Dr. Murray is Associate Professor and Dean, Saint Louis University, School of Nursing, Dr. Schappe is Professor, Webster University, Mr. Kreienkamp is Vice President, Human Resources, Lutheran Senior Services, Ms. Loyd is Assistant Professor, College of Nursing, University of Missouri-St. Louis, and Dr. Buck is Associate Professor and Director, Nursing Program, Maryville University, St. Louis, Missouri.
The authors acknowledge the contributions of the Missouri Hospital’s Association and the Kansas educators to the development of the clinical faculty academy.
Address correspondence to Teri A. Murray, PhD, RN, Associate Professor and Dean, Saint Louis University, School of Nursing, 3525 Caroline Mall, St. Louis, MO 63104; e-mail: Tmurray4@slu.edu.
It is projected the national shortage of RNs will produce a need for 340,000 to 1 million new and replacement nurses throughout the next decade (American Association of Colleges of Nursing [AACN], 2009a; Auerbach, Buerhaus, & Staiger, 2007; U.S. Department of Health and Human Services, 2006). Despite the enormity of this shortage, nursing schools are turning away thousands of qualified applicants because of limited faculty and clinical resources (AACN, 2009a).
The need to increase the RN work-force will require new and innovative approaches that allow nursing schools to expand their existing capacity to admit more qualified students. Key stakeholders such as hospitals, schools, industry, and government organizations have begun to develop strategic partnerships to assist in expanding the capacity of nursing education programs (Joynt & Kimball, 2008).
Academic and service entities have long realized the need to partner if they are to adequately address workforce challenges. The majority of these partnerships have taken the form of a strategic alliance between an academic enterprise and a health care organization to expand faculty and student capacity. These partnerships have demonstrated success and made sustainable gains in expanding capacity and increasing the number of RN workforce entrants (Allen, Schumann, Collins, & Selz, 2007; Bleich, Hewlett, Miller, & Bender, 2004; Murray, 2007, 2008; O’Neil & Krauel, 2004). For the most part, the partnerships have served to benefit each partner instead of expanding faculty and student capacity within the larger geographic community.
This article describes a unique academic-service community collaborative aimed at increasing the student and faculty capacity in a midwestern metropolitan area. There was growing concern among health care organizations that area nursing schools were forced to turn away hundreds of qualified applicants in the midst of a 9.5% statewide shortage of RNs (Missouri Hospital Association, 2005). Collectively, the schools had experienced a 70% increase in qualified applicants, but most of the schools could not admit all of the qualified applicants primarily due to faculty constraints. The diminishing pool of faculty was identified as the predominant factor contributing to the RN shortage in the community. It became apparent that if there were not enough qualified faculty to teach, the area RN shortage would worsen (Allen, 2008). Moreover, the continued RN shortage could compromise the quality and safety of patient care provided in the community as higher RN staffing levels have been associated with reduced hospital mortality, hospital-acquired pneumonia, unplanned extubation, failure to rescue, nosocomial bloodstream infections, and length of stay (Dall, Chen, Seifert, Maddox, & Hogan, 2009; Shipman & Hooten, 2008).
The Workforce Collaborative
As a key stakeholder, the state hospital association hosted a series of meetings between health care organization and academic leaders to discuss the growing RN and faculty shortages within the metropolitan area. During the meetings, many factors contributing to the need for an increased RN workforce were discussed, such as the aging population; advances in medical science that have increased life expectancy and longevity; the burden of chronic disease demanding a high need for health care services; an aging RN workforce causing a higher number of RNs nearing retirement coupled with older entrants into the field; and workplace discontentment causing increased turnover and vacancy rates. However, the primary concern raised was the inability of area nursing schools to accommodate enrollment increases due to the lack of faculty (AACN, 2009a; Murray, 2008).
With the state hospital association as the buttress, the health care organization and academic leaders formed a unique Workforce Collaborative Pilot Project (WCPP) to address the primary barrier to expanding student capacity, the difficulty in finding clinical faculty. The collaborative consisted of the state hospital association and its 33 member hospitals, the state board of nursing, and 11 nursing schools within the metropolitan area. The state hospital association asked each hospital to contribute monies to support the initiative based on its respective number of hospital beds. The 33 hospitals located within the metropolitan area contributed a total of $150,000 as seed money to fund the project. The contribution from each hospital was based on the hospital size using full-time equivalents and the number of beds as a measure.
With modest funding, the WCPP was launched with three key objectives:
- Expand the pool of educators involved in preparing the next generation of nurses.
- Increase nursing school enrollments by 335 additional nursing students each year in the metropolitan area for the next 5 years.
- Implement and evaluate an innovative educational model that could be sustained or replicated.
The initial seed money was used during a period of 2.5 years. The project then was subsidized by the state hospital association as a regular line item in its budget. The health care organization leaders agreed to share resources, clinician expertise, and clinical facilities with the nursing schools in hopes of recruiting students after they graduated. The health care organizations committed a select group of nurse clinicians to teach as clinical faculty for the nursing schools. The hospital nurse clinicians served as part-time clinical faculty for the schools. The chief nurse executives agreed to provide the nurse clinicians with release time (50%) from the nurses’ regular responsibilities for their educational responsibilities (e.g., preparing for and supervising students in the clinical setting, grading papers, student conferences). The schools then could increase enrollment by allowing the loaned faculty to provide clinical instruction, thereby expanding faculty capacity.
With limited research to support the level and amount of knowledge, skills, and competencies needed for the preparation of clinical faculty, and because excellent nurses are not necessarily expert teachers, the academic leaders (deans and directors from involved nursing schools) committed seasoned full-time academic faculty to design a 2-day clinical faculty academy (CFA) to help prepare the nurse clinicians for their role as clinical faculty (Jarrett, Horner, Center, & Kane, 2008). The nurse clinicians also were required to attend course and program orientations provided by the nursing school where they would serve as faculty.
Given the lack of evidence-based research to support the pedagogy of clinical teaching, some of the schools assigned a seasoned faculty member as a clinical teaching mentor to the nurse clinicians. In addition, the WCPP incorporated various safeguards to ensure a quality educational experience for students by:
- Reducing the student-to-clinical faculty ratio from the typical ratio of 8:1 to a ratio of 5:1 for clinicians who had not previously taught.
- Requiring the nurse clinicians to attend the CFA.
- Documenting the roles and responsibilities of the hospitals, nursing schools, and nurse clinicians as clinical faculty.
- Evaluating the performance of nurse clinicians as clinical faculty and the students taught by them.
The state board of nursing had two regulations that could either facilitate or impede the WCPP’s work to expand educational capacity. The first requirement was that nurses who teach in a baccalaureate program possess a master’s degree, and the second requirement was the ability to request approval for a pilot project. Pilot projects are defined as those educational activities that deviate from the regulatory requirements.
Spearheaded by the state hospital association and the academic leaders, the WCPP submitted a letter requesting the state board of nursing to consider the proposed project as a pilot demonstration project and allow nonmaster’s-prepared faculty to teach the clinical component of the nursing program. The state board of nursing approved a temporary exemption to existing regulations requiring a master’s-prepared RN to teach as long as the clinical nurse was enrolled in a graduate program leading to a master’s or doctoral degree. This action was taken with the goal of increasing the master’s-prepared faculty pipeline. The state board of nursing approved the pilot demonstration project for a 5-year period from 2005 through 2010.
Although limited clinical sites were another reason cited for the nursing schools’ inability to admit more qualified applicants, the collaborative focused on the expansion of faculty capacity through the use of the nurse clinicians serving as clinical faculty. If the chief nurse executives were willing to support the use of the nurse clinicians as faculty and agreed to share resources, the hospital would make available a clinical unit suitable to meet the course objectives. The partnership involved the schools’ use of the hospitals’ human, physical, and financial resources with the goal of expanding capacity in nursing schools as a mechanism to alleviate the nursing shortage (Murray, 2008).
The Clinical Faculty Academy
The purpose of the clinical faculty academy was to provide hospital nurse clinicians with academic sessions on the art and science of teaching. To accomplish this objective, an academic steering committee composed of five academic leaders (deans or directors) and a consultant from the hospital association was created to develop, plan, implement, and evaluate the CFA. The academic steering committee ensured the CFA was designed to provide the nurse clinicians with a foundation that would support them in the role of clinical faculty and to supplement the academic support provided by each nursing school for its instructors.
There was little dissension among the constituents (educators, clinicians, health organization leaders, and school faculty), if any, related to the development of the CFA. This was primarily attributed to the large degree of buy-in from the constituents. Initially, some school faculty members were wary of the ability of clinicians to assume the role of clinical faculty, but they faced the reality that the clinicians were no different than adjunct (contract) faculty hired on a semester-by-semester basis with little or no teaching experience or formal training. The health care organization leaders relied heavily on the expertise of the academic steering committee to develop the appropriate objectives for the CFA.
The 2-day CFA, which was approved for 12.75 continuing education units through the state nurses association, provided didactic content on the following objectives:
- Identify the context and processes necessary for curriculum development and program planning.
- Discuss legal issues related to the education of students in clinical settings.
- Discuss the process of clinical evaluation for students at various levels in the curriculum.
- Describe learning experiences that engage students in developing clinical expertise.
- Explore the challenge of multiple roles as staff, adjunct clinical faculty, and other professional and life roles.
- Describe approaches to clinical preconferences and postconferences.
- Discuss challenges presented by students in the clinical setting (e.g., tardiness, lack of preparation, inappropriate behavior).
- Integrate best practices of clinical teaching.
- Describe the variety of written assignments that may be required of students during clinical experience.
Each CFA would have at least nine seasoned faculty from the participating schools serve as instructors. This greatly assisted with faculty buy-in of the CFA because it provided the faculty with a degree of control over the content and information provided to the nurse clinicians.
In addition, a 3-hour follow-up session was scheduled approximately 8 weeks after the CFA for the nurse clinicians. The purpose of the follow-up session was to assess how the nurse clinicians were progressing in the role of clinical faculty, what was working well, what opportunities for improvement could be implemented, and what might have been provided through the CFA that would be helpful to new clinical faculty members. The follow-up sessions were designed to meet the following objectives:
- Reinforce strategies that promote success in the role of clinical faculty.
- Promote a sense of community among clinical nursing faculty.
- Identify common concerns and issues encountered in the role of clinical nurse faculty.
- Identify resources that promote continued problem solving skills and leadership for clinical nurse faculty.
Evaluative feedback from each follow-up session has led to some changes and additions to the content of the CFA. To date, the WCPP has held seven CFAs in the metropolitan area, resulting in the participation of 100 hospital-loaned instructors, 19 hospital partners, and 13 academic partners.
Nursing School Enrollment
With the expansion in the number of clinical faculty, schools have been able to significantly increase the number of students enrolled in their programs. To date, through the efforts of the WCPP, area nursing schools have expanded enrollment by 1,046 additional new students: 360 in the 2005–2006 academic year, 311 in the 2006–2007 academic year, and 375 in the 2007–2008 academic year. The ability to sustain increased enrollments in nursing schools for the long term is possible only if the area hospitals can continue to supply nurse clinicians to serve as clinical faculty for the schools. Allowing nurses who are currently working on and making progress toward their master’s degree to serve as clinical faculty may encourage some nurses to want to work as full-time faculty after completing their degree.
Student Evaluative Data
Clinicians were evaluated using an end-of-the-course clinical evaluation tool. This tool focused on the nurse clinician’s ability to connect theory and practice, foster learning, and provide meaningful feedback.
For the first three semesters of the project, evaluation scores for the nurse clinicians were compared with those of the school instructors who taught the same course in the same semester. There were no significant differences between the scores of the nurse clinicians and the nurse educators.
School Faculty Evaluation
Qualitative feedback from the school faculty was mixed. In general, school faculty members viewed the project as a positive move in expanding capacity but had three major concerns about the use of nurse clinicians. First, the nurse clinicians varied in levels of skill, commitment, and teaching ability.
Second, some nurse clinicians were assigned to more than one school. All of the faculty frowned on the practice of the hospitals using nurse clinicians to teach at multiple schools. For example, rather than release a clinician 50%, some hospital partners decided to have the clinician teach 100%, thus eliminating the need to find another clinician. As a result, the nurse clinician would be assigned to teach at two different schools. Because the initiative was new, there was no discussion with the hospital partners upfront about limiting the number of schools assigned to the clinicians. Faculty thought the nurse clinicians were not skilled enough to take on this type of teaching load specifically with different institutions and levels of students. It was the perception of the faculty that teaching for more than one school simultaneously would threaten the quality of teaching, although there was no evaluative data or evidence to support this belief.
Third, the academic administrators were dissatisfied with the length of time taken for the hospitals to identify the nurse clinicians. This led to a delay in communicating with clinicians about scheduled orientations, creating a time and scheduling crunch.
Positive comments included statements acknowledging that the nurse clinicians’ familiarity with the policies, procedures, and other health care staff integrated students into the clinical setting more quickly.
Hospital Partner Feedback
Most of the concerns in this section emerged during the implementation phase and, in hindsight, should have been discussed at the forefront. Many of the nurse administrators did not understand why nurse clinicians had to spend time in the clinical laboratories at the nursing school. Many of the nursing courses were front loaded with laboratory time prior to going to the clinical setting. Thus, the administrators did not have a clear understanding that not all of the clinicians’ time would be spent on the clinical unit.
It also was problematic when nurse clinicians were asked to supervise students on another unit instead of the nurses’ unit of employment. In fact, some clinicians refused to teach unless it would be on their work unit. This created problems for and tensions with nonparticipating schools because the school that had been on the unit but was not participating in the initiative would be displaced to another unit to accommodate the wishes of nurse clinicians.
In a few cases, nursing administrators recruited nurse clinicians who attended the CFA. Then, due to changes in enrollments for a particular course, those nurse clinicians were not needed for that particular semester.
Finally, administrators were concerned about the return on the investment. Although the initiative was a community-driven project for the greater good, administrators were concerned about productivity and the budgetary bottom line. It was hoped the new graduates would seek employment at the hospital, which possibly would decrease recruitment and orientation costs; however, the actuality of this had not yet been realized.
Graduate Degree Attainment by Nurse Clinicians
One of the goals of the initiative was to increase the pipeline of master’s-prepared faculty. Of the total number of hospital-loaned nurse clinicians who served as clinical faculty for the schools, more than half already had graduate degrees. During the next 2 years, 30 additional nurses who taught under the initiative are expected to complete their master’s degree.
Although clinicians had to demonstrate proof of enrollment in a graduate program via academic transcript to the institution in which they were assigned to teach, the actual tracking of program completion proved difficult because clinicians might not teach for the same school every semester. To improve this process, a central repository of all loaned clinicians with their academic record should be maintained by the academic steering committee or the board of nursing.
Updates on the WCPP and evaluative information were shared with the hospital and nursing school communities at annual joint meetings of the hospitals and nursing schools. The purpose of the annual meeting was to review the data compiled during each year of the initiative, voice concerns, and problem solve. The meetings were well attended as there was a high level of interest in the initiative and its progress. In addition to sharing the evaluative data, participants discussed issues that could impede the progress of the initiative. Among the issues and concerns expressed at the meeting included the need for the WCPP to:
- Identify a formal process of requesting the use and confirmation of nurse clinicians as loaned instructors.
- Review the financial costs associated with the initiative.
- Seek out additional hospital-loaned nurse clinicians.
- Review the capacity of area hospitals to handle clinical rotations.
- Reexamine clinical rotation sites to ensure the sites meet students’ educational needs.
- Evaluate the respective school’s ability to provide hospital-loaned nurse clinicians with an appropriate orientation, including faculty responsibilities.
In addition to these concerns, the issue of clinical site capacity would need to be addressed to continue with the collaborative. The participants agreed to create two task forces with specific purposes. The first was a clinical education task force that would explore ways to address a potential shortage of clinical sites in the area and explore new methods of structuring clinical education that would still meet the educational needs of schools. The second was a capacity task force that would gather information on the current number of hospital clinical sites available for use by nursing schools in the metropolitan area and the number of clinical sites required by area nursing schools to educate their current and expanded enrollments, to determine whether issues of capacity actually existed.
The task force members consisted of representatives from both hospitals and nursing schools. Further follow-up sessions are planned to report the progress of the two task forces.
Discussion and Conclusion
The WCPP has shown excellent progress in meeting its objectives in the past year. First, the number of hospital-loaned nurse clinicians teaching in the clinical setting has been expanded. In total, 100 nurses in the metropolitan area were loaned to area schools to serve as clinical faculty. Second, 32 of the loaned clinical faculty already had a master’s degree, and the baccalaureate-prepared nurses who are working on their master’s while teaching are making progress toward completing their master’s degree. During the next 2 years, 30 nurses who taught under the initiative are expected to complete their master’s degree. Finally, nursing school enrollment for the metropolitan area has increased by a total of 1,046 students who would have been turned away due to insufficient faculty.
Quality measurements remain positive. The CFA consistently received high ratings from participants. Student evaluations of the loaned clinical instructors from hospitals also were positive.
In the future, the academic steering committee will continue to monitor the WCPP. To date, NCLEX-RN® pass rates have not shown any indication that loaned instructors have adversely affected the quality of education received by nursing students in participating schools. As students continue to matriculate through the nursing education programs, evaluative data will continue to include NCLEX pass rates to measure any changes in student performance in nursing schools that are participating in the project.
Because the hiring of RNs in many states has stabilized due to the economic downturn, the lessons learned from this project may be more significant now than ever given the faltering economy. The shortage, far from over, will intensify as a result of the hiring freezes and delays posed by the current economic climate. As the economy rebounds, the aging nurses who delayed retirement will retire, spouses who were laid off will regain employment, those part-time nurses who resumed full-time employment due to the recession will return to part-time status, and those per diem nurses who increased work hours will return to the pre-recession hours, thus creating a greater need for more RNs to fill the void (AACN, 2009b). The lessons learned from this community-wide academic partnership may prove invaluable in addressing future nursing education and workforce capacity issues as the economy recovers.
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