Journal of Nursing Education

Major Article 

Developing a Statewide Nursing Consortium, Island Style

Lois Magnussen, EdD, APRN; Victoria Niederhauser, DrPH, RN; Charlene K. Ono, MS, APRN-BC; Nancy Katherine Johnson, MSN, APRN; Joyce Vogler, DrPH, APRN; Clementina D. Ceria-Ulep, PhD, RN

Abstract

This article describes the transformational changes in the scope and pedagogy of nursing education within a state university system through the development of the Hawaii Statewide Nursing Consortium (HSNC) curriculum. Modeled after the Oregon Consortium for Nursing Education, the HSNC used a community-based participatory approach to develop the curriculum to support all students within the state who are eligible to earn a baccalaureate degree. The curriculum was designed as a long-term solution to the anticipated shortage of nurses to care for Hawaii’s diverse population. It is also an effort to increase capacity in schools of nursing by making the best use of resources in the delivery of a baccalaureate curriculum that offers exit opportunities after the completion of an associate degree. Finally, it provides new ways of educating students who will be better prepared to meet Hawaii’s health needs.

Dr. Magnussen is Professor Emeritus and former Chair, Hawaii Statewide Nursing Consortium, Dr. Vogler is Associate Professor and Director, Hawaii Statewide Nursing Consortium, Upper Division (2011–2012), and Dr. Ceria-Ulep is Associate Professor and Department Chair, University of Hawaii at Manoa, School of Nursing & Dental Hygiene, Honolulu; Ms. Ono is Chair, Health Education Division, Kauai Community College, Lihue; Ms. Johnson is Chair, Allied Health Department, University of Hawaii Maui College, Kahului, Hawaii; and Dr. Niederhauser is Robert Wood Johnson Executive Nurse Fellow (2008–2011), Dean, and Professor, College of Nursing, University of Tennessee Knoxville, Knoxville, Tennessee.

This study was funded in part by the Hawaii State Center for Nursing, a grant from the Robert Wood Johnson Foundation Evaluating Innovations in Nursing Education project, and the Carl D. Perkins Vocational and Technical Education federal program.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Lois Magnussen, EdD, APRN, 511 Hahaione St., 12D, Honolulu, HI 96825; e-mail: magnusse@hawaii.edu.

Received: January 29, 2012
Accepted: July 18, 2012
Posted Online: January 14, 2013

Abstract

This article describes the transformational changes in the scope and pedagogy of nursing education within a state university system through the development of the Hawaii Statewide Nursing Consortium (HSNC) curriculum. Modeled after the Oregon Consortium for Nursing Education, the HSNC used a community-based participatory approach to develop the curriculum to support all students within the state who are eligible to earn a baccalaureate degree. The curriculum was designed as a long-term solution to the anticipated shortage of nurses to care for Hawaii’s diverse population. It is also an effort to increase capacity in schools of nursing by making the best use of resources in the delivery of a baccalaureate curriculum that offers exit opportunities after the completion of an associate degree. Finally, it provides new ways of educating students who will be better prepared to meet Hawaii’s health needs.

Dr. Magnussen is Professor Emeritus and former Chair, Hawaii Statewide Nursing Consortium, Dr. Vogler is Associate Professor and Director, Hawaii Statewide Nursing Consortium, Upper Division (2011–2012), and Dr. Ceria-Ulep is Associate Professor and Department Chair, University of Hawaii at Manoa, School of Nursing & Dental Hygiene, Honolulu; Ms. Ono is Chair, Health Education Division, Kauai Community College, Lihue; Ms. Johnson is Chair, Allied Health Department, University of Hawaii Maui College, Kahului, Hawaii; and Dr. Niederhauser is Robert Wood Johnson Executive Nurse Fellow (2008–2011), Dean, and Professor, College of Nursing, University of Tennessee Knoxville, Knoxville, Tennessee.

This study was funded in part by the Hawaii State Center for Nursing, a grant from the Robert Wood Johnson Foundation Evaluating Innovations in Nursing Education project, and the Carl D. Perkins Vocational and Technical Education federal program.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Lois Magnussen, EdD, APRN, 511 Hahaione St., 12D, Honolulu, HI 96825; e-mail: magnusse@hawaii.edu.

Received: January 29, 2012
Accepted: July 18, 2012
Posted Online: January 14, 2013

National initiatives have placed the agenda for transformation of the nursing educational system at the forefront of efforts to revolutionize health care in the nation. Recently, the Institute of Medicine’s (IOM) report, The Future of Nursing: Leading Change, Advancing Health (2010), called for better use and preparation of nurses, including a mandate that 80% of all nurses have baccalaureate preparation by 2020. On a similar note, the study of professional education conducted by the Carnegie Foundation for the Advancement of Teaching (Benner, Sutphen, Leonard, & Day, 2010) found that schools of nursing were lagging behind in responding to changes, fostered by science and technology, in the practice setting. They recommended that nursing faculty teach for a sense of salience, with more integration of classroom and clinical teaching.

These current calls to action were not the first recommendations for changing professional nursing education. In 2003, the IOM issued its summit report Health Professions Education: A Bridge to Quality. This report proposed a set of core competencies that should be included in the education of all health professionals. In another call for reform, the Pew Commission (O’Neil & the Pew Health Professions Commission, 1998) urged health professionals to examine the qualities that constitute a competent health care professional. The past and current studies and reports inspired nursing faculty members at the University of Hawaii to transform the nursing education model in the state. This article describes the transformational changes in the structure, scope, and pedagogy of nursing education through the development of the Hawaii Statewide Nursing Consortium (HSNC).

Background

The HSNC is a statewide coalition representing University of Hawaii nursing programs. The University of Hawaii is the only state-supported institution of higher learning in Hawaii. University of Hawaii campuses are located on the four main islands (Hawaii, Kauai, Maui, and Oahu). Six undergraduate nursing programs are within the islands: two baccalaureate programs at University of Hawaii Hilo and University of Hawaii Manoa and four associate in science degree programs at University of Hawaii Community College, Kapiolani Community College, Kauai Community College, and Maui College. Prior to the current efforts, each of the nursing programs offered a separate curriculum and few, if any, resources were shared.

In May 2005, University of Hawaii nursing faculty first met with Dr. Christine Tanner, who presented the initiative undertaken by the Oregon Consortium for Nursing Education (OCNE) and the principles underlying their curriculum reform. There was an overwhelming agreement that Hawaii could move in the same direction, adapting the OCNE model to fit its needs, and that offering a unified, competency-based curriculum at all state-supported nursing programs would greatly improve academic progression in the state. Thus, in 2005, the group embarked on a statewide curriculum project.

To further this effort, the HSNC developed three goals:

  • Increase the number of nurses prepared to meet the changing health care needs of the people of Hawaii.
  • Increase efficiency in the educational preparation of nurses.
  • Increase access to nursing education throughout the state.

After the goals were established, a set of four strategic initiatives guided the work of the group. These initiatives included:

  • Designing a statewide nursing curriculum to meet community needs.
  • Integrating innovative teaching strategies that make efficient and effective use of technology and simulation.
  • Doubling the number of graduates between 2005 and 2012.
  • Maintaining and enhancing quality through the design of a statewide curriculum at the associate, baccalaureate, and master’s levels, enabling more efficient use of faculty and resources.

The Practice and Education Environment

Although the calls for reform and influence of the OCNE model were pivotal in fostering the change effort, other factors within the environment of Hawaii also influenced the nurse leaders to move forward with collaborative planning. An established articulation agreement already enabled associate degree graduates to progress to the baccalaureate degree at University of Hawaii Manoa without repeating basic nursing coursework, yet only approximately 5% of students enrolled in the baccalaureate degree completion programs offered at the two campuses. Because almost all associate degree nursing graduates took at least 3 years to complete their basic preparation and another 3 years to complete a baccalaureate degree, the educational pathway was long. In addition, issues of credit transferability (for non-nursing courses) arose and expectations differed, with some students adjusting to the 4-year campus academic environment. Because the instruction has traditionally been different between campuses, the students were often frustrated. With the unified approach to instruction from the beginning, the students can transfer between campuses with less frustration. Furthermore, with three of the community college programs located in rural communities, which were spread across several islands, access to the only educational advancement opportunities on two islands limited enrollment into the RN-to-BS programs throughout the state.

