Journal of Nursing Education

Major Article 

Creating Innovative Programs for the Future

Patricia E. Allen, EdD, RN, CNE, ANEF, FAAN; Vicki A. Keough, PhD, APRN-BC, FAAN; Myrna L. Armstrong, EdD, RN, FAAN

Abstract

Although several major national mandates advocate for a better educated workforce, this push comes at a time when the competition for faculty, financial resources, advanced technology, and students remains strong. If nurse educators are seriously considering creating a new nurse program at their school, some key points are essential during the development stage. Using the innovation frameworks from the Institute of Healthcare Improvement, from the global design firm IDEO, and from Gladwell’s The Tipping Point: How Little Things Can Make a Big Difference, this article examines the informal, formal, internal, and external work needed during program conceptualization, initial program exploration, resource infrastructure, support, and evaluation for an effective and innovative plan. [J Nurs Educ. 2013;52(9):486–491.]

Dr. Allen is Professor and Director of the Center for Innovation in Nursing Education, School of Nursing, and Dr. Amstrong is Professor Emerita, Texas Tech University Health Sciences Center, Lubbock, Texas; and Dr. Keough is Dean and Professor, Loyola University Chicago, Niehoff School of Nursing, Maywood, Illinois.

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

Address correspondence to Patricia E. Allen, EdD, RN, CNE, ANEF, FAAN, Professor and Director of the Center for Innovation in Nursing Education, Texas Tech University Health Sciences Center, School of Nursing, 3601 4th Street, Lubbock, TX 79430; e-mail: patricia.allen@ttuhsc.edu.

Received: December 13, 2012
Accepted: April 24, 2013
Posted Online: August 19, 2013

Abstract

Although several major national mandates advocate for a better educated workforce, this push comes at a time when the competition for faculty, financial resources, advanced technology, and students remains strong. If nurse educators are seriously considering creating a new nurse program at their school, some key points are essential during the development stage. Using the innovation frameworks from the Institute of Healthcare Improvement, from the global design firm IDEO, and from Gladwell’s The Tipping Point: How Little Things Can Make a Big Difference, this article examines the informal, formal, internal, and external work needed during program conceptualization, initial program exploration, resource infrastructure, support, and evaluation for an effective and innovative plan. [J Nurs Educ. 2013;52(9):486–491.]

Dr. Allen is Professor and Director of the Center for Innovation in Nursing Education, School of Nursing, and Dr. Amstrong is Professor Emerita, Texas Tech University Health Sciences Center, Lubbock, Texas; and Dr. Keough is Dean and Professor, Loyola University Chicago, Niehoff School of Nursing, Maywood, Illinois.

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

Address correspondence to Patricia E. Allen, EdD, RN, CNE, ANEF, FAAN, Professor and Director of the Center for Innovation in Nursing Education, Texas Tech University Health Sciences Center, School of Nursing, 3601 4th Street, Lubbock, TX 79430; e-mail: patricia.allen@ttuhsc.edu.

Received: December 13, 2012
Accepted: April 24, 2013
Posted Online: August 19, 2013

To advance a better educated workforce by 2020, many nurse educators around the country are considering new nursing programs (Institute of Medicine, 2010). Henry Ford once said, “If I’d asked customers what they wanted, they would have told me ‘A faster horse!’” because he felt “people don’t know what they want until you show it to them” (Isaacson, 2011, p. 349). Thus, nurse educators will need to be the leaders at the academic “inaugural forefront as architects” of tomorrow’s nurses, anticipating “what they’re going to need, before they do” (Isaacson, 2011, p. 570). We had recent experience in setting up new nursing programs in each of our schools, one private and one public, and will share our lessons learned in this article.

Some comfort might have been obtained by observing the past, trying to re-create or revert back to previous successful programs; however, gone are the days of automatic success in the “you build it and they will come” philosophy. Traditional planning produces traditional nursing programs, but the current times need new ideas and programs to improve patient care delivery and outcomes while reducing costs. Extensive preparation is required and competition is strong, not only for faculty, money, and technological delivery but also for students. This article challenges educators to be part of nursing’s redesign. Administrators must rethink standard practices, seek new ideas, and examine the environment to project different skills that today’s graduate nurses need for future health care. In other words, ascribe to Wayne Gretzky’s maxim of “skate where the puck’s going, not where it’s been” (Isaacson, 2011, p. 349). Crucial steps are highlighted in this article to successfully launch an innovative nursing program, including (a) conceptualization of the plan, (b) initial program exploration, (c) resource infrastructure investigation, (d) garnering support and suggestions for working the system to maneuver the political obstacles, (e) evaluation, and (f) administrative management (Figure).

Steps for creation of a new program.

Figure. Steps for creation of a new program.

Conceptualization

Just as health care reform has challenged health care systems to create innovative delivery systems, nursing education programs must also be carefully scrutinized, not only for quality but for creativity. To stimulate this creativity, IDEO, an award-winning, global design firm and national leader in “the art of innovation,” created a “Deep Dive” framework (an in-depth topic exploration) using brainstorming (Kelly, 2001, p. 8). A similar innovation framework is also used by the Institute for Healthcare Improvement. Brainstorming begins by gathering a group of innovators and early adopters of preferably six to 10 participants to form the conceptualization team. This brainstorming must be intentional, driven by a process, and where all ideas are brought forward for consideration; all participants are encouraged to think outside the box and explore what might be. Usually, conceptualizing what might be emerges from intense dialogue about what is and where the future of nursing needs to move. Frequently, rethinking something as complex and tradition bound as nursing education allows new educational prototypes to emerge. By brainstorming, educators can transcend old assumptions, explore radical tangents, and unleash new solutions to prepare a quality nursing workforce.

The conceptualization team requires support and acknowledgement by the administrative leadership team of the important work being done in program development. Supporting this initiative is critical to school-wide acceptance of the emerging program and ultimately encourages innovation throughout the school. Finally, the brainstorming session(s) should conclude with a conceptualization of goals of the program, the outcomes, and the proposed time line for development (Massoud, Nielsen, Nolan, Schall, & Sevin, 2006). Leadership support for the opportunity to conceptualize is rewarded by the team’s submission of an identified plan of action.

Initial Program Exploration

Although the nursing literature can be a rich source of information, the fact remains that most published articles are based on at least one previous year’s research on the topic. When preparing for a new program, literature reviews should be focused on gathering information on current economics, trends, management, and policy issues in health care that is found in national newspapers, news magazines, and other national reports, such as from the Institute of Medicine, Robert Wood Johnson Foundation initiatives (Hassmiller, 2011), as well as publications of the American Association of Colleges of Nursing and National League for Nursing.

In his book, The Tipping Point: How Little Things Can Make a Big Difference, Malcolm Gladwell (2002) speaks of the “Law of the Few,” meaning one should seek out “a few” stakeholders who will support his or her ideas and move them forward (p. 31). This direction from Gladwell to seek out a few stakeholders is ideal for initially creating innovative programs. One suggestion toward this goal is to seek holistic assessments externally. Another suggestion may be to talk to many, while gelling new program concepts, which means opening the net widely, both in nursing and outside of the profession, to determine what others are doing with their best methods and ideas, which could lead to shameless borrowing (Billings, Allen, Armstrong, & Green, 2012). Also, appoint an External Advisory Focus Group that represents a variety of stakeholders, including top business and public leaders, community college representatives, regional health care personnel, and other health care disciplines, as valuable partnerships can evolve from this dialogue. In addition, talk with your graduates, the students who applied but who did not attend your school, and even those who did not complete the program. Only after your basic redesign is conceptualized should you determine whether there are similar major nursing programs in the state, region, or nation that might have or be thinking about similar proposals.

The program needs to be aligned with the new learning and practice environments; how will you be “preparing the students differently for the teaching–learning experiences?” (Dickerson, 2012, p. 447). Gladwell (2002) speaks to the “Power of Context” (p. 30). This concept relates to social acceptability—how is it socially, environmentally, economically, and politically feasible? New learning styles and patterns of modern education are important. Today’s students use iPads®, iPhones®, YouTube, Internet learning, distance learning, blogs, social media sites, immersions, and Skype for their didactic learning. Consider new methods for patient or client experiences based on the scaffolding theory, such as the clinical coach model, where the student stays with one experienced, baccalaureate-prepared staff nurse for an entire semester, working the same schedule as the coach (Allen, VanDyke, & Armstrong, 2010). How will your program incorporate these current and future methodologies?

Resource Infrastructure

Human

An existing review of your resources is essential to the planning of a new program.

Faculty. How will your faculty “engage in a different kind of facilitator–learner relationship?” (Dickerson, 2012, p. 447). The new facilitator–learner relationship goal is to prepare nurses with exceptional clinical reasoning skills for the complex health care environment of the 21st century. Dickerson (2012) encourages faculty to focus on the learner’s needs and be willing to “prepare differently and teach in a new way” (p. 447). No longer is content delivery the focus of the faculty role. Faculty should facilitate the development of sound clinical reasoning skills through a learner-centered lens. The keys to clinical reasoning occur by blending strong critical thinking skills, knowledge of current evidence, and knowledge from experience.

The faculty content delivery model is an important decision to be made, which should be based on the scale of the proposed program and faculty philosophy and skills. Most faculty are comfortable with the traditional professoriate role for content delivery, with one faculty or team for one class. A new disaggregated model has emerged, designed for consistency of content delivery and ease in allowing programs to scale up with large enrollments. This disaggregated role allows the traditional professoriate role to be broken into discreet parts by separating the role of course design, teaching, and assessment of student learning into a team or department approach for course delivery (Rosenbloom, 2011). For example, the design team pulls the course content together, a specific set of instructors provides the delivery of content, an assessment team analyzes student performance, and everyone analyzes course quality.

Consider faculty salary requirements. Our schools regularly scan regional and national publications on nursing faculty salaries and talk with local faculty and deans to make sure salaries are competitive. Also, think about alternative work styles, where faculty could be on campus at designated times but have the flexibility to work from home at other times, or even tele-commute outside of the state.

Are additional faculty skills needed to teach in the new program? If there is a great deal of online learning, consider setting aside a fund for faculty development and certification for online teaching. For instance, both of our schools created a budget for faculty to become certified in online education before teaching an online course.

Also, a decision must be made regarding a mix of full-time and part-time faculty. From our experience, if part-time faculty are used, they should be seasoned educators.

Staff. Seasoned staff with great enthusiasm, creativity, and energy are essential to successfully launch and maintain a new program. Building a team concept is important. Staff are often the first contact for potential students, and spending time to allow them to build a team dynamic is important. The staff are seen by many program innovators as just as important to the success of a program as dynamic faculty, when they respond rapidly and accurately to potential student inquiries. Absence of student support in these areas can drastically affect student retention. In some programs, student inquiries are required to be answered within 24 hours. Instructional designers and technology staff are also essential during a state-of-the-art, successful program launch, as well as when scaling up technology needs to accommodate larger cohorts of students.

Fiscal

Return on Investment. Determining the estimated cost of your initiative for startup and maintenance can be a powerful tool to assist with thinking through the relationship of the desired results and what is believed to be futuristic resources. Return on investment (ROI) is not a term nursing faculty are accustomed to using, but establishing an ROI is crucial to conversations with potential funders and leadership within the university, especially the chief financial officer. If nothing else, it might help the planners to rethink some of the optimistic elements of the initial planning.

A simple model for ROI is based on the potential tuition dollars generated, minus the costs for program operation, including all human and physical resources. The ROI of the first year will be less than any consecutive years, as the startup costs are the greatest at this point of development. When the tuition revenue continues to grow from increasing enrollments, additional faculty and staff can be hired (Billings et al., 2012).

Unexpected costs for program startup mainly occur in marketing, travel, and faculty candidate interviews. Specifically, in the experience of the authors, the production of marketing videos, brochures, and travel to market the program can often double the estimate, as well as exceed printing and mailing costs by approximately 25%. The design and frequent updates for Web site maintenance is an important cost to continue to anticipate. To maintain a cushion for unexpected costs, fees may be added to student program costs for online learning, orientation, and graduation.

Another model for ROI in state institutions uses state formula funding dollars generated by new program startup to estimate return. If the university is reimbursed for dollars generated retrospectively, as is the case in Texas, earnings can be estimated, minus expenses, and you can then predict what formula funding dollars will be obtained in the new biennium or fiscal year in your state (Billings et al., 2012).

Marketing. Consider the actual product (program), the geographical market, by what distribution channel, and whatever promotional mix can be achieved within your resources. Prospective nursing students lead complex, busy lives, trying to stay afloat in today’s economy, so getting them into or back to school is a unique challenge. How do you unfreeze them from their current lives and entice them to enter your program? Potential students may not know they need your proposed program; therefore, for this idea to stick in the minds of prospective students and stakeholders, marketing must draw in the audience and make them want to pay attention and seek more information. Gladwell (2002) called this concept, “The Stickiness Factor,” meaning there needs to be ideas that “stick” in the minds of the consumer (p. 29). Prospective nursing students should be given help to visualize their personal use of the educational product and how the unique nature of the program will benefit patient care. Marketing materials may accomplish this by including statements such as “meeting minimum professional educational requirements,” “state of the art,” “all baccalaureate nursing staff,” and “moving the magnet mission forward” to help potential students move toward the application phase.

Timing is also an important factor with potential nursing students, as they do not drop into school the next day for admission. The time range from point of initial contact to admission can be 6 months to 3 years after a student makes an admission decision, completes specific general education requirements, and applies; therefore, the effective advertising frequency for awareness is at least five to seven times (Bennett, 2011). Marketing of the program via the health care facility’s Web site and brochure distribution is considered minimal in today’s technology-driven world. Within health care facilities, the “word of mouth buzz” is powerful, as are assistive e-mails and exciting Web designs. Successful graduates can be beneficial, so provide them with marketing resources they can readily share with their colleagues. Social media is also an effective marketing tool. Consider marketing on Facebook® through an established school Facebook page and create an ad on the Facebook sidebar for extended distribution. Establish a Twitter account for the school to provide tweets on program application deadlines and links to program information.

Many prospective, mature students from diverse backgrounds and experiences and even RNs are unfamiliar with the tedious and disconcerting admission process of the university community, thus the admission process should be clear and concise. Potential applicants need to receive personal feedback and quick responses when the admission process poses problems for them. Students need to build confidence in their skills for success in education. Create a “journey” for them by encouraging them to submit their transcripts for a pre-assessment of completed prerequisites; after review, an advisor can help them to develop a personal path toward entry. Also, provide easy access to any financial aid packages and scholarships through brochures, e-mails, and a scholarship Web page.

Garnering Support

Considering the “Law of the Few,” find the key stakeholders and garner their support (Gladwell, 2002, p. 31). Internally, innovative educators need to be politically astute and assess who are the supporters and the objectors. Gather all resources while conceptualizing the prospective program. Although a small faculty group of creative thinkers and early adopters during strategic brainstorming might have produced initial innovative ideas for a new program, there is a tendency to separate the planners from other faculty. Being more inclusive of all faculty will provide synergy and support for new programs within a school. A focus should be on preventing building vertical silos and promoting a concentration solely on “their program”; even the word “department” could indicate detachment (Isaacson, 2011, p. 408, p. 567, respectively). No one should be separated from working on the same bottom line of the school’s mission. Instead, push for integration, cohesiveness, and flexibility, as faculty learn collectively from each other, and this team effort is valuable. By emphasizing the major program purpose(s) for the right reasons, the total faculty can identify with it philosophically, visualizing the fit within the total school’s mission, rather than how it will yield more students, tuition, and thinking the new program just means “more work” (Isaacson, 2011, p. 78). In addition, in spite of today’s digital world, encourage as many face-to-face meetings and random discussions whenever possible to promote more creativity and “spontaneous, innovative serendipity thoughts” (Isaacson, 2011, p. 431).

Skeptics

Innovation will always draw some naysayers who will focus on the barriers to success. Although this is not unusual, addressing concerns immediately will decrease some of the negative voices. Program launch and success over time will also address much of the resistance. From conception, a committed group of innovators, both faculty and administrators, who understand the potential impact of the innovation, must be prepared to address the concerns and questions from those who do not yet share the vision of the innovation. Other opposition will arise from the seasoned senior faculty members who may have been excluded in the early dialogue about this program; our suggestion is to enlist their participation as soon as possible, as they can help to strengthen the model development with their diversity of opinion.

For prelicensure program innovation, expect the threat of NCLEX® failure to be the most frequently talked about reason this innovation will not work. All new programs for prelicensure education should have standardized testing built into the model throughout the program. These periodic testing results can assure both the naysayers and the innovators that the program is on track to produce safe and knowledgeable new graduates who are ready for the NCLEX testing.

Every school, whether state funded or private, has their own unique process for obtaining approval for new and revised programs. The process may be through a state higher education board and board of regents or a governing body, such as a university-wide council. Anticipate what questions and concerns will arise from an administrative perspective. Remember, the president and other administrators are thinking about the needs, operation, and strategic plan of the entire university. For example, one author (V.A.K.) introduced a revised RN-to-baccalaureate nursing program that would allow RNs to obtain college credits for professional education and development projects in the form of a portfolio. This had never been done in an undergraduate program; therefore, it was clear there would need to be buy-in from the president, the provost, chairs of the university, and the school of nursing undergraduate curriculum committees. To convince these stakeholders that such students would indeed demonstrate rigor in the credits awarded, a template was designed to clearly delineate the essential categories that would encompass the specific criteria eligible for credits and designated a rubric for how the credits could be evaluated.

Other questions to consider are:

  • Will other programs within the university suffer if this program is successful?
  • Who will benefit from this program?
  • Is there a group that will be disadvantaged if this program is implemented?
  • Will this program draw students from other majors?
  • Does the university have the resources to serve additional students if the program reaches the success predicted?

A private meeting and conversation with the university president or provost to seek out information about any fears or concerns regarding the program should occur before the project is fully designed. For a state university, a larger perspective will require administrators to determine those in their service area who offer such a program and how program startup will impact the existing service area’s resources already in use by other programs. Presidents in the state university system want to be good stewards of limited state resources. In this way, any concerning issues are addressed early in the program design phase.

Accreditation

Are there any goals within your innovative program of having a presence beyond your state boundaries? Currently, seeking approval for delivery of out-of-state online programs can be time consuming, costly, and labor intensive, with some states requiring large fees for in-state delivery and extensive documentation of the program’s purpose and features. Recently, the President’s Forum and the Council of State Governments National Center for Interstate Compacts (2012) began developing a process to make state authorization more uniform, effective, and efficient with a consensus document, known as the State Authorization Reciprocity Agreement. Eventually, this document will reduce the requirement to potentially seek approval in each of the 54 states and territories before the delivery of the new program in another state.

Evaluation

“Begin with the end in mind” (Covey, 2004) echoes the need to plan for evaluation before any program is launched. The entire process of responding to the accreditation questions will provide fundamental feedback on the quality. Know what your outcomes will be and make plans for evaluation in the design of the program. A strong external advisory committee may be a key source for the evaluation of program design, as well as well-stated measurable outcomes related to program productivity and the attributes of graduates. Administrators need to depend heavily on evaluation from students, employers, and alumni, as well as national ranking scores obtained by graduates, for feedback on program quality. Also, curriculum drift, faculty turnover, applicant pool rankings, and availability of resources can all impact the product produced, which should be of concern to nursing school administrators.

Generally, wait for three cycles of student outcomes after the program has been implemented before making major curricular changes to avoid the “second year concerns” (Isaacson, 2011, p. 430). First-year students in the new program often are above-average achievers, have been waiting to enroll in this new program, are eager to learn, are psychologically prepared for school, and tend to be different students than the second-year enrollees. The second cohort admitted tends to be average students who are not seen as motivated, and the enrollment does not achieve the expected quota, which could cause some doubts and concerns within administrators and faculty, tempting them to institute major changes. Try to push aside the temptation to make major changes until after the third class is enrolled.

Administrative Management

Typical prