requires less time and effort in the delivery of the course content for the faculty (Foshay & Bergeron, 2000; Thurmond, 2002)? Information sharing is not learning, and faculty should ensure that Web courses offer students the opportunity to learn. The accountability for the quality of the course rests with faculty, who are responsible for facilitating the learning outcomes for the student, not merely presenting information (Billings, 2000; Carr & Bromley, 1997). Another ethical principle for faculty to consider is fidelity, which in its most basic form is keeping promises. Through course objectives, faculty communicate to students the knowledge and skills they will attain in the course. When courses are offered on the Web, this same commitment or promise is made to students. The consideration for faculty is whether the objectives can be met by students and facilitated by faculty if the course is delivered on the Web. There is limited literature on the ethical considerations by faculty when deciding to use technology to deliver courses. However, the literature clearly addresses the need to offer quality online courses. Quality is more than placing lecture content on a Web page (Billings, 2000; Carr & Bromley, 1997; Thurmond, 2002). Inherent in this issue of quality is the question of whether the faculty has the skill and resources
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to offer a quality course online. These skills are more than knowing the mechanics of navigating the software such as WebCT or Blackboard. Foshay and Bergeron (2000) noted three required components for effective Internet-based instructional delivery: management of the learning environment, courseware, and groupware. Faculty need skills and resources for managing the learning environment including understanding the curriculum and how the online course fits into the curriculum design, assessing learning needs in an online environment, developing prescriptions for student learning, monitoring student progress, keeping records, and reporting. Courseware is the basic structure of the online system such as Web CT, and groupware refers to options such as e-mail, chat rooms, and threaded discussion groups that create a community of learners.
Students When deciding to offer a course on the Web, faculty should consider the ethical issues related to students and the use of technology. One issue is how students learn about ethical behaviors when it comes to technology. Ethical behaviors traditionally develop from values of various communities such as family, friends, peers, and school. In the traditional classroom setting, faculty and peers provide a major influence. In Web-based courses, students are challenged because they do not have a community in these contexts. Without this framework for ethical decision making, the difficulty of taking account of others is increased, and unethical acts may occur more frequently. Additionally, the autonomy and anonymity of cyberspace may contribute to a lack of accountability among students for their unethical acts in a Webcourse (Bodi, 1998; Napper, 2001). These acts may include violation of Johnson's (1998) three P's of technology ethics: 1. Privacy: "I will protect my privacy and respect the privacy of others." 2. Property: "I will protect my property and respect the property of others." 3. Appropriate use: "I will use technology in constructive ways."
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Violation of the three P's may be a greater possibility in Web-based courses because of the special challenges posed by ethical problems involving computers. Bodi (1998) summarized these challenges as follows: • The speed of communication alters relationships among people because it does not give time to reflect on the possibility or implications of unethical use. • Information in electronic form is more fragile than on paper because it can be changed more easily and is more vulnerable to unauthorized access. • Intellectual property rights, plagiarism, and privacy become issues. • Efforts to protect information integrity, confidentiality, and availability often conflict with the benefits of information sharing. • Means of authorization and authentication are lacking, which expose technology to unethical practice, (p. 2)
Students' understanding of ethical principles needs to be assessed. Access to the institution's technology should not be given unless students have demonstrated knowledge of ethical principles. Faculty should use an honor code and hold the student responsible for its enactment. In addition to the honor code, student education about the ethical use of computers and records of that education should be kept on file (Johnson, 1998). Faculty also should be vigilant about using whatever tracking systems are available to them to detect unethical behaviors, such as plagiarism, ghost test-takers, and similar acts, to ensure that students are following through with the tenets of the honor code. Thus, faculty need to prepare students ethically to take courses on the Web. Johnson (1998) suggested articulating, discussing, reinforcing, and modeling ethical behaviors by faculty. He also suggested displaying lists of acceptable conduct such as the "Ten Commandments of Computer Ethics" (Computer Ethics Institute, 2001). Faculty also may need to learn about strategies for creating an environment that helps students to avoid temptations such as password security and use of proctors, secured computer screens, and similar measures during testing. This preparation also should include a review of the school's policies for copyright infringement, plagiarism, cheating, and other forms of academic misconduct, regardless of the medium for the course, and the consequences for violation of these policies. Unfortunately, some students do not necessarily follow these rules unless they see direct
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implications and meaning in their own life (Brown, 2002). This view can have far-reaching implications for nursing students given that there is a positive correlation between classroom cheating and unethical clinical behaviors (Bodi, 1998; Brown, 2002). This correlation is significant for Web-based courses because the potential for cheating online is increased.
OTHER FACULTY ISSUES Workload and Reward Two other issues for faculty are workload and reward for developing Web-based courses. The concern about the additional time commitment for preparing and teaching online courses has been noted (Aggarwal, 2000; Billings, 2000; Ryan, Hodson Carlton, & Ali, 1999). In a study by Palloff and Pratt (2001), 90% of the faculty reported the need for substantially more preparation time to develop online courses and additional time once the course was offered. Providing timely feedback, fostering a sense of community, and maintaining the integrity of the course also required more time. In that study faculty (88%) indicated that they did not receive any additional compensation or reduced workload for developing and teaching Web-based courses. ScheWeber, Kelly, and Orr (as cited in Robinson & Borkowski, 2000) found that faculty spend 2 1/2 to 3 times more hours developing online courses. The additional time commitment reduces the time available for other activities that may be necessary for promotion, tenure, and merit. Although institutions have a moral responsibility to adequately compensate faculty, most institutions do not have a structure in place that rewards faculty for developing online courses (Brown, 2000; Palloff & Pratt, 2001; Robinson & Borkowski, 2000). There also are differences among faculty as to what are considered adequate rewards. For some faculty, the rewards of offering online courses may be personal and intrinsic, such as the opportunity to use new teaching techniques, provide innovative instruction with the Web, and receive recognition for creativity in teaching. Other faculty, however, may seek monetary rewards. Faculty who are faced with the pressures of promotion and tenure are less likely to spend the time required in redesigning courses for the
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Web if not rewarded for that work (Robinson & Borkowski, 2000). The time difference for development and delivery of online courses should be included as part of the faculty reward system. Scholarship related to teaching online courses can be considered in tenure and promotion decisions. For example, funded projects, peer reviewed articles, and presentations at conferences about online teaching and the outcomes of student learning in Web-based courses should be considered similarly to other research grants and publications in promotion and tenure decisions. Faculty should be cognizant but not fearful of the additional requirements for teaching online courses. The key to resolution of these issues is to negotiate effectively with administration for the rewards prior to developing Web-based courses (Palloff & Pratt, 2001).
Support Although the rewards of developing and offering online courses may be successfully negotiated to the satisfaction of all involved, adequate faculty support is crucial. This support can include internal grants for course development, release time for training and development, reduced teaching loads, and technological resources to support faculty (Brown, 2000; Palloff & Pratt, 2001; Robinson & Borkowski, 2000). Faculty need access to consultants to assist with instructional design and to technical experts who can manage the software and handle the day-today technical issues that may arise. Many institutions have developed resource centers that support faculty in the use of technology (Brown, 2000). Faculty can support each other, and strategies should be developed for gathering them together to share their experiences and innovations. Brown-bag lunches are a good way to do this. One other support strategy is making resource manuals and other literature available on site for faculty (Palloff & Pratt, 2001; Robinson & Borkowski, 2000). Support to evaluate the effectiveness of online courses also should be available (Brown, 2000).
Ownership With the proliferation of online courses, the issue of ownership has become more significant than ever (Billings, 2000). Although rarely a discussion for face-to-face courses, the growing trend is for institutions
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to claim ownership of online courses. Traditionally, with face-to-face courses when faculty leave the institution, they take their lectures and other course materials with them. However, because online courses are housed on a university server, sometimes indefinitely, the course materials are always available for new faculty to use. The issue of ownership is becoming more of an issue because of the potential for profit either to the university or faculty member if the course is offered through some other organization than the university. Some universities are outsourcing the development of courses to content experts and then having their own faculty teach them. This strategy can severely limit the faculty member's academic freedom and use of own expertise in the course (Palloff & Pratt, 2000). Thus, the faculty member should negotiate and clarify ownership issues from the beginning. Clarification of this issue will prevent future conflict for the person who develops the course as well as others who are asked later to teach it. Although faculty may limit the dissemination of their course, as intellectual property, by restricting who has access to it, it is better to address the issue of ownership up front and frankly. PARAMETERS FOR WEB COURSES In addition to consideration of the ethical and other issues previously presented, there is one essential question that any nursing faculty must answer prior to developing and implementing an online course. Should this course be Web-based? This is not an easy question to answer. However, resolution of ethical issues may be complicated if the parameters for Web-based courses are not considered up front. What are the educational parameters for determining the appropriateness of offering a course on the Web? Faculty should answer four questions in making the decision whether to offer a Web-based course: 1. 2. 3. 4.
What What What What
are the objectives of the course? population is the course intended to serve? are the tradeoffs of Web-based courses? faculty training is required?
Course Objectives The goal of any course is to provide the necessary content to students in a manner that facilitates learning. This is a two-part statement asking
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(1) if a Web course will provide the necessary content for meeting the intended objectives, and (2) if the course will provide this content in a manner that will facilitate learning. The first part of the statement is easy to understand. Faculty should assess whether a Web-based course can be designed, using a variety of teaching methods, to provide all of the necessary content for the course objectives. However, the second part of the statement is more complex. Can a Web course provide the appropriate type of learning activities based on the objectives for the course? Although some courses such as nursing research, health care informatics, and pharmacology may be taught easily via the Web, faculty may decide that other courses such as ones with clinical components are better if Web-enhanced or offered in a more traditional format.
Targeted Population What population will be served by the Web-based course? The most likely answer to this question is nontraditional distance education students. However, faculty also should consider if the target population is basic undergraduate students and, if so, what level? Beginning nursing students may have minimal, if any, experience with Web-based learning. Is the population upper-level nursing students? Have they had any prior courses offered by distance education? Although many college students are competent in using the Internet, they may not have experience in completing a course on the Web. Along the same line, is the targeted population adult students who are returning to school? These students may not have the same computer skills or comfort levels as traditional entering freshmen. Introduction of a nursing Web course may be beneficial to these students only after a thorough computer orientation and selected Internet experiences. Where is the targeted population from? Are students in rural or urban settings? If the population is rural, do they have the available resources, for instance, the computer technology and reliable Internet service, to take an online course? A thorough investigation into the targeted population is a must for any faculty developing a Web course.
Trade-Offs Another consideration is what are the trade-offs in offering a Web course, and is the faculty willing to accept them? A review of the advantages and
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disadvantages of online courses is critical. There are several advantages to Web-based courses. The most prominent are rapid transfer of material (Marchessou, 2000), effective and efficient communication of information, student and faculty flexibility, and an expanded access to resources. Economic benefits can include reduced reproduction costs and need for classroom space (Tetiwat & Igbaria, 2000; Thede, 1999). But online courses also have drawbacks. The major disadvantages are the loss of personal contact between faculty and students, cost and complexity of computer equipment for the students and institution, need for technology training and support for faculty, and initial time and effort for course design and implementation. An online course usually means there will be little, if any, face-toface contact between faculty and students (Anderson, 2001; Billings, 2000). Faculty and students who benefit from face-to-face verbal exchange may find an online course cold and uncomfortable as an environment for learning. To compensate for this, online courses can be designed with several other methods for communication between faculty and students such as chat rooms, discussion boards, and videoconferencing, to name a few. In some studies, students have reported that there is an enhanced sense of connectedness to and interaction with the faculty member (Billings, 2000). Faculty should determine if the advantages outweigh the lack of face-to-face contact and if it is an acceptable tradeoff to their teaching style. For students to take an online course, they must purchase or have access to certain equipment. The student's computer must connect to a reliable Internet service provider with adequate bandwidth and have enough memory and processing capability to operate the course software. The larger the bandwidth of the Internet service, the more efficient the transfer of course material will be. Unfortunately, there are still several areas in the country that do not have access to wide bandwidth, and wide bandwidth usually is more expensive (Anderson, 2001; Fwlton, 2001; Thede, 1999). There are two major components to a personal computer that must be considered in designing a Web course: central processing unit (CPU) and random access memory (RAM). A student with a computer with a lower level CPU will be more limited in information processing. Increased RAM in a computer increases the applications that can be run and their speed (Foshay & Bergeron, 2000; Thede, 1999). Faculty then should consider what trade-offs would be necessary in terms of quality
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and complexity to accommodate the needs of the students who have lower level computers. Inherent in this trade-off is whether it is fair to students who could accommodate a higher-level course presentation, but will not have access to such a course because the faculty is trying to accommodate the lowest common denominator.
Faculty Training The design and implementation of a Web-based course requires special technology, training, and support (Carr & Bromley, 1997). There are certain skills that faculty should have to design, implement, and maintain effective online courses. These skills should be a major consideration in deciding if an online course is appropriate for faculty. Does the faculty have the necessary training and time to design and maintain an online course? Are there experienced support personnel to assist in the design and maintenance of an online course? Before any faculty training begins, faculty should examine their beliefs about Web courses. The design and implementation of a Web course will require faculty to examine teaching and the role of faculty from a nontraditional perspective. The initial training should include an in depth discussion of philosophical views about teaching and theoretical frameworks for teaching and learning in Web courses (Billings, 2000; Foshay & Bergeron, 2000). Faculty should be assisted by experts in the field to make the transition from teacher-centered to learner-centered pedagogies required for teaching on the Web (Billings, 2000; Wolfe, 2001). The initial design and implementation of a Web-based course is expensive, labor intensive, and time consuming. Thus, faculty need training in how to develop these courses so they can make the best use of their time and resources. Although faculty should be comfortable with computers, they do not have to be Web designers or computer programmers. For example, integrated e-learning systems such as WebCT and Blackboard are "allin-one" course packages that allow faculty to offer online courses with minimal technological skills and prior training. SUMMARY This chapter provides the educator with some ethical considerations for online courses. Included are several parameters to assist faculty in
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deciding whether to offer a Web-based course and in developing strategies for resolving ethical issues.
REFERENCES Aggarwal, A. (Ed.). (2000). Web-based learning and teaching technologies: Opportunities and challenges. Hershey, PA: Idea Group Publishing. Anderson, T. (2001). The hidden curriculum in distance education: An updated view. Change, 33(6), 29-35. Billings, D. M. (2000). A framework for assessing outcomes and practices in Webbased courses in nursing. Journal of Nursing Education, 39, 60-67. Bodi, S. (1998). Ethics and information technology: Some principles to guide students. The Journal of Academic Librarianship, 24, 459-463. Brown, D. G. (Ed.). (2000). Teaching with technology: Seventy-five professors tell their story. Bolton, MA: Anker Publishing. Brown, D. L. (2002). Cheating must be okay—Everybody does it. Nurse Educator, 27(11), 6-8. Carr, A. A., & Bromley, H. (1997). Technology and change: Pre-service perceptions on agency. Teaching Education, 8, 15-22. Cobb, K., Billings, D. M., Mays, R. M., & Canty-Mitchell, J. (2001). Peer review of teaching in Web-based courses in nursing. Nurse-Educator, 26(6), 274-279. Computer Ethics Institute. (2001). The Ten Commandments of Computer Ethics. Retrieved April 14, 2002, from http://www.cpsr.org/program/ethics/cei.html Foshay, R., & Bergeron, C. (2000). Web-based education: A reality check. Tech Trends, 44(5), 16-19. Fwlton, K. (2001). From promise to practice: Enhancing student Internet learning. Multimedia Schools, 8(2), 16-24. Johnson, D. (1998). Teaching ethical technology behaviors. Book Report, 17(1), 96-99. Marchessou, F. (2000). Some ethical concerns in ed-tech consultancies across borders. Educational Research and Development, 48(4), 110-114. Marquis, B. L., & Houston, C. J. (2000). Leadership roles and management functions in nursing: Theory & application (3rd ed.). Philadelphia: Lippincott. Napper, V. S. (2001). The professional code of ethics: Same principles, new context. Tech Trends, 45(3), 13-14. Palloff, R. M., & Pratt, K. (2001). Lessons from the cyberspace classroom: The realities of online teaching. San Francisco: Jossey-Bass. Robinson, P., & Borkowski, E. Y. (2000). Faculty development for web-based teaching: Weaving pedagogy with skills training. In A. Aggarwal (Ed.), Web-based learning and teaching technologies: Opportunities and challenges (pp. 216-226). Hershey, PA: Idea Group Publishing. Ryan, M., Hodson Carlton, K., <Sr Ali, N. S. (1999). Evaluation of traditional classroom teaching methods versus course delivery via the World Wide Web. Journal of Nursing Education, 38, 1-6.
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Sullivan, E. J., & Decker, P. J. (2001). Effective leadership and management in nursing (5th ed.). Upper Saddle River, NJ: Prentice Hall. Tetiwat, D., & Igbaria, M. (2000). Opportunities in web-based teaching: The future of education. In A. Aggarwal (Ed.), Web-based learning and teaching technologies: Opportunities and challenges (pp. 17-32). Hershey, PA: Idea Group Publishing. Thede, L. Q. (1999). Computers in nursing: Bridges to the future. Philadelphia: Lippincott. Thurmond, V. A. (2002). Considering theory in assessing quality of web-based courses. Nurse Educator, 27, 20-24. Wolfe, C. (2001). Learning and teaching on the World Wide Web. San Diego: Academic Press. Yeaman, A. (2000). Coming of age in cyberspace. Educational Technology Research and Development, 48(4), 102-106.
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Part IV
Innovative Strategies
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Chapter 18 Interdisciplinary Education: Breaking Out of the Silos Denise G. Link
he need for interdisciplinary practice in health care is not a new concept. We have known for some time that patients with complex health care problems require the care of a variety of professionals from different disciplines. In these situations, specialists with different interests and backgrounds are sharing the care of one patient. However, often what individuals and health care institutions label "interdisciplinary" care is really "multidisciplinary" care in which the clinicians involved provide their services to a person in parallel, with little if any communication, shared responsibility, or common goals. This often results in wasted resources, unnecessary delays in care, duplication of services, and confusion on the part of the patient and family. The nurse is the one professional who communicates regularly with the other providers of care and the patient. Nursing has always been the glue that holds the health care team together, taking on the day-today responsibility for the coordination of patient services in acute care and outpatient settings. This chapter describes an interdisciplinary educational program jointly sponsored by a public university and a state Area Health Education Center (AHEC) and how the challenges that inhibit the progress of interdisciplinary education in the health professions were overcome.
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EFFECTIVE INTERDISCIPLINARY PRACTICE True interdisciplinary practice does not just happen. If professionals are to practice in an interdependent manner with mutual respect and 325
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understanding for each other, valuing the contributions of each discipline, students must be taught the principles of interdisciplinary practice. Opportunities to practice the skills required for this type of health care delivery need to be included in their clinical experiences. Programs must provide more than discipline-specific content; they also must include the process of practicing collaboratively with others to meet the needs of the client. This means more than learning how to "deal with" other members of the health care team. Effective interdisciplinary practice requires knowledge about other disciplines and their scopes of practice and roles, organizational and systems theory, and cultural competence, as well as skills in team formation, communication, conflict resolution, negotiation, and group process (Hall & Weaver, 2001). Learning these concepts and skills side by side in one course with members of other disciplines provides opportunities for the students to learn about each other's roles and how to practice interdependently. Students in an interdisciplinary course require the guidance of faculty of experienced professionals who embrace the interdisciplinary model, who have been educated and trained in interdisciplinary education and practice, and who are able to act as facilitators and role models. Health care policy think tanks, commissions, and professional organizations, including nursing, have published numerous position statements in support of interdisciplinary education for the health care professions (American Association of Colleges of Nursing, 1995, 1997, 1999; Pew Health Professions Commission, 1995). Yet, approaches to the education and training of students remain largely discipline-bound (Lowry, Burns, Smith, & Jacobson, 2000) and successful models for this type of professional preparation are lacking.
Responding to a Changing Environment The health care needs of society are becoming more complex, requiring more than one set of skills or knowledge. The expertise that is required to provide safe and effective health care is greater than one person can achieve and maintain at a reasonable level of competence when serving diverse populations with multiple or complicated health problems. In addition, there is pressure from health care insurers, employers, government agencies, and the public to contain health care expenditures at
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the same time that the demand for expensive high-quality, high-tech health care is increasing. Interdisciplinary care is not always needed; patients with simple, straightforward health problems do not need the care of an interdisciplinary team. Interdisciplinary teams are most effective in terms of cost and appropriate use of human and material resources when the required patient care is complex. However, all clinicians must know how to practice and deliver interdisciplinary care when it is appropriate and when the need arises. Educational institutions that prepare the health care workforce are under increasing financial pressure as well. Government funding for education has been on the decline since the 1980s, stimulating administrators in higher education to explore ways to reduce costs while holding the line on tuition increases to keep programs competitive in the education market. Institutions are finding ways to collaborate within and among their organizations to provide quality education at the lowest cost. This includes offering faculty joint appointments in two or more departments or schools, and sharing courses, classroom space, library holdings, computer hardware and software, sites for clinical experiences, and other resources. In traditional education programs, health professions students are taught through use of examples and principles of isolated professional roles rather than cooperative ones (Fulginiti, 1999). If we expect professionals to work interdependently, students should be taught instead how to communicate effectively and practice collaboratively with those from other disciplines as part of their educational preparation (Connelly, 1978). Separate training encourages the members of individual disciplines to hold on to their independence and autonomy, a type of behavior that does not support effective teamwork in the practice setting (Cooper, Carlisle, Gibbs, & Watkins, 2001). A wise person once said "if we continue to do things in the same way, we should not expect different outcomes." If we want our graduates to behave differently, we need to educate them differently.
CHALLENGES TO SUCCESSFUL INTERDISCIPLINARY EDUCATION Challenges to successful interdisciplinary educational programs have remained essentially the same since the first programs came into being
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in the late 1940s (Baldwin, 1997). The existence of different academic calendars and schedules among the participating departments is one of the most frequently cited barriers. Other problems that must be addressed relate to academic standards that can vary significantly among schools within the same institution or education system, grading scales, how different programs calculate credit hours and course credits, and even the wording used in course objectives. Money becomes an issue when deciding how to allocate tuition between programs when students are enrolled in a course that is offered outside their academic home. Inexperience and lack of professional skills in students can prevent them from achieving course outcomes; these factors should be considered and addressed in enrollment criteria and curriculum planning. Preconceived ideas and attitudes among students about what represents appropriate role function for their own and other disciplines can create barriers to both enrollment and to learning once they are in the course. Faculty members are not experienced in teaching in interdisciplinary programs, and they often do not value interdisciplinary learning. Differences in disciplinary cultures and the tendency to view one's profession as separate and distinct from others discourage the participation of clinicians of one discipline in the educational programs of another. Inappropriate formulas to calculate faculty work effort and reward structures that treat the faculty participation in such courses as voluntary deter faculty who may be inclined to participate. Interdisciplinary educational initiatives that lack institutional support in the form of funding, resources (such as staff and space), time for team development, and administrative leadership will also not attract faculty or students. Finally, a lack of clinical sites for students to observe and participate in interdisciplinary practice prevents the development and proliferation of courses that involve the simultaneous education of students from different disciplines. It is not enough to only talk about how to do interdisciplinary practice any more than it would be appropriate to simply talk about how to insert a catheter. While the steps in the process can be taught, having an opportunity to perform and practice interdisciplinary health care delivery with expert support allows for feedback on performance, redirection as appropriate, reflection on behaviors, and evaluation of the effectiveness of the instruction and the care provided. BENEFITS OF INTERDISCIPLINARY EDUCATION There are a number of potential benefits of interdisciplinary education to the academic setting. One benefit is that greater efficiency of educational
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effort can be obtained when students from two or more disciplines who need the same information can receive that instruction in the same course. Students who participate in such courses can gain appreciation of other professionals and greater respect for each other's knowledge and expertise. Participation in interdisciplinary programs also may stimulate the creation of new alliances among diverse faculty. Through interdisciplinary courses that also provide service to the community, there is potential for improvement in public relations as local residents learn more about the positive contributions of the university to health care. Finally, educational institutions that offer training in interdisciplinary practice will graduate students who are better prepared to enter the workforce and able to serve the needs of society more effectively and efficiently, leading to increased satisfaction among graduates, employers, and consumers.
IMPETUS FOR THE PROJECT The university where the program was initiated is a public health sciences academic institution in the northeastern United States that has multiple campuses located throughout the state. The university system is composed of seven schools: two allopathic medical schools, one osteopathic medical school (SOM), a school of nursing, a school of other health related professions, a dental school, and a school of public health. The school of osteopathic medicine, in partnership with three AHECs, initiated the grant proposal and application for funding. In reviewing their program of study, the educational administration of the SOM perceived a disconnect between how students were being prepared to practice and the changes occurring in the health care environment. Students had clinical experiences in private and public health care facilities, and there were isolated occasions in which they provided services in cooperation with other disciplines. However, there was no comprehensive or organized effort to include skills and clinical experiences in the curriculum that would support involvement in interdisciplinary practice of primary care after graduation. The administration recognized the need to prepare students in a different way if the increasingly complex needs of diverse and changing populations were to be addressed by tomorrow's health care workforce. While many health care disciplines were represented within the boundaries of the university, interdisciplinary education required more than locating students and faculty from different disciplines in close proximity
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to one another. Physical closeness does not reduce barriers to true interdisciplinary practice; educating professionals together does. Funds were available through the Health Resources and Service Administration (HRSA) to support the development and testing of an innovative educational program that would prepare clinicians to practice collaboratively in community, ambulatory, and managed care settings. Plans were established to develop a course that would bring students and faculty from the various schools together to learn the principles and experience the practice of interdisciplinary health care. Nursing practice is congruent with the interdisciplinary health care model. Both nursing and interdisciplinary practice embrace a type of heath care that is client centered, with an emphasis on a health model rather than an illness model, and that fosters collaboration among team members including the client. At the School of Nursing, we welcomed the opportunity for our faculty and students to participate in the design and implementation of the project.
LAYING THE FOUNDATION A grant was obtained through the Model State Supported AHEC Program, U.S. Department of Health and Bureau of Health Professions, HRSA. The directors of the three AHEC programs that served the southern part of the state were on the advisory committee as were community members and consumers, representatives from health care institutions, business persons, practitioners, administrators of schools within the university, faculty, and students. The goal was to develop a course in interdisciplinary primary care that would be open to all students registered in any of the university schools and the school of social work in another state university. A separate institute was established to direct the project and coordinate all the activities related to the course. Under the direction of the program administrator, who was a nurse educator, this core group met over several months and produced an outline of program goals, objectives, and outcomes. Two experts in curriculum development, one of whom was a nurse, designed the course using the guide provided by the committee. After several drafts and revisions, the course, Principles and Practice of Interdisciplinary Health Care Delivery (PPIHCD), under the direction of the Interdisciplinary Institute-AHEC, was ready to be
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presented to the deans and curriculum committees of the individual schools for their approval and support. Valuable feedback was obtained from these individuals and groups, which was used to further refine the course. PPIHCD was accepted for credit as an elective in the schools of dentistry, health related professions, nursing, and osteopathic medicine and in the school of social work in the other participating university. As the course was working its way through the various school committees, memoranda of understanding were initiated with clinical sites throughout the southern part of the state that could provide opportunities for students to participate in multidisciplinary and interdisciplinary practice in the community as part of the program activities.
Assembling the Education Team The program director then solicited university faculty participation to develop the content for each class and the methods of evaluation, and to teach in the course. Many of the first volunteers were members of the original advisory committee. This charter group of instructors participated in a series of faculty development workshops that focused on the principles and practice of interdisciplinary education, development of collaboration skills, and team formation. Experts from across the country were enlisted to offer instruction in group process, cultural competency, conflict resolution, and other subject areas that would help the faculty to work together as an interdisciplinary group and provide a model for the students.
Faculty Development Faculty development workshops were planned for the future to continue to assist the original faculty in advancing their skills and to bring new participants into the group. The participants were reimbursed directly or through their respective schools through funds from the grant for their time spent in workshops, class preparation, and teaching. After completing the workshops, faculty worked in small groups of two or more to plan their assigned classes and how they would teach the course. An effort was made among the team members to coordinate
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what content each would cover on their day. A faculty handbook was developed that contained current e-mail addresses and other contact information for all the faculty and administrative participants, role definitions for faculty members and moderators, a syllabus template, course goals and objectives, directions for completing course assignments, and evaluation criteria. Each faculty member also was provided with a binder that included a detailed outline for the complete 42 hours of didactic material, readings, suggested learning activities, and case studies to use for lesson planning. Faculty team members attended each other's classes when possible. The workshops, small group work, course materials resources, and attending each other's classes served several important functions: 1) prevent or correct any redundancy in content, 2) avoid gaps in instruction, 3) maintain course continuity, 4) reinforce concepts from one day to the next, and 5) facilitate and support the formation and practice of the faculty team.
IMPLEMENTING THE INTERDISCIPLINARY COURSE The initial offering of the course was a 60-hour, 2-week intensive pilot project targeted to graduate students in medicine, nursing, dentistry, physical therapy, social work and other health care professions. The course was divided into ten, six-hour days with seven days of classroom time for didactic material and three days of practicum or field experience. In a subsequent offering, the course followed a more traditional semester schedule with ten weekly class meetings. Both formats were found to be successful for recruitment of students and faculty, so that currently the course is offered twice during a calendar year, once in each format. All students took the course as an elective. The third time the course was offered, master's students in nursing were permitted and encouraged to register for PPIHCD in place of their required course in advanced practice nursing role theory. The class size was limited to 16-20 students to maximize interaction among the students and to keep the student teams small. The student teams were assigned to clinical settings that provided opportunities for them to meet the goals and objectives of the course. At first the students were permitted to choose their own team members. In later course offerings they were assigned to teams as it was found that the students tended to form teams with members of their own discipline, which was
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counterproductive to the purpose of the course. Because of the financial support through the grant, the course was offered to enrollees free of charge. Not only did this serve as an incentive for student registration, it also enabled the administrator to avoid having to deal with the issue of tuition allocation across academic programs, at least for the time being.
Course Content The first day of class consisted of presenting an overview of the course and review of the syllabus and assignments. Major concepts that would be addressed in depth as the course progressed were introduced and discussed. An important activity on this first day was sharing information among the students about their disciplines including scope of practice, educational preparation, licensing, values, and major role functions. The concept of primary care and how it related to interdisciplinary practice also was discussed. The students frequently identified this part of the course as one that was enlightening and useful. The following class meeting focused on the stages of team development and factors that facilitate and inhibit effective team formation and function. Strategies were reviewed for settling differences among team members, such as negotiation and conflict resolution, and how to collaborate effectively with people who have different interpersonal styles. The importance of developing cultural competency, in relation to both social and disciplinary cultures, was illustrated to the students through discussion of ideas of culture, cultural sensitivity, and effective communication. The class included information about the use of a translator in a clinical situation and a session with a consumer who did not speak English who shared her experiences in the American health care system. Another part of the course included an exploration of organizational context and dynamics of interdisciplinary teams in various health care settings. The effect of hierarchy, power, rules, and financing as well as values and goals of an organization on team function were considered. This class also included a review of general systems theory and continuous quality improvement. The next class involved a discussion of health belief models, differences that exist between consumers and health care providers, and the constructs of health, wellness, disease, and illness. A panel of experts led a discussion of legal issues such as individual and joint liability, scope
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of practice, and professional regulation. Students assessed concepts such as compliance, control, autonomy, informed consent, and paternalism in the class devoted to ethical practice considerations.
Practicum Component Field experiences provided opportunities to assess and evaluate health care teams in action against what was being presented in class. The students performed economic, social, and cultural assessments of the populations served in the clinical sites. They also analyzed consistencies and discrepancies in the site service model compared with the ideal model of interdisciplinary health care delivery. These assessments were submitted as part of the course assignments. The students were required to prepare a 45-minute team presentation that addressed a problem discovered during their field experience. The student team used concepts and strategies learned in class to describe and explain the problem and to propose solutions. Each student also submitted a report that discussed her or his own experiences related to field practice and team development and reflections on the overall course experience. Daily process recordings, class and practicum attendance, and active participation also were included in the evaluation and grading criteria.
PROGRAM EVALUATION The evaluation data presented here is a summary of feedback that was obtained each time that PPIHCD was offered over the course of two years, with a total of 63 students completing the course. Qualitative data were obtained through student course evaluations and from individual interviews that were conducted by the program director (Igo, 2002). Student reactions to the course and the opportunity to participate in it were overwhelmingly positive. Most expressed the opinion that the course was well timed in their professional development, that the concepts and skills offered should be introduced early in a professional program, and that all students should be given the chance to take the course. Although some of the content was included in their own programs of study, they believed that the lessons were better learned and had a stronger impact on them in an interdisciplinary course.
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The informants realized that they had already developed negative attitudes and stereotypes about members of other professions. For example, medical students expressed that they mainly viewed social workers as "hand holders" and had no idea of the knowledge and expertise those clinicians had to offer on legal issues and accessing resources in the health care system. Nurse practitioner students realized that they had already formed negative attitudes about physicians and that they were projecting this to the medical students in the class. Students learned that their perspectives on health care often did not consider the need to include the patient as part of the team. Many skills related to interdisciplinary practice were acquired in the course. The participants gained insight about their personal behaviors, and some also found that they could apply the principles of conflict resolution and cooperation to other areas of their lives. The course helped students feel more relaxed because they learned that they did not have to know everything and that there were competent clinicians from other disciplines and material resources available to support them in practice. The faculty facilitators for the course found that participating in the course enhanced their teaching practices. Many reported learning new teaching strategies and developing competence in using cooperative teaching methods as an alternative to lecture format. They became aware of instructional and human resources for faculty within and outside the university system. The faculty also valued the contact with instructors from other departments and schools as well as the exposure to interdisciplinary literature published in fields other than their own. Collaborative grant writing projects among schools were inspired by participation in the course as well as research activities between the university and the community. The objective of these research initiatives is to measure the impact of interdisciplinary care on patients and populations. The course has been a unifying force in the university, with movement away from competition toward cooperation. In addition, the course has provided a forum for biopsychosocial research in an environment where the biomedical model is dominant.
SIGNIFICANCE TO NURSING EDUCATION Although the course described was a clinical course offered to graduate students, there are many areas at all levels of health care education in
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which disciplines can share content, human and material resources, and learning activities. The most obvious areas are in science and humanities courses in undergraduate programs with content required by all future health care clinicians. While maintaining separate courses may be more convenient in terms of scheduling, it also serves to perpetuate the tendency toward disciplinary isolation, elitist professional identities, and stereotypes about the rigor of the academic programs of study in disciplines other than one's own. Professionals can and must learn to respect and trust persons from other disciplines with whom they will practice. By fostering collaborative learning in undergraduate programs, it is possible to lay a foundation of sharing and diversity that can continue in postgraduate education. Rather than detracting from the professional socialization process, interdisciplinary study has the potential to strengthen professional identity and collegiality. Learning together can lead to working together. In addition to the general study and core curriculum courses, there are opportunities for interdisciplinary learning in the clinical setting. While entry-level students must practice the patient care skills that are part of their particular scope of practice, one of the skills that should be mastered by all health care clinicians is the ability to communicate effectively and collaborate appropriately with other members of the health care team. Interdisciplinary grand rounds, clinical pre- and postconferences that involve multiple disciplines, and opportunities for informal consultation and discussion on the clinical unit can offer many valuable learning opportunities. As in classroom learning, having students in close proximity in a health care setting does not promote interdisciplinary practice; planning for and implementing learning experiences that place students, faculty, and clinicians in situations in which they must problem solve together does. Learning to work in an interdisciplinary team should occur early in the educational process. However, students need to be grounded in their own profession's values and scope of practice to actively contribute to the work of the group and to appropriately represent their discipline on the health care team (Petrie, 1976). For example, seniors in undergraduate nursing programs, second- or third-year medical students, fourth-year social work students, and students in graduate programs such as second-year nurse practitioner and physical therapy students should be sufficiently socialized to their disciplinary roles so that they ready to progress to learning about how to work collaboratively. It is
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important to place students with comparable skill and academic levels together in the same course so as to facilitate collegial rather than hierarchical relationships.
OVERCOMING OBSTACLES The preceding suggestions may seem difficult to achieve. However, many of the issues that have been identified as barriers to the implementation of interdisciplinary programs can be anticipated and overcome by thoughtful planning, networking, negotiation, and revision. First, there needs to be a willingness on the part of administrators to commit the necessary institutional support in the form of funding, time, space and staff. Next, faculty who are interested in both academic and clinical interdisciplinary practice must be recruited; these individuals need education and training in the principles and skills of interdisciplinary practice that will enable them to be effective course facilitators and role models. At the same time, department heads and faculty of the various programs must work together to find solutions to issues related to scheduling, credit allocation, tuition sharing, and other administrative and curricular concerns. Financial support and resources are always an essential part of any successful new initiative. Funds from government and philanthropic organizations are available for programs that develop and implement ways to enhance the quality of care to underserved populations in urban and rural areas (Holmes & Osterweis, 1999). In position papers and reports, these organizations and others have promoted interdisciplinary practice as a means to meet the health care needs of an increasingly diverse and aging society. They also realize that in the real world of practice after graduation, health care providers will have to perform in situations with professionals from many different disciplines working with the same patient.
NURSES AS LEADERS IN INTERDISCIPLINARY EDUCATION Nurses in clinical and academic settings are well prepared to assume a leadership role in the promotion, development, and implementation
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of interdisciplinary education programs. We have a long tradition of collaborating with a multitude of health care professionals. Nurses are the primary facilitators of communication among clinicians, patients, and family members. Educators and clinicians in nursing need to be actively involved with other disciplines in education if we are to prepare a workforce that will embrace a richer, more diverse health care paradigm. Participation in the design, implementation, and evaluation of interdisciplinary education programs provides an opportunity to advance the nursing profession, increase knowledge among the disciplines of the role of nursing on the health care team, increase the visibility of nursing in the health care arena and in the eyes of consumers, establish nursing as a full partner on the health care team, and promote appropriate utilization of nursing services. Interdisciplinary education has the potential to reduce stereotyping and hierarchical relationships while promoting mutual respect and appreciation of the contribution that each discipline makes to quality health care.
ACKNOWLEDGMENT The author acknowledges the assistance of Lorraine Igo, RN, EdD, in the preparation of this chapter.
REFERENCES American Association of Colleges of Nursings. (1995). Interdisciplinary education and practice. Position Statement. Retrieved August 2, 2002, from http:// www.aacn.nche.edu/Publications/positions/interdis.htm American Association of Colleges of Nursing. (1997). Once rare, interdisciplinary training gains ground. Issue Bulletin. Retrieved August 2, 2002, from http:// www.aacn.nche.edu/Publications/issues/97july.htm American Association of Colleges of Nursing. (1999). Nursing education's agenda for the 21st century. Position Statement. Retrieved August 2, 2002, from http:// www.aacn.nche.edu/Publications/positions/nrsgedag.htm Baldwin, D. C. (1997). The evolution of interdisciplinary education. In D. Holmes (Ed.), Proceedings of the 4th congress of health professions educators (pp. 3-12). Washington, DC: Association of Academic Health Centers. Connelly, T. (1978). Basic organizational considerations for interdisciplinary education development in the health sciences. Journal of Allied Health, 7, 274-280.
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Cooper, H., Carlisle, C, Gibbs, T., & Watkins, C. (2001). Developing an evidence base for interdisciplinary learning: A systematic review. Journal of Advanced Nursing, 35, 228-237. Fulginiti, V. (1999). The right issue at the right time. In D. Holmes & M. Osterweis (Eds.), Catalysts in interdisciplinary education (pp. 7-24). Washington, DC: Association of Academic Health Centers. Hall, P., & Weaver, L. (2001). Interdisciplinary education and teamwork: A long and winding road. Medical Education, 35, 867-875. Holmes, D., & Osterweis, M. (1999). What is past is prologue: Interdisciplinarity at the turn of the century. In D. Holmes & M. Osterweis (Eds.), Catalysis in interdisciplinary education (pp. 1-6). Washington, DC: Association of Academic Health Centers. Igo, L. (2002). Health professions students' responses to a model interdisciplinary educational experience. Unpublished doctoral dissertation, Widener University, Chester, Pennsylvania. Lowry, L., Burns, C., Smith, A., & Jacobson, H. (2000). Compete or complement? An interdisciplinary approach to training health professionals. Nursing and Health Care Perspectives, 21(2), 76-80. Petrie, H. (1976). Do you see what I see? The epistemology of interdisciplinary inquiry. Journal o/Asthetic Education, 10, 29-43. Pew Health Professions Commission. (1995). Critical challenges: Revitalizing the health pro/essions for the twenty-first century. The Third Report of the Pew Health Professions Commission. Retrieved August 2, 2002, from http://www. fu tureheal th. ucsf. edu/summaries/challenges .html
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Chapter 19 Using Clinical Scenarios in Nursing Education Catherine Nored Dearman
he purpose of professional nursing education is to prepare practitioners who not only possess the knowledge and skills for practice, but who also have the ability to develop their own theory of practice (Gaberson & Oermann, 1999). Nurse educators are charged with designing and implementing nursing curricula that provide sufficient clinical practice opportunities, assure competence in skills, respond to and reflect the diversity of the population, and promote the acquisition and retention of nursing knowledge. However, nurse educators struggle with the definition of clinical competence, the breadth and depth of knowledge that is required, evaluation and measurement of that knowledge, and mechanisms for promoting effective student learning. Diversity in students' social and educational background poses an additional set of considerations for educators. The Pew Commission, the National Council of State Boards of Nursing, and national accrediting agencies such as the Council on Collegiate Nursing Education (CCNE) and the National League for Nursing Accrediting Council (NLNAC) have individually and collectively made a case for significant changes in the preparation of nurses. Nursing is a practice discipline and, as such, demands that nurses engage in critical thinking, clinical reasoning, and active problem solving to address patient care concerns. Shifts in demographics, with an older and more diverse population, an increased number and severity of disease processes, and more varied practice sites require that nurses possess a broad knowledge base and
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engage in ongoing adaptation to a dynamic health care environment. Simultaneously, the profession of nursing is experiencing one of the worst shortages in history. Nurse educators must view these issues as a catalyst for change. Review and analysis of current educational practices is essential if nursing education is to answer the calls to provide larger numbers of better qualified graduates. Active learning strategies that encourage students to practice clinical decision making in a safe environment may provide the answers nurse educators seek. Active learning strategies enhance the student's ability to acquire a broad knowledge base, engage in exploration, inquiry, critical thinking, reasoning, and decision making, and retain the information over time (Johnson, Zerwic, & Theis, 1999; Vanetzian & Corrigan, 1996; Youngblood & Beitz, 2001). Clinical scenarios are one type of active learning strategy that encourages students to apply concepts to a practice situation and use critical thinking without jeopardizing client safety or student learning. Critical thinking is crucial to the full expression of the spirit of inquiry and exploration. Students must actively engage in critical thinking within clinical scenarios, working individually or in groups, to identify and explore options for nursing care, make appropriate selections or timing of care, and evaluate the effectiveness of their interventions. The final phase of any clinical scenario experience is debriefing. Debriefing allows the student to reflect on alternatives and link them to outcomes. Reflection provides the student with the opportunity to process the experience, consider alternatives, and reconcile actions with rationale (Chiodo & Flaim, 1993). This chapter focuses on the incorporation of clinical scenarios presented through photographs, video- and audiotapes, case studies, and simulations into the curricula, describes the effective use of these strategies in the classroom, clinical laboratory, and online setting to foster active learning, and gives some examples of them. The attributes of critical thinking, clinical reasoning, and self efficacy are used as a basis for the discussion of clinical scenarios. Depth and breadth of implementation also are addressed. Finally, debriefing after a learning episode is presented as a strategy to assist students in making explicit connections between the classroom and clinical environment.
CRITICAL THINKING IN CLINICAL SCENARIOS Critical thinking is an active analytic process that helps students raise pertinent questions and critique solutions (Alexander & Giguere, 1996).
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A person who can think critically demonstrates a willingness to test opinions and consider all perspectives. Neill and colleagues (1997) suggested that large, impersonal lectures are not conducive to thorough, interactive, and engaged clinical analysis. "Spoonfeeding" didactic information to nursing students at any level is a dangerous practice. Students must be given the opportunity to consider and independently synthesize new information. Some educators suggest that critical thinking is not only a technical but also an emancipatory process calling for nursing curricula that "free" students' minds and help them use their knowledge in clinical practice (Youngblood & Beitz, 2001). Critical thinking or "thinking about thinking" is one mechanism faculty can use to effectively bridge the gap between the classroom and clinical experience. The idea is not new. Critical thinking exercises have been incorporated into the nursing curriculum for over two decades. However, an emphasis on critical thinking is not being realized in student outcomes. While engaging in critical thinking as a part of problem solving and decision making was listed as the most important entry level competency for nurses, it ranked among the lowest of observed competencies (Shell, 2001). New graduates are particularly at risk for poor clinical judgment. Nursing practice today and in the future demands effective management of complex problems, clinical reasoning, and the ability to select and process information that determines a specific course of action. Traditionally the development of these skills has occurred primarily in the clinical setting. Employing active learning strategies in the classroom and online environments, however, broadens the students' use of these skills and enhances their critical thinking ability. Benner (1984) suggested that "expertise develops when the clinician tests and refines propositions, hypotheses, and principle-based expectations in actual practice situations. Experience is therefore a requisite for expertise" (p. 3). Clinical scenarios allow the simulation of actual practice settings and client situations and can generate a sense of urgency in the practitioner. As students progress through the clinical scenario and make decisions about the situation, they must actively analyze the information provided, develop alternatives for care, select the alternative supported by the evidence, and critique their solutions. As such, they are actively engaging in critical thinking (Loving & Wilson, 2000). Success in teaching critical thinking requires innovative strategies. In nursing education, as with other service professions, developing students' clinical analytical skills within the context of a caring frame-
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work is a multilayered endeavor. Students need a variety of learning experiences that focus on problem solving and decision making in clinical situations (Johnson, Zerwic, & Theis, 1999). Given the preponderance of evidence to support the incorporation of critical thinking into the curriculum, why then is it not being done consistently in nursing education programs? According to the National League for Nursing (1999), 40% of faculty respondents reported that teaching critical thinking was the area in which they were least prepared. Lack of exposure to critical thinking as a student, a perceived need to focus teaching on the content, time, class size, pressure to conduct research, lack of perceived benefits of teaching critical thinking, and students' resistance to active learning, lack of motivation, and concerns about grades rather than learning were cited as reasons why faculty resist teaching critical thinking (Shell, 2001). The simple fact is that teaching critical thinking and offering opportunities for students to develop critical thinking skills are not easy. Instituting a program to foster critical thinking requires faculty to become facilitators of learning rather than providers of information. Some faculty are uncomfortable with the idea that students may ask questions that they cannot answer. The classroom atmosphere needed to foster critical thinking among students requires faculty preparation and an openness to alternatives that must be engendered and supported by nurse educators and administrators alike.
BUILDING SELF-EFFICACY THROUGH CLINICAL SCENARIOS Bandura (1997) defined perceived self-efficacy as "beliefs in one's capabilities to organize and execute the courses of action required to produce given attainments" (p. 3). Self-efficacy influences one's level of motivation and the amount of persistence to accomplish a difficult task (Tompson & Dass, 2000). Personal triumphs can become transformational experiences. Tompson and Dass (2000) further suggested that improving self-efficacy through simulations can be transferred to and enhance selfefficacy in other domains. While Kolb (1984) purported that experiential learning is ongoing, Bandura advanced the idea that cycles of experiential learning build generative not fixed skills resulting in enhanced selfefficacy.
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Bandura (1997) identified "self-regulatory skills" as those needed to construct and evaluate alternative courses of action, set attainable goals, and create self-incentives to sustain engagement in taxing activities. Success, then, is a precursor for more success. Self-efficacy increases one's feelings of personal control over meaningful outcomes. Clinical scenarios build self-efficacy and self-regulation by allowing students to practice skills such as communication, assessment, planning, intervention, and evaluation in situations simulating "real life." Success in these clinical scenarios builds self-efficacy, which then can be transferred to the actual clinical setting. Clinical scenarios also allow the student to repetitively engage in a patient situation, selecting different alternatives for care. Student learning is maximized, and overall patient care is improved through these clinical scenarios.
CLINICAL SCENARIOS Clinical scenarios can take many forms: photographs, video- and audiotaped scenarios, case studies, and simulations. The common thread is that the scenario requires active participation by the student and faculty facilitation of the process.
Photographs A photograph can be used in a variety of content areas to promote critical thinking and evaluate depth and breadth of student knowledge. A photograph is a simple tool that fixes a client situation for a group of learners so they can fully explore it without the complication of time changes. Faculty set the stage for discussion of a photograph of a laboratory setting or a simulated patient environment or situation. Students can work individually or in small groups to formulate a response to the photograph following the guidelines provided by course faculty. A series of photographs depicting changes in a clinical situation can be beneficial to assist students in making decisions and realizing the outcomes of those decisions. The benefit of a photograph over a videotape is that students see one image at a time rather than a series of them, which may alter their perspectives. A photograph can be used in any clinical course. For example, in a community health nursing course, a photograph or series of them can
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be used to facilitate a discussion of community resources, typical housing, epidemiological issues, safety needs, and other characteristics of the community. A comparison of photographs can help the student understand the needs of the populace, diversity, and resources available for planning interventions prior to actually entering the community. The faculty member can facilitate the discussion and redirect students without endangering community relationships or student learning. An example of a clinical scenario on client safety using a photograph is shown in Figure 19.1. The sample questions can vary in depth and breadth of knowledge and observational methods that the faculty wants to foster. The exercise in Figure 19.1 can be beneficial to novice students entering the clinical setting for the first time. Many faculty focus on assessment of the patient's environment when they orient students to the clinical setting; use of a photograph saves time and enhances the experience for the student. The same photograph can be used to question students about communication, how to approach the patient, infection control, and other clinical issues. For example, a patient could be photographed asleep with an untouched breakfast tray beside the bed. The student could then be asked how they would approach the patient. Or, the environment could contain numerous types of sophisticated equipment, and the student could be asked to prioritize the assessment of the environment, offering the faculty a glimpse into what the student perceives as most important. The discussion of the student's approach is the critical element, not the photograph itself. Allowing the student to "practice" his or her approach to a patient in this manner fosters the development of information gathering skills, enhances the student's view of alternatives or options in care, and facilitates the selection of one or more interventions that can be tested and evaluated without placing a client at risk. Using the same photograph but changing the client's age can assist the student in developing age-specific approaches. Similarly, using clients with different cognitive or physical abilities and cultural or ethnic backgrounds increases student awareness of diversity that sometimes cannot be achieved in actual clinical settings. The adage "a picture is worth a thousand words" is relevant here. Faculty also can verbally describe the environment or use simple drawings that demonstrate the location of items in the room followed by similar discussions. Role play also can be used with students assuming
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FIGURE 19.1
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Clinical scenario using photograph.
Faculty script: This is a photograph of an actual patient environment. Pretend you are in the clinical setting and this is your first visit to your patient's room. Assess this environment. Now let's talk about what you observed. 1. 2. 3. 4.
What was your overall sense of the environment? Describe the environment. What did you notice first? Describe the bed. What did you notice (e.g., height from floor, bedrails up or down, placement of personal belongings, etc.)? What safety issues did you identify (e.g., placement of telephone, electrical cords wrapped on bed rails, impediments to bathroom access, etc.)?
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the roles of patient, nurse, and possibly visitors. The photograph can serve as the "backdrop" to the role play, and students can demonstrate how they would approach the patient.
VIDEO- AND AUDIOTAPED SCENARIOS Video- and audiotapes allow students to review and critique their own and other students' actions and behaviors in an atmosphere that is conducive to learning. Without the pressure of a grade or the stress associated with an acute patient situation, students are more open to discuss various approaches to clinical problems. In most situations, there is no single correct way to react, and students have the opportunity to explore different alternatives. There are two ways to use video- and audiotapes in the educational process. In either type, faculty staging is vital to the process. One use of the video- or audiotape is to play a "clip" and ask the student to respond. In this process, the teacher provides the framework for student observation and response. For example, for the same video clip, the novice student may be asked to validate the steps of an intervention, whereas the more experienced student may be asked to formulate a series of interventions and prioritize them. The second way to use video- and audiotapes in the educational process is to tape the student interacting with other students or in a simulated patient care situation. The student can be asked to analyze actions taken and identify changes needed in interventions. In both methods, immediate feedback from peers and faculty improves students' awareness of the effects of their actions and possible alternative approaches.
CASE STUDIES Case studies are tried and true methods of fostering clinical reasoning and judgment. The case provides the student with a description of a clinical situation, nurse-patient interaction, or experience of the patient in the health system, which students then analyze. These "real-life" situations help students focus on the issue at hand while using critical thinking, reasoning, reflection, and creativity to decide on interventions.
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The cases can be simple or complex depending on the level of the learner and the objectives being addressed. Case studies can be used as a part of the traditional classroom instruction and in the online environment as preparation for class, an instructional method, or for evaluation. Case studies may be analyzed by students individually, in small groups, or by the class as a whole. Table 19.1 presents an example of a case study. When using case studies, the teacher serves as the facilitator of learning, not as the provider of information. Student perception of this strategy may not be positive at first. However, repeated exposure to active learning promotes self-direction, intellectual curiosity, and skill enhancement. Rogge (2001) used cases to assist students enrolled in a pathophysiology course in preparing for a class as a means of maximizing class time and student learning. In preparing for class by reading the textbook, students may not understand the material because of their lack of experience in the area. Without the prerequisite knowledge, students may be unable to participate in active learning strategies. In preparation for class using Rogge's technique, students are provided with a case study and a series of questions to answer about it. Students read assigned material related to the case to answer the questions. Students meet in a seminar prior to class and during that time they share the material they obtained from readings related to the case. Faculty are available during the seminar to clarify and validate student responses and redirect them when necessary. Following the seminar, the regular class session begins using traditional methods of lecture/ discussion on the same topic. Structuring courses in this manner eliminates the need for faculty to "review" previously learned material such as anatomy and physiology since the case required that review to answer the questions (Rogge, 2001). According to Benner (1984), "case studies should contain some irrelevant, extraneous material and, in some instances, insufficient information to make an intelligent choice" (p. 31). The ability of the learner, however, needs to be considered. Novice students are easily distracted and become frustrated when they try to resolve all issues inherent in the case. For such learners, cases should be relatively simple, including requisite material to make appropriate decisions with limited extraneous data. As the learner progresses, the cases can become more and more difficult, requiring a higher level of discrimination and clinical reasoning.
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TABLE 19.1 Sample Case Study Case The client is a 25-year-old gravida iv, para ii who is at 37 weeks gestation. She has two living children, boys who are 3 and 5 years old. The client experienced a spontaneous abortion at 12 weeks with her previous pregnancy and became pregnant again within 6 weeks of the abortion. The second pregnancy ended in an emergency cesarean delivery because of severe fetal distress, but she wants to attempt a vaginal delivery of this third child. The client and her husband desperately want a daughter but have elected not to know the gender of this baby until delivery. The client has no known allergies and suffers from no known acute or chronic health problems. She is of average height and weight and has gained 20 pounds during this pregnancy. Her physician, after determining that the incision from the previous cesarean is in the lower uterine segment, has approved her for a vaginal birth after cesarean (VBAC). The client presents to the labor department in early labor with contractions every 5-7 minutes, of moderate intensity and lasting 45-50 seconds. She is accompanied by her husband and her mother. Physical and vaginal examination results include: cervix 3 cm dilated and 80% effaced, oral temperature of 98.7, pulse rate of 88, blood pressure of 130/78, and respiratory rate of 24 breaths per minute. The physician orders an IV of Lactated Ringers solution at 125 ml/hour and an external fetal monitor. The fetal monitor indicates that the fetal heart rate is ranging from 124-130 beats per minute with good beat to beat and long-term variability. Laboratory data indicate no variations from normal. Questions: 1. 2. 3. 4. 5. 6. 7.
What inferences can you make about this clinical situation from the information provided? What actions by the nurse are appropriate at this time? What comfort and safety measures should you implement now? As she progresses in labor? What complications do you anticipate? How will you know if she develops these complications? How would you assess the client's emotional state? What else do you want to know about this situation?
Faculty expectations of the student drive the content and direction of the case. Case studies can be adapted to any level of student and can incorporate different levels of nursing practice. Involved cases are effective for preparing advanced practice nurses to differentially diagnose patient
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conditions. Variations in client situations, laboratory data, and history and physical findings are limited only by the imagination of the faculty. Case studies also can be used to teach case management (Jennings, 2000) and to develop self-directed learners (Hewitt-Taylor, 2001).
CLINICAL SIMULATIONS Clinical simulations depicting actual nursing situations provide students with the opportunity to practice, learn, and even make mistakes in a controlled environment without endangering the patient (Johnson, Zerwic, & Theis, 1999). Clinical simulations require the student to be an active learner and use previous knowledge and skills, directed toward the goal of providing the patient in the simulation with the best care possible. Simulations have been employed as a teaching strategy using a variety of formats from written latent images to interactive video and virtual reality to teach simple as well as complex concepts. Johnson and colleagues (1999) used simulations in the final senior nursing course. The course provided students with an opportunity to synthesize information from prior experiences. The simulations crossed all specialty areas, focused on content and experiences that beginning graduates would encounter, and integrated concepts and processes central to the curriculum. The simulations allowed students to validate their knowledge, patient management abilities, and decision-making skills as a "nurse" through an interactive role play experience. Incorporating role play into the simulations permitted the students to experience the role of the patient, giving a new perspective to the activities. Simulations brought "course content to life" without the stress of a real patient or the fear of making a mistake. They required students to think and react to a variety of situations without the benefit of preparation, to "think" rather than "memorize." Johnson and colleagues (1999) also found that the simulations increased students' confidence in their own critical thinking and problem-solving abilities. Dearman and colleagues (2001) developed a student-student-faculty triad combining RN to BSN students and traditional students in a laboratory simulation/role-play. The traditional student assumed the role of the nurse, the RN to BSN student "played" the supervisor/ preceptor, and the faculty person was the patient and evaluator of the experience. The simulation was designed to allow the RN student to
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develop supervisory and management skills, the traditional student to encounter a "real-life" situation, and the faculty to evaluate both students. An unexpected benefit was a closer, collegial interaction between both groups of students (Dearman, Lazenby, Faulk, & Coker, 2001). Tompson and Dass (2000) cited the difficulty they encountered in teaching students to "apply" management principles. To meet this need, they designed simulations to provide a more realistic decision-making scenario and objective feedback by faculty mimicking that found in real management decisions. Students reported that the simulations were interesting, novel, and motivating, and that they exerted more effort and acquired more knowledge than in the traditional classroom experience (Tompson & Dass, 2000). Simulations can effectively encompass the complexities of "true to life" dilemmas, allowing students to develop their own personal abilities for managing them. Learning facts, models, and techniques is part of classroom learning, but students also must be confident that they can make strategic decisions independently after the course has been completed (Tompson & Dass, 2000).
DEBRIEFING Debriefing, the discussion of an event immediately following that event, allows the student to reflect on the experience and their response to it. Debriefing following clinical scenarios, whether photographs, videoand audiotapes, case studies, or simulations, is key to the learning process and provides a forum for the application of knowledge to the scenario (Chiodo & Flaim, 1993). Learning occurs when students have an opportunity to reflect on the experiences they have had in the scenario. During debriefing faculty integrate the scenario experience into the learning environment, helping students understand the concepts that apply to the specific case and to other cases. Students learn new information and then "tie" it to prior knowledge; they connect each part to one another and to the whole (Dearman, 1988). Chiodo and Flaim (1993) presented a debriefing model that structures the experience for students and faculty. The first phase of the model is recall. In this phase students recall the decisions they made during the clinical scenario and outcomes of those decisions. Inference
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is the next phase and requires that students engage in a discussion of the alternatives that were available other than the decisions they made. Faculty can be of particular assistance in helping students identify unrecognized alternatives and prioritize them according to the patient situation. Discussion of the objectives embedded in the exercise, how the student viewed the scenario, and the rationale for prioritization of alternatives occurs next. Conceptualization of the entire case and comparison to "real life" is the next phase. The final phase is making generalizations and drawing conclusions based on the clinical scenario. Sample questions used in debriefing include: • What decisions did you make in the scenario? • What alternatives did you consider before making those decisions? • Would you make the same decisions again? • What if the patient were older? Younger? • What changes would be necessary if this patient had remained at home rather than being admitted to the hospital? Debriefing is not summarizing. In summarization, the teacher discusses the purpose of the scenario and the major issues involved; that process is teacher-driven. Debriefing provides feedback to the teacher on the value of the experience to the student and provides closure. This closure is the beginning of further reflection by the student that will form the basis of future clinical decisions.
ONLINE ADAPTATION The clinical scenarios presented in this chapter also can be used for online instruction. Adapting the photograph to the online environment is not difficult, and the process of group discussion is similar. In the online environment students have constant access to the photograph unless it is used as part of a synchronous chat, or they can download it, which is not true in the traditional classroom. When using role play with the photograph, students can interact with each other via computermounted video cameras or by typing in their responses. The video and audio clips can be used the same way in the online environment as in the traditional classroom. Faculty should be aware,
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however, of the technological capability available to the "end user." The student with the poorest technological support should be the yardstick by which faculty measure the usefulness of any video- or audiotape presentation. A small portion of a tape that requires 30 minutes for the student to download and view would not be feasible. In such a situation, faculty may elect to use video- and audiotapes as an adjunct to the instruction rather than requiring them. Case studies and simulations can be used effectively in an online environment with minor alterations in presentation. The case can be used as a synchronous chat or as an asynchronous group assignment. Similar to other online strategies, faculty should be aware of the ease with which the student can access the information. SUMMARY This chapter discussed various ways of using clinical scenarios such as photographs, video- and audiotapes, case studies, and clinical simulations in the educational process. Critical thinking and clinical reasoning are enhanced by the use of these active learning strategies. According to Bandura (1997), self-efficacy is transferable and generalizable. Knowledge gained in one area is transferable to other areas and generalizable to new and different situations. Success in clinical scenarios builds selfefficacy, which then can be transferred to the actual clinical setting. As educators, we do not have to "teach" everything to students, but we have the responsibility to help students develop the foundation for their nursing career. REFERENCES Alexander, M. K., & Giguere, B. (1996). Critical thinking in clinical learning: A holistic perspective. Holistic Nursing Practice, 10, 15-22. Bandura, A. (1997). Self efficacy: The exercise of control New York: W. H. Freeman. Ben-David, M. F. (2000). The role of assessment in expanding professional horizons. Medical Teacher, 22, 472-479. Benner, P. (1984). From novice to expert. Menlo Park, CA: Addison-Wesley. Chiodo, J. J., & Flaim, M. L. (1993). The link between computer simulations and social studies learning: Debriefing. Social Studies, 84, 119-122. Dearman, C. (1988). The relationship between the reading ability of students currently enrolled in master's programs in the southeastern United States and the readability
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of their research texts. Unpublished doctoral dissertation, University of Mississippi, Oxford. Dearman, C, Lazenby, R. B., Faulk, D., & Coker, R. (2001). Simulated clinical scenarios: Faculty-student collaboration. Nurse Educator, 26, 167-169. Gaberson, K., & Oermann, M. H. (1999). Clinical teaching strategies in nursing education. New York: Springer Publishing Co. Hewitt-Taylor, J. (2001). Self-directed learning: Views of teachers and students. Journal of Advanced Nursing, 36, 496-504. Jennings, A. (2000). Teaching case management: A case study approach. Nurse Educator, 25, 87, 94. Johnson, J. H., Zerwic, J. J., & Theis, S. L. (1999). Clinical simulation laboratory: An adjunct to clinical teaching. Nurse Educator, 24, 37-41. Kolb, D. A. (1984). Experiential learning: Experience as the source of learning and development. Englewood Cliffs, NJ: Prentice Hall. Loving, G. L., & Wilson, J. S. (2000). Infusing critical thinking into the nursing curriculum through faculty development. Nurse Educator, 25, 70-75. .National League for Nursing Department of Professional Development. (1999). Delphi survey of nursing faculty: Information about nursing. New York: National League for Nursing. Neill, K. M., Lachat, M. F., & Taylor-Panek, S. (1997). Enhancing critical thinking with case studies and nursing process. Nurse Educator, 22, 30-32. Rogge, M. M. (2001). Transforming pathophysiology instruction through narrative pedagogy. Nurse Educator, 26, 66-69. Shell, R. (2001). Perceived barriers to teaching for critical thinking by BSN nursing faculty. Nursing and Health Care Perspectives, 22, 286-291. Tompson, G. H., & Dass, P. (2000). Improving students' self-efficacy in strategic management: The relative impact of cases. Simulation and Gaming, 31(1), 22-42. Vanetzian, E., & Corrigan, B. (1996). "Prep" for class and class activity: Key to critical thinking. Nurse Educator, 21(2), 45-48. Youngblood, N., & Beitz, J. M. (2001). Developing critical thinking with active learning strategies. Nurse Educator, 26, 39-42.
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Index
Academic engagement of students, 134 American Association of Colleges of Nursing distance education recommendations, 174-175 on distance technology, 283 position statement, 43 on scholarship, 138 Associate degree education and baccalaureate degree education, 29-30, 38-39 community-based clinical experiences in, 29-30, 300-302 in distance education, 297-306 outcomes of, 16, 35, 36-38, 303-306 and service learning, 28, 30-33 Associate degree nurses, ties to community, 36-37 Care Groups, 147-161 Care Group Model, 154-157 evolution of, 150-154 mentor role in, 154 outcomes of, 157-158 protective environment in, 154-157 remediation plan in, 153 student outcomes in, 157 student perceptions of, 153-154 and supplemental instruction, 157-158
Case studies as clinical scenarios, 348-351 in distance education, 196, 205-206, 224, 231 Clinical experiences; see also Community-based clinical experiences and distance education, 183-184, 300-302 as focus of preceptorships, 93-95 and history of nursing, 92 in nurse-midwifery and nurse practitioner program, 238-239 and practicum in distance education, 185 student assignment, 11 Clinical scenarios as active learning strategy, 342 for building self-efficacy, 344-345 case studies as, 348-351 clinical simulations as, 351-352 critical thinking in, 342-344 and debriefing, 352-353 online adaptation of, 353-354 photographs for, 345-348 video- and audiotapes for, 348 using for nursing education, 341-355 Collaborative learning, see Interdisciplinary education Community assessment, Web-based, 257-259
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358
INDEX
Community-based clinical experiences aggregate team approach, 10 in associate degree education, 2933, 300-302 in community-based nursing education curriculum, sample, 11-18, 250-255 community nursing centers in, 7 faculty supervision in, 20-22, 36, 46-47, 54-55, 56 group approach, 9-10 integration with courses, 11-18, 4647, 54-55 partnerships in, 6-7, 28-33, 39, 43-57 projects in, 7, 14-19, 28-29, 30-33, 48-52, 205-206, 250-255 structure of, 6-8, 11-18, 31, 32, 230-232 student assignment in, 11, 32, 3335, 54-55, 229, 238-239 student resistance to, 22 team project approach, 10 Community-based nursing education; see also Community-based clinical experiences activities in, sample, 15 approaches for, 9-10 baccalaureate and higher degree programs, 18-19, 38-39 benefits of, 4 challenges in, 19-22 communication in, 21-22 and community health nursing, 5 costs of, 21 curriculum, sample ADN, 27-41 curriculum, sample RN and graduate, 18-19 curriculum, sample undergraduate, 11-18 definition of, 3 and distance education, 227-243 goals of, 4, 27-28, 43-44 flexibility, need for, in, 19-20
key components, 6 literature review, 29-30 and nursing in the community, 6 19130 Zip Code Project, 27-41 partnerships in, 4, 43-57 philosophy of, 4, 27, 29-30, 43-48 projects, sample graduate student, 19, 238-239 projects, sample undergraduate student, 17 safety in, 21 and service learning, 27-39 and specialty clinical practice, 21 and state board of nursing, 21 student activities in, 9-10, 31-35, 55, 236-239, 250-255 student work characteristics, 9 Community college and 19130 Zip Code Project, 28 teaching in, 134 Community health nursing, 5 Community nursing centers in community-based clinical experiences, 7 setting up and maintaining, 8 Community nursing practice, skill set for, 30 Correspondence courses, 169 Creativity conditions for, 193-195 definition, 192 giving feedback to encourage, 202, 204 importance of, 192 teaching, online, 191-207 teaching modalities and, 194-195 Critical thinking and clinical scenarios, 342-344 and discussion boards, 196 faculty resistance to teaching, 344 and observed student competencies, 343 Discussion boards advantages and disadvantages of, 195
INDEX
and critical thinking, 196 reflection in, 197-198 teacher's role in, 196-198 writing style in, 196 Distance education; see also International distance learning collaboration; Nurse-midwifery and nurse practitioner program; Online learning and accountability, 185-186 adjunct faculty for, 299 American Association of Colleges of Nursing recommendations for, 174-175 assessment of, 173-175 benefits of to students, 165-167, 180-181, 195, 197-198, 209, 216-219. 228-229, 230, 246, 267-268, 281-282, 297-299, 303-304 and budgetary constraints, 297-307 challenges of, 166, 175-178, 182183, 212, 219-222, 229, 234235, 246-247, 249, 262-264, 268, 269-271, 288-293, 299, 309-320 and clinical courses, 183-185, 300-302 clinical instructors for, 301-302 costs of, 178, 181, 212, 273, 291292, 299, 310, 314-315 course development, 173, 179-180, 211-214, 230, 246-247, 249, 269-273, 284-285, 302, 314-319 course ownership, 181-182, 292, 315-316 definitions of, 167-168, 245-246 developmental principles of, 174 and distance learning, 167-168 enrollment in, 165-167, 209, 211, 216, 223, 227, 234, 303-304 evaluation in, 173-175, 215-219, 242, 255-257, 259-260, 275-276, 292, 302,303-305, 303-305
359
faculty, use of off-campus, 178 faculty development, 179, 212-213, 232-234, 314-315, 319 faculty issues, 177-178, 212-215, 219-220, 260-264, 292-293, 319 faculty role, 184 faculty selection, 176, 304, 319 faculty support, 176-177, 213-215, 219-220, 314-315 faculty types and pay structures in, 177,314-315 future directions in, 185-187, 223224, 243, 277-278 and generation-X learners, 299 growth in, 165-167, 209, 211, 216, 223, 227, 234, 303-304 guidelines for, 173-175 institutional considerations, 173175, 181-182, 273, 297-299, 305-306 institutional cooperation in, 166 lessons learned, 305-306 library access in, 172-173, 222, 235-236 marketing of, 182 National Organization of Nurse Practitioner Faculties guidelines for, 175 needs analysis for, 182 and nursing shortage, 298 and on-campus course equivalence, 302 and partnerships, 186 practicum experiences in, 185, 238239, 269, 275, 300-302 preceptor role in, 184, 229, 233234, 238-239 rationale for, 165-166, 209, 227, 245, 267, 281, 297-299 residency requirements and, 181, 231-232, 238 reusable learning objects in, 173 in rural areas, 298, 245-265 student characteristics, 182
360
INDEX
evaluation inconsistencies among, Distance education (continued) 150-151 student perceptions of, 180-181 isolation of, 135 student performance in, 175, 181, and learning communities, 136-137 221, 242, 259-260 preparation of, 109-130, 133-145 and technology, 168-172, 185-186, responsibilities in clinical experi235, 247 ences, 19-20 testing in, 215, 222, 231, 239, 242, Faculty-student partnerships 255-256, 259-260, 300, 302 benefits of, 30, 36, 110, 113, theory courses in, 300 116-119 synchrony in, 168 challenges in, 119-121 Distributive learning, see Distance and community of scholarly caring, education 114-116 creating, 128-130 Enrichment program development definition of, 127-128 assessing situation, 70-73 development stages, 126-127 communicating, 76-78 independent study in, 112 drafting plan, 74 lessons from, 121-124 evaluation, 85-87 promoting, 114-116 getting approval, 76 grant search, 73-74 Health promotion and disease prevenimplementation, 81-85 tion, 28, 31-35; see also 19130 literature review, 73 Zip Code Project preparing for program, 78-81 and Healthy People 2010 Objectives, preparing proposal, 75-76 27, 35, 46, 48-49 soliciting support, 74-75 Enrichment program for student reten- Interdisciplinary course, sample; see tion; see also Enrichment proalso Interdisciplinary education gram development content, 333-334 development of, 68-87 education team, 331 newsletter, 83-84 faculty perceptions of, 335 orientation, 82-83 foundation of, 330-332 results of, 86-87 funding for, 330 study groups in, 84 impetus for project, 329-330 transitional workshop, 84-85 implementation, 332-334 Ethics; see also Web-based courses, ethpracticum component in, 334 ics of program evaluation, 334-335 ethical theories, 310-312 student perceptions of, 334-335 Interdisciplinary education; see also InFaculty; see also under Distance educaterdisciplinary course, sample tion; Online learning benefits of, 328-329 and centers for teaching excellence, challenges to, 327-328 137 and changing environment, 326-327 clinical teaching, 136, 139 clinical setting in, 336 development, 135-137 for effective teamwork, 327
INDEX
faculty development, 136-138, 331-332 faculty inexperience in, 328 funding for, 337 nurses as leaders in, 337-338 overcoming obstacles, 337 rationale for, 325-327 significance for nursing education, 335-337 student preparation for, 336 International distance learning collaboration costs of, 278 course coordination in, 269-271 development of course, 269 evaluation in, 275-276 findings and recommendations, 276-277 and international differences, 277 and learning resources, 273 memo of understanding, 273 participant qualifications, 273 preceptor orientation in, 276-277 preceptor role in, 271-272 program implementation, 273-275 rationale for program, 268 requirements for, 268 teaching practicum in, 275 Internet learning, see Distance education; Online learning Intervention categories ongoing, 82 proactive, 81-82 transitional, 82 Laboratory skills mentors as teachers of, 152 teaching, 147-159 Master Educator's Guild, 139-141 award for master educator, 143 benefits of, 143-144 master educator identifiers, 141 rationale for, 139
361
selection of master educator, 141-142 Mentoring; see also Peer mentor-tutors; Preceptors benefits of, 149 with Care Groups, 147-161 and faculty development, 135, 137 in faculty-student partnerships, 109-130 and partnerships, 149 requirements for, 149 students as mentor, 77-78, 79, 81, 82,84 National Organization of Nurse Practitioner Faculties guidelines for distance education programs, 175 Nontraditional students; see also NURS model enrichment program for, 62 environmental variables and, 62, 68, 70, 71 and professional integration variables, 68 retention of, 61-88 and survival skills, 81 NURS model assumptions of, 65 definitions, 66-67 goals, 63, 65 overview, 65, 67-68 and program outcomes, 86 Nurse-midwifery and nurse practitioner distance education program clinical experiences in, 238-239 course coordinators in, 232 curriculum, 230-232, 236-239 development of, 228-230 evaluation of, 242 faculty, 232-234 faculty support, 240-241 orientation, 236-237 preceptors in, 233-234
362
INDEX
Nurse-midwifery and nurse practitioner distance education program (continued) regional clinical coordinators in, 233 student council, 241-242 student population, 234-235 student support, 239-240 Nursing in the community, 6, 28-29, 30-33, 46-48 Nursing education, history of, 91-93 Nursing shortage, and distance education, 298 19130 Zip Code Project background, 28-29 colearners in, 36 data collection in, 33-34 educational goals of, 35 mission, 35 partners in, 31-32 programs offered, 34 student activities in, 32-33 student diversity in, 37-38 surveillance interventions in, 35 Online learning; see also Distance education; International distance learning collaboration; RN-BSN online program, sample, 209225; Rural health online course; Web-based courses, ethics of advantages and disadvantages of, 317-319 approaches, 195-205 appropriateness of, determining, 310-312, 316-319 benchmarks for, 174 benefits of, 217 challenges of, 219-222 clinical courses in, 300-302 clinical scenarios in, 353-354 components of instructional delivery in, 312 computer requirements for, 318-319 confidentiality and privacy in, 264
course conversion for, 179, 213215, 219-220 course development for, 246-247, 249 course expectations, 263 course objectives, 316-317 course ownership, 315-316 creativity in, fostering, 191-207 equivalence with on-campus courses, 175, 302, 304 ethical issues in, 309-321 evaluation of instruction, 215-216 expectations in, 221 faculty concerns, 212, 219-220 faculty development for, 212-213, 319 faculty rewards in, 314-315 faculty role in, 212 faculty skills needed for, 248 faculty support in, 315 faculty workload in, 314-315 future directions for, 223-224 instructor modeling in, 261 lessons learned, 260-264, 305-306 management tools in, 256-257 modifying strategies for technology in, 262-263 and nonparticipating students, 214 projects in, 205 rationale for, 209 resources for, 176-177, 221 roles and responsibilities in, 260-261 sample RN-BSN program in, 209-225 security in, 263 sojourner groups in, 205-206 and student computer skills, 220 student considerations, 220-222 student ethics and, 313-314 student participation, 256, 262 student rationale for enrollment in, 216-217 student satisfaction with, 218-219, 303-304
INDEX
targeted population, determining, 317 technology needed for faculty in, 248 terminology in, 246 testing in, 302 theory course in, 300 Partnerships; see also Faculty-student partnerships; Partnership development steps and academic institutions, 46-47, 55-56 benefits to faculty, 46-47 and community, 47-48 and community action, 52 and community service, 47 development, 48-52 and distance education, 186 evaluation in, 52 faculty-student partnerships, 109-130 formal agreement in, 52 funding issues, 56 group decision making in, 56 group dynamics in, 53-54 and health care institutions, 44-46 importance of, in nursing education, 39 key community members in, 53 and mentoring, 149 for nurse educator preparation, 109-131 and nursing shortage, 45 open forum in, 52, 53 potential partners in, 45, 50-51 problems in, 55-57 professional-community partnerships, 43-58 publicity for, 54 rationale for, 44-48 resources for development, 49 rewards for participation in, 57 selection of issues in, 53
363
selection of partners, 55 student learning experiences in, 46 student participation in, 54—55 sustaining, 53-54 topic identification, 48-49 in videoconferencing, 284-285 Partnership development steps awareness of issues, 50-51 community action, 52 development of partnership, 51-52 evaluation, 52 social inventing steps, 111-116 topic identification, 48-49 Peer mentor-tutors benefits of using, 82 orientation, 79, 81 role of, 79-80 selection of, 79 and study groups, 84 Practicum; see also Clinical experiences in distance education, 185 in interdisciplinary course, 334 Preceptors; see also Preceptorship in distance education, 184, 233-234, 238-239 in international distance learning collaboration, 271-272 nonhealth care providers as, 20 orientation of, 97-98 pay for, 103 qualifications of, 96 role of, 96 selection of, 95, 96-97 stress in, 99-101 support for, 98, 100-102 workload of, 93, 100 Preceptorship; see also Preceptors benefits of, 102 characteristics of successful program, 101-102 collaboration in, 94-95 and competence of nursing students, 94
364
INDEX
Preceptorship (continued) complexities of, 96 and critical thinking skills, 94 evaluation of programs, 102 faculty role in, 97, 101 focus of, 93-95 future directions, 102-103 history of, 91-93 and international experiences, 103 learning objectives in, 94-95 nurse educator's role in, 93-94 preparation for, 97-99 and professional socialization, 93 program creation, 101-102 status of, in nursing education, 91 student screening, 98 warm body syndrome in, 95 Prenursing students, using Care Groups with, 147-161 Psychomotor learning, 147-149 RN-BSN online program, sample background, 210-211 enrollment in, 223 evaluation of, 215-216 outcomes, 216-219 plans for implementation, 211-213 student satisfaction with, 218-219 theoretical basis, 213 Rural health online course community of learners, building, 249, 255 content and assignments, 250-255 evaluation in, 259-260 faculty-student contact in, 249, 255 format of, 249 grading and assignments, 255-257 scholarly paper in 259 student participation, 256 student perceptions of, 260 Web-based community assessment, 257-259 Service learning and community-based nursing education, 30-33
definition of, 5 19130 Zip Code Project, 28-41 and partnerships, 31 Socialization, professional, 93 Software, course design, 247, 249 Student retention; see also Enrichment program; Enrichment program for student retention academic performance and, 68 assessment of rates of, 71 nurse educators' role in, 61-62 strategies for, 68-87 studies of, 63 Teaching excellence; see also Master Educator's Guild barriers to, 134-136 centers for, 137 in clinical instruction, 143 overcoming barriers to, 136-138 and promotion and tenure, 138-139 Technology; see also Videoconferencing in distance education, 168-172, 185-186, 235 modifying strategies to fit, 262-263 for Web-based courses, 247 Telemedicine, 282-284 Videoconferencing areas for evaluation, 283-284 clinical evaluations through, 286, 292 examples of, 285-287 implications for nurse educators, 291 with international connections, 289-291 interpersonal interface challenges in, 289 literature review, 282-284 and partnerships, 284-285 planning and implementation, 284-287 rationale for use of, 281-282
INDEX
suggestions for using, 291-293 and technical difficulties, 288-289 and technical interfaces, 285 Web-based community assessment, 257-259 Web-based course management systems, 171-172 Web-based courses, ethics of appropriateness of modality, determining, 316-319 ethical theories and, 309-311 faculty considerations in, 309-312
365
honor code, 313 preparing students for online learning, 313-314 special challenges, 313 student considerations in, 312-314 Writing-to-learn content and principle-oriented writing, 202 creative writing, 200 designing assignments, 199-200 evaluation of, 202, 204-205 reflective writing, 200-202 sample assignment, 203
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Annual Review of Nursing Education Topics and Authors for Volume 2
New Nursing Education Models: Certificates DIANE M, BILLINGS Program Evaluation: What's New DONNA L. BOLAND Evaluation and Grading Practices PEGGY L. CHINN Using the Holistic Paradigm in Teaching BONNIE W. DULDT Transition Issues for Nursing Graduates JUDY E. BOYCHUK DUCHSCHER Feminist Pedagogy as a Strategy for Empowering Students ADELINE R. FALK-RAFAEL, PEGGY L. CHINN, MARY ANN ANDERSON, HEATHER LASCHINGER, AND ALICEBELLE RUBOTZKY What Programs Are Teaching Us About the State of Nursing Education BARBARA R, GRUMET Evidence-Based Course Fosters Transformative Learning Environment in Graduate Program KATHLEEN T. HEINRICH Advances in Clinical Teaching and Nontraditional Clinical Sites MARSHA L. HEIMS Concept Mapping DONNA D. IGNATAVICIUS
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TOPICS AND AUTHORS FOR VOLUME 2
Student Academic Dishonesty MARIANNE R. JEFFREYS AND LORI STIER Computerized Testing MARILYN KLAINBERG Technology Innovation in Clinical Nursing Education CHERYL P. MCCAHON AND SHEILA A. NILES Service Learning: What It Is and Is Not HELEN MELLAND Innovative Methods for Development of Staff Competencies MAGDALENA A. MATED AND EILEEN MCMYLER Clinical Simulations PATRICIA GONCE MORTON AND CAROL A. RAUEN Using the Human Patient Simulator in Teaching WENDY M. NEHRING AND FELISSA R. LASHLEY Advances in Nursing Professional Development BELINDA E. PUETZ Preparing New Faculty for Teaching JANET HOEY ROBINSON Critical Thinking: What's New and How to Foster Thinking Among Nursing Students CAROL SEDLAK AND MARGARET O. DOHENY
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Educating Advanced Practice Nurses and Midwives From Practice to Teaching Joyce E. Thompson, RN, CNM, DI-.PH, FAAN, FACNM, Rose M. Kershbaumer, MMS, RN, CNM, MSN, EdD, and Mary Ann Krisman-Scott, RN, PhD, FNP "This book should be required reading for every academic and clinical faculty member...address[es] all aspects of classroom and clinical teaching, including 'how to' specifics." —Helen Varney Burst, RN, CNM, MSN, DHL, (Hon.) FACNM Yale University, School of Nursing New teachers of advanced practice nurses who are making the transition from clinician to educator are the main audience for this text. It will help them develop an understanding of APN curricula, of how adults learn, and the role of the educator. The text is based on the successful APN education program at the University of Pennsylvania. It is a useful text in education programs for nurse practitioners, midwives, clinical nurse specialists, and nurse anesthetists. Partial Contents: A Brief History of Midwifery and Nurse Practitioner Education in the United States • Making the Transition from Clinician to Teacher • Ethics, Values, and Moral Development in Teaching • Educational Philosophy and Adult Learning Theories Nurse's Book Society Selection Springer Series on Teaching of Nursing 2001 232pp 0-8261-1437-7 hard
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Annual Review of Nursing Research, Volume 21 Research on Child Health and Pediatric Issues Joyce J. Fitzpatrick, PHD, RN,FAAN, Series Editor, Margaret Shandor Miles, PhD, RN, FAAN, and Diane Holditch-Davis, PhD, FN, FAAN, Volume Editors This 21st volume of the Annual Review synthesizes nursing research to date on child health and illness, including family issues. Ages range from pre-term babies to adolescents, with a focus on chronic illness. A special final chapter reviews the highlights of the past 10 volumes of the Annual Review of Nursing Research, to mark the 20th anniversary of the Review. Partial Contents: Introduction • Enhancing Nursing Research With Children and Families Using a Developmental Science Perspective Preterm Infants • Development Transition from Gavage to Oral Feeding in the Preterm Infant, S.M. Thoyre Children With Health Problems • Growing Up with Chronic Illness: Psychosocial Adjustment of Children and Adolescents with Cystic Fibrosis, B. Christian Parent and Families • The Sibling Experience of Living with Childhood Chronic Illness and Disability, M. Van Ripe • Maternal Mental Health and Parenting in Poverty, L. Beeber and M.S. Miles A Review of the Second Decade of the Annual Review of Nursing Research Series 2003 384pp (est.) 0-8261-4133-1 hard 536 Broadway, NY, NY 10012 • www.springerpub.com Order Toll-Free: 877-687-7476 Fax: (212) 941-7842 • Tel: (212) 431-4370