The nurse educators were also aware of figures that projected a dramatic nursing shortage in Hawaii because of an increase in demand and a decrease in supply (LeVasseur, 2007). Forecast data indicated that Hawaii could expect a dramatic demographic shift related to its aging population over the ensuing 15 years, occurring at a pace twice that of the rest of the United States. Between 2000 and 2020, the number of people aged 60 years and older living in Hawaii was expected to increase by almost 75% and people aged 85 years and older by 121%. By 2020, one of every four people would be 60 years or older, and one of 35 people would be 85 years or older (Executive Office on Aging, State of Hawaii, 2003). This aging phenomenon would directly influence the Hawaii nursing workforce in terms of both supply and demand for services. The 2009 Hawaii Registered Nurse Survey (LeVasseur, 2010) indicated that more than 70% of active RNs approaching their 50s and 60s would gradually retire from the workforce during the next 15 years. This loss of nurses would be proportionally greater on the neighboring islands (Hawaii, Kauai, and Maui). The Hawaii State Center for Nursing projected that demand for RNs in Hawaii by 2020 was expected to grow by 28%, whereas growth in supply of RNs was expected to be less at 8.9% (LeVasseur, 2007). This shortage of approximately 2,670 RNs would be equivalent to the loss of all RNs at the two major health centers: Hawaii Pacific Health System and The Queen’s Health System.

It should be noted that since planning for the new initiative began in 2005, the national picture has somewhat changed. Currently, new nursing graduates are faced with an unexpected delay in hiring (or face being hired in a lower grade position such as a unit secretary or a nurses’ aide) within the health care sectors. New graduates face difficulty in securing their first job; however, indicators predict this dynamic will change when the recession is over. Yet, according to the Oregon Center for Nursing’s report, Nurses Wanted: The Changing Demand for Registered Nurses in Oregon (2011), employment of RNs in the United States is expected to grow by 22% from 2008 to 2018, which is much faster than the average growth for all occupations. Growth will be driven by technological advances in patient care, which permit a greater number of health problems to be treated, and by an increasing emphasis on preventive care, which is particularly responsive to nursing measures. In addition, similar to the Hawaii projections, the number of older people, who are much more likely than younger people to need nursing care, is projected to grow rapidly. Employment of RNs in acute care (hospital) settings is expected to grow more slowly than in other sectors. Employment of RNs in nursing care facilities and home health care is expected to grow because of increases in the number of older adults, who are the primary consumers of these services.

This new dynamic supports the IOM’s (2010) reported forecast regarding the need for nurses educated with the baccalaureate degree. The data provided in the most recent Hawaii State Center for Nursing report (LeVasseur, 2010), based on a response rate of 40% (8,000 of the 19,999 nurses in the state), indicated that 60% of the respondents already possessed a baccalaureate degree in nursing. The percentage of nurses in Hawaii with a baccalaureate degree is somewhat higher than the national norm of 50% reported in the IOM (2010) document; however, it is still well below the 80% target to be reached by 2020.

On another front, there was a national call to revisit and rethink nursing pedagogy. The National Research Council’s report How Students Learn (Donovan & Bransford, 2005) suggested that many educational practices were not conducive to learning. In preparing students for the NCLEX®, many nursing faculty used teaching strategies that encouraged memorization of large amounts of material, or surface learning (August-Brady, 2005; Entwistle & Ramsden, 1983). Consequently, it was argued that most students did not retain coursework on a long-term basis. The group agreed to use a curriculum development process based on principles of learning used in the Wiggins and McTighe model (2005) of “backward design,” which shifted the process of curriculum design so that specific learning outcomes were sought, rather than covering the content outlined in textbooks. Wiggins and McTighe suggested there is a distinction between knowing and understanding.

The faculty were also aware of the literature that pointed out that management of curricular content was one of the pressing issues in nursing education (Giddens & Brady, 2007). The IOM (2003) identified overly crowded curricula as one of the challenges of health care reform. Traditionally, most faculties have attempted to cover all of the content in textbooks in class. Because the advancement of medical science has increased content volume in nursing textbooks, it has become more difficult for students to develop an understanding of the concepts introduced during one semester. Destuffing the nursing curriculum became a mantra for the Hawaii curriculum planning group.

The positive example of change provided by OCNE catapulted the Hawaii curriculum steering committee into planning for reform. It was anticipated that in addition to the pedagogical changes, through development of a single curriculum, the statewide curriculum would minimize unnecessary duplication of services, capitalize on existing and new technological tools, and streamline nursing education delivery in the state of Hawaii. Furthermore, reducing the length of time (from 3 years to 1 year) required for associate degree graduates to obtain the baccalaureate degree (Table A; available as supplemental material in the online version of this article) would create a cost-effective educational alternative that requires less time commitment from nursing faculty and allows students to proceed more quickly into their careers. The group realized that the unification of the educational programs would maximize the state of Hawaii taxpayer investment by creating one pathway to the baccalaureate for students throughout the state. At the full implementation, the consortium effort will increase the number of nurses in Hawaii prepared with the baccalaureate degree.

Preliminary Planning and Stakeholder Buy-In

In preparation for the statewide effort to design a unified curriculum, the HSNC began their work, meeting monthly in face-to-face meetings. The HSNC represents all nursing faculty in the University of Hawaii system; however, the group participating in deliberations (referred to in this article as the steering committee) included the directors of each campus’s nursing program, the Dean of University of Hawaii Manoa’s School of Nursing and Dental Hygiene, key faculty from each campus, community representatives, and representatives from the University of Hawaii System Academic Planning Office. In the initial planning, representatives from community nursing groups were invited to become members and attended the meetings periodically.

It should be noted that membership in the HSNC came to be differentiated from the HSNC curriculum adopters. The curriculum discussions included representatives from all campuses; however, the first wave of curriculum implementation included three (of the six) undergraduate nursing programs: those at the University of Hawaii Manoa School of Nursing and Dental Hygiene, University of Hawaii Kauai Community College, and University of Hawaii Maui Community College. The second phase of curriculum implementation occurred in fall 2012, when Kapiolani Community College launched the curriculum.

The first task of the steering committee was to deliberate about key competencies that would serve as the program outcomes. The group began by reviewing the OCNE competencies and found they closely paralleled two key national initiatives: the Pew Commission’s Recreating Health Professional Practice for a New Century (O’Neill & the Pew Health Professions Commission, 1998) and the IOM report Health Professions Education: A Bridge to Quality (2003). The steering committee adopted competencies that used key aspects of each initiative.

Laying the Foundation for the Curriculum

The steering committee realized it was important to use the OCNE model as a framework but to adapt it to our unique set of circumstances, population, culture, and programs. To begin the process, draft competencies were created and debated over 1.5 years (Table B; available as supplemental material in the online version of this article). Next, the steering committee developed outcomes based on the competencies for each year of the 3-year curriculum (Table B) The final task, to lay the foundation for the new curriculum, was to identify the health indicators, disparities, and major health issues in the state. This information was then used to guide focus areas throughout the curriculum.

Concurrent with the discussions about important competencies for the curriculum, the steering committee laid out the broad strokes of the curriculum. The following were points of agreement:

  • The curriculum should be a 4-year baccalaureate program with options for community college students to either exit with an associate degree after the third year or automatically continue to the fourth year in a seamless progression.
  • The curriculum would be concept based, incorporating an active learning pedagogical approach (Giddens & Brady, 2007; Hardin & Richardson, 2012).
  • Due to the need to incorporate more clinical applications into the classroom setting (Benner et al., 2010; Donovan & Bransford, 2005), all nursing courses would be large credit courses (i.e., 9 to 10 credits) that allowed for blending the theory with the clinical components.
  • The courses would begin with health promotion and progress in a spiral fashion (Harden & Stamper, 1999; Ross, Noone, Luce, & Sideras, 2009) to introduce health issues across the life span.

After the competencies and benchmarks for each year were established, the next phases included creating the curriculum; developing the courses; infusing technology, academic policies and procedures; clinical redesign; and changing instructional practices. Each of these phases is summarized in the following sections.

Creating the Curriculum

Nursing education content has continued to expand to levels that are unmanageable for students and faculty alike. Although there was a belief that the current curriculum was overstuffed, it became apparent early on that it would be difficult to correct this without expert consultation. Nursing faculty were reluctant to let go of some content. The HSNC steering committee learned from our OCNE mentors that they had engaged nurses from the nursing practice arena to assist with defining essential knowledge based on their practice experience. We convened group discussions with practice representatives from key areas, such as pediatrics, medical–surgical, and psychiatric settings, to inform us on what they considered essential knowledge. This information, as well as data from the Hawaii Health Data Warehouse regarding key health indicators in Hawaii, was used to define the essential concepts for the HSNC curriculum. Because the curriculum was integrated and not conceptualized along traditional specialty boundaries, this work was essential. Even with this assistance, it was not easy to reduce the amount of material to be included in the curriculum, and this is a task with which the faculty continues to grapple. However, the answers to the question of essential knowledge became the concepts to be included in the curriculum.

The next steps were to organize the integrated curriculum in a way that made sense for the optimal achievement of the competencies. Following the essential content discussions with the practice partners, it was apparent that adopting a basic schema would assist in developing an organizing framework for the curricula. After some debate and discussion about various taxonomies, we agreed to use the Diagnostic Division Index (Doenges & Moorhouse, 2008) to organize the physiologic concepts that were essential for nursing education. It also became apparent that there should be three levels of conceptual focus: professional (HSNC Competencies), physiological (Doenges & Moorhouse, 2008), and environmental (those pertaining to community and public health issues) (Table C; available as supplemental material in the online version of this article).

Developing the Courses

The extent to which the courses would remain medical specialty specific, or integrated according to concepts basic to nursing, was a point of extensive discussion. The faculty group was interested in following an integrated course model. It was believed that this type of organization would assist in making the curricular approach more conducive to deep, rather than surface, learning (August-Brady, 2005; Entwistle & Ramsden, 1983) because students would be freed from the “content saturation” (Giddens & Brady, 2007, p. 66) that has been typical in the nursing curricula. However, it was not easy to achieve agreement on this issue. A key issue in the discussion was regarding the specific integration of psychiatric, mental health, obstetrics, and pediatric nursing. The psychiatric nursing group agreed that much of their specific focus could be achieved within any nursing course because mental health should be a focus in all of nursing. In the spirit of consensus, the specialty group agreed that their unique concepts would be integrated within all courses.

The courses differed from those in the OCNE curriculum in that they each focused on a lifespan approach to health promotion related to the concepts in spiral fashion rather than a locus-of-care approach. In addition, unlike the OCNE curriculum, all students would receive a specific psychiatric clinical experience at the end of the second year and a focus on psychopathology in the final pathophysiology course in the senior year. Finally, (again, unlike OCNE), the taskforce agreed to recommend a lifespan family health course (Health and Illness II) in the first semester of the junior year that would allow the concepts to be introduced as they applied to family issues, including childbearing, childrearing, and the menopausal phase. These agreements gave flesh to the curriculum plan. The curriculum framework, course titles, descriptions, and credit hours were discussed and approved in concept approximately 3 years prior to implementation (Table A).

Having made the structural decisions regarding the curriculum, the steering committee was free to develop the course descriptions for each of the identified nursing courses. They agreed that each clinical nursing course (six courses) should be based on the HSNC competencies, with the nine student learning outcomes for each course being derived from each of the nine competencies.

When the basic planning was conceptually sound, the group was free to move to develop the specific courses. Each specialty group’s basic list was separated into the physiologic concepts identified in the Doenges and Moorhouse (2008) document, and each item was fit into the course most appropriate for it. The work of course development was given to course groups that comprised faculty from all campuses who would later teach the course.

Infusing Technology

As indicated in the strategic initiatives, during the initial planning for the curriculum it was realized that technology should be used fully to support the HSNC curriculum. Technology has dramatically influenced the development of the curriculum and has been the source of creative teaching tools. We recognized that offering the curriculum via distance for the senior-level courses would be one way to augment the resources used for course delivery. In addition to specific online course delivery for nonclinical nursing courses, all courses use a University-sponsored distance learning Web site that provides resources for enrolled students. It should be mentioned that online course delivery is not new technology, and many academic institutions currently serve diverse geographic regions via Web-based instruction.

A dedicated HSNC Web site, accessible to all faculty members, was set up to serve as a repository for all documents supporting the consortium. This Web site contains all policies and program agreements, as well as the audiovisual files of faculty development programs. Furthermore, each course has its own link on the Web site so faculty can access the official syllabi and share course materials. The Web site allows interactive communication among faculty members and is based on the knowledge that a key factor in conserving faculty time is the sharing of teaching materials. The resources on the Web site include items such as student-ready case studies, simulation scenarios, group discussion guides, concept-based learning activities, reference lists with study guides, and clinical learning activities. The instructional design involved in developing, pilot testing, and revising these learning objects requires enormous time, but faculty have found these instructional aides to be useful.

A state-of-the-art simulation laboratory is available at all campuses and provides a preclinical experience for students. In addition to course-based faculty, clinical faculty trained as simulation instructors are a resource to support the use of simulation in each nursing course. These faculties support the simulation experience for students by helping them to develop a concept map for each case they experience during the clinical simulation. Finally, a Web-based series of case exemplars is available and is being further developed to provide real-life cases to meet curriculum concept-based instructional requirements.

Academic Policy and Procedures

The Hawaii State Board of Nursing had been apprised of the reform efforts from the outset, and prior to seeking campus approval, a formal proposal was sent to them requesting approval of the revised curriculum. The proposal was submitted as a joint application from all campuses planning to implement the HSNC curriculum. Approval was provided by the Board of Nursing, although the curriculum was viewed as a revision and not as a new curriculum (given that all campuses were already approved as providers of basic nursing education). The next levels of approval came from campus and curriculum committees on each campus. Each campus separately sought the required levels of individual approvals; however, documents were freely shared among the campuses, which made the process much more manageable. The final approvals were sought with a petition for substantive change from the National League for Nursing, which was the accrediting agency for the community college nursing programs. The University of Hawaii Manoa sought this approval with the application for reaccreditation from the Commission on Collegiate Nursing Education. All appropriate approvals were secured before the campuses launched the first class of the HSNC curriculum (Figure).

Flow chart describing the process of developing the Hawaii Statewide Nursing Consortium.

Figure. Flow chart describing the process of developing the Hawaii Statewide Nursing Consortium.

Clinical Redesign

Evidence points to the need to reexamine clinical nursing education (Benner et al., 2010; IOM, 2010; Tanner, 2006a). The methods to educate nursing students clinically have not changed in the past 30 years, despite significant changes in the health care environment. Prior to implementation of the HSNC curriculum, a major effort was made to reexamine clinical teaching and open up discussions with the nursing community about better ways to educate students in clinical settings. This process, described in detail elsewhere (Niederhauser, Schoessler, Gubrud-Howe, Magnussen, & Codier, 2012), brought practice and academia together to develop creative clinical learning opportunities in the hope of better preparing graduate nurses for the current work environment.

During spring 2010, seven models of clinical learning were implemented and evaluated. The focus of the evaluation was on the return on investment in terms of efficiency and effectiveness.

The clinical models evaluated included:

  • Use of avatars for conducting health assessment clinical learning.
  • Student learning outcome assessment for concept-based learning activities during hospital clinical rotations, coupled with simulation experiences in early medical–surgical nursing students.
  • Use of nontraditional settings for clinical learning of leadership skills.
  • Promotion of methods to engage staff nurses in clinical teaching using Tanner’s (2006b) four phases of the clinical judgment model (noticing, interpreting, responding, reflecting).
  • Evaluation of simulated learning in crisis early recognition and prevention for advanced medical–surgical students. Many of these new clinical learning models were replicated and expanded for use with the new curriculum.

Additional clinical learning opportunities created for the HSNC curriculum included a combination of case-based learning using simulation and The Village case studies. The Village is a group of families, developed by the consortium faculty members, that mimic the ethnic, racial, socioeconomic, and health and wellness issues in the Hawaiian population. For example, the Kahue family is Native Hawaiian and includes a tutu (grandmother), a mother, a father, a teenage girl (who is pregnant), and a hanai child (adopted); another family is a young military couple who have relocated to the islands. Each family has several members, and the cases unfold as the student progresses throughout the curriculum. These cases present themselves using different media, such as high-fidelity simulation or written case studies.

Changing Instructional Practices

Although most faculty agreed on the importance of changing the pedagogical approach, it has not been easy to let go of accepted classroom practices based on a teacher-focused approach. In anticipation of that, the consortium engaged in faculty development during the entire period of curriculum planning. We engaged the services of nationally recognized consultants to provide faculty workshops and seminars. During the planning years, at least one national consultant was brought in each year for the all-campus meetings on Oahu. Journal articles that highlighted the rationale and strategies for changing one’s instructional paradigm were shared via an online mailing list. Faculty discussion groups were convened as lunchtime sessions to share examples of how one might use an active learning strategy instead of solely relying on PowerPoint® presentations to cover the material. The word cover took on a pejorative meaning in the effort to change, as the faculty realized that developing the evidence-based practice capabilities of our students shifted the focus of gathering information to them. Faculty shared with each other during the videoconferencing course group meetings. Teaching objects, such as concept-based learning activities, were (and continue to be) shared via the HSNC Web site.

On another front, a nursing Curriculum Development course, offered through the University’s graduate program and taken by many faculty members, was revised to highlight the importance of curriculum and pedagogical reform. These strategies have been instrumental in bringing about change and will be continued, given that some faculty members have disclosed the need to make this change with “baby steps.”

Meeting the State Need for Nurses

Because the HSNC curriculum has not been in place long, it is unclear how it will influence the number of nursing graduates within the state. However, the HSNC work commenced during a period when the state of Hawaii recognized and planned for the effects of a nursing shortage by increasing the amount of funding provided for nursing faculty positions on each campus. As a result, additional students have been admitted to each program. In 2005, a total of 237 graduates completed either the associate or baccalaureate degree in nursing within the University of Hawaii system. By 2010, a total of 310 nursing students were graduated. Although the final numbers have not yet been provided for 2012, indications are that although the goal of doubling the number of graduates from nursing programs across the University of Hawaii system has not been met to date, a modest increase has been more than adequate to meet state needs.

Lessons Learned During the Implementation

As with any innovation, there were stumbling blocks to address during the early implementation phase.

Maintaining Momentum for Planning

Theories of change describe the challenges faced by any undertaking that changes basic patterns of behavior, or “how we do things.” A major focus of the HSNC curriculum is to engage in pedagogical reform. In addition to changing the curriculum pattern, as well as courses that were taught with a certain comfort level by nursing faculty, we were looking at changing the pedagogical pattern. The prospect of undertaking a change of this magnitude was somewhat daunting in the beginning of the curriculum change work, and it certainly engendered some stress. Although faculty members were inspired as we began the planning process, the enthusiasm needed to be rekindled from time to time. The series of faculty development offerings described previously in this article also helped to maintain the momentum. These workshops were instrumental, not only in helping faculty to understand the reason and the mechanism for changing pedagogy but also to maintain enthusiasm.

One of the faculty members, inspired by the change effort, developed a newsletter featuring testimonials and pictures of University of Hawaii students from each island. The newsletter was titled “Students as Learners and Teachers,” or “SALT.” The metaphor of salt was used because salt preserves (students in the HSNC curriculum will preserve knowledge), salt mixed with water disinfects, salt adds flavor, and salty water reduces stress (e.g., swimming in ocean water, sweating during exercise). Salt is also present in the tears needed to get through the program and tears of joy at graduation. This newsletter was distributed to students and teachers as a way of sharing the responses of students experiencing the new teaching paradigm.

Facing the Challenge of Losing Campuses to the Effort

Although the initial curriculum discussion centered around the plan to have all nursing programs within the University of Hawaii system participate, various factors led to a decision by three of the campuses to decline offering the curriculum in the first wave of implementation. One additional campus agreed to offer the curriculum beginning in fall 2012. Each campus declining the first phase offering had individual reasons. Common factors revolved around schools having other priorities at the time, such as the process of seeking National League for Nursing Accrediting Commission reaccreditation or responding to unique community needs. The nonparticipating campuses indicated that they would like to remain in the HSNC, as they saw many benefits to working on issues with the Consortium. Rather than leading to a schism that would fracture group solidarity, the Consortium chose to regard the campuses choosing not to launch the curriculum as continuing partners—members of the Consortium but not sites where the curriculum would be offered. This flexibility in membership has led to continuing good relationships and continued input from all campuses regarding issues that are faced.

Requirements for Maintaining Group Cohesion and Buy-In

The best advice we can offer to others contemplating a unified curriculum plan is that flexibility should be key in working as a group. The HSNC agreed early on that we would respect local judgment in most issues, particularly in the community colleges, where there is a mandate to serve the community. We allowed for local control of specific issues, such as admission processes and requirements and requirements for clinical settings. The group agreed that individual campus choice to respond to community needs should be respected; however, it was agreed that as a fundamental principle, we all would offer the same curriculum plan and would keep sacred the outcome competencies and student learning outcomes for each course. We also use a shared academic policy regarding evaluation and grading within consortium courses.

Maintaining Faculty Buy-In in the Face of Hard Work

As the courses were launched, it became apparent that even with the underlying conceptual work completed, the effort required for making a course operational was tremendous. In addition, faculty groups needed to plan new strategies for their teaching, and it was tempting to rely on the trusted lecture approach to teaching even when there was an emphasis on the use of active learning strategies to foster deeper learning by students. Also, students who have been brought up in a system where they are the recipients of faculty wisdom are often much more comfortable with the lecture approach, where they are given everything they need to know about a subject in a box. A key factor in maintaining faculty enthusiasm for the change has been the interaction among all campuses in the consortium meetings and the regular videoconferencing within statewide course groups. However, change efforts take time and energy, and the support given to faculty in the form of dialogue, workload credit adjustments, and mentoring will need to be maintained for some time.

Funding to support travel for neighboring-island faculty to meet in face-to-face workshops with their Oahu peers at least twice per year has been secured from the Hawaii State Center for Nursing, as well as from the Carl D. Perkins Act funds available through the community colleges from the Office of Vocational and Adult Education. These semi-annual meetings at the end of each semester have been instrumental in maintaining enthusiasm for the changes in the curriculum. Faculty members find benefit from the enrichment of direct interaction and sharing with each other. In addition, each course group holds monthly videoconference meetings during the semester to discuss common issues.

Expense of Blurring the Lines Between the Clinical Experience and Theory

With the implementation of the curriculum, it became apparent that the high-credit courses posed some problems with faculty workload, cost of offering the curriculum, and, finally, the effect of course failure on students. In the original curriculum, part-time and nontenure-line faculty had become accustomed to having student contact for only 2 days per week. They were not expected (or paid) to attend the classroom sessions and could do their preparation for the clinical experience and the grading of student work on a flexible time schedule. The obvious drawback to that approach (which influenced the decision to offer the clinical and theory portions of the class in a blended manner, blurring the lines between the two) was that the clinical faculty were often unaware of the material that had been covered in class and did not always make a connection between the two. On the other hand, students sat in a classroom with clinical information provided in an abstract fashion that lacked an easy application to actual practice. This lack of clinical applicability affected students’ practice capabilities. As Benner et al. (2010) pointed out, the influence of the decontextualized information was apparent.

But when faculty began teaching the high-credit courses and were required to attend more of the campus-based classes, they found this was overwhelming. The change required them to be on campus at least 4 to 5 days per week. Faculty were scheduled with a new approach to the clinical experience that encouraged them to work to support the course as a group, sharing campus instruction, and each accommodating a group of 13 to 14 students. For faculty, who in the previous curriculum had been scheduled to take two groups of 8 to 10 students each to a clinical experience (approximately 16 to 20 students), the responsibility for only one group of 13 to 14 students was seen as somewhat of a relief. However, the additional contact time was a point of contention. It was also recognized that the initial launching of the curriculum was more time intensive for faculty than had been expected. Our mentors from OCNE had given us some advice about expecting the first year to be the most difficult, but it was hard to predict every issue that needed to be solved when undertaking a change of this type. We also found that in a large program where faculty hiring is an ongoing issue, the mentoring role of the course coordinator becomes more pivotal to course success because he or she is required to make sure each new faculty understands the curriculum and can effectively work as part of the team. This aspect of course coordination, in addition to the already complex need to arrange off-site clinical experiences, has significantly increased the workload.

Regarding student failure, with high-credit courses a failure would have a substantial effect and unintended consequences for students, even when they returned to complete the course successfully. There has been considerable discussion about this and for a brief period, faculty contemplated changing the blending of theory and clinical experience so that each course would be split into two course syllabi, one for each aspect of instruction. When faculty realized the effect the split would have on hiring, as well as the commitment to base classroom instruction on active learning and the use of clinical applications, they agreed to revisit the issue. The decision was finally made to continue with the high-credit courses. Currently, the Vice Chancellor for Academic Affairs is considering a change proposed by the institution’s faculty senate that would allow students to replace a failed course grade by the grade earned on the repeat. If implemented, this change would lessen the effect of failure in a high-credit nursing course, provided the student is eligible to repeat the course (i.e., this is the first critical nursing course the student has failed).

Program Evaluation

Recognizing this was a total transformation in the way we educate nurses, the steering committee sought funding for a strong formative and summative evaluation process. In fall 2010, the Robert Wood Johnson Evaluating Innovations in Nursing Education funded a mixed-methods research study on the effect of implementing a statewide nursing curriculum on the work life of faculty, the cost of the change, and the curriculum effects on student outcomes. Our study has completed the first year of data collection, and analysis is underway.

Conclusion

The HSNC curriculum was developed as a joint project by all nursing faculty teaching in the University of Hawaii system, which includes a comprehensive campus, a research intensive campus, and four community colleges located on three islands. Because of the commitment to group solidarity and consensus building, the group has remained cohesive, and by August 2012, four of the six nursing programs are offering the Consortium Curriculum. The key factors included in the plan have been:

  • Meeting community needs for baccalaureate nursing education across the state.
  • Increasing the numbers of nurses graduated by increasing educational efficiency.
  • Reforming educational pedagogy to focus on active learning strategies, including using simulation and distance technology.

This curriculum change has been faculty driven and remains in the hands of faculty for full implementation. Hawaii has demonstrated that statewide curriculums, like the OCNE curriculum, can be adapted according to local health, community, and schools’ needs and serves as a well-developed plan for offering a nursing curriculum.

References

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Flow chart describing the process of developing the Hawaii Statewide Nursing Consortium.

Table A. University of Hawaii (UH) Statewide Nursing Consortium Curriculum.

Flow chart describing the process of developing the Hawaii Statewide Nursing Consortium.

Flow chart describing the process of developing the Hawaii Statewide Nursing Consortium.

Table B

Table B. University of Hawaii Statewide Nursing Competencies

Table B

Table B

Table B

Table B

Table B

Table C

Table C. Hawaii Statewide Nursing Consortium (HSNC) Concept Development

Table C

10.3928/01484834-20130114-01

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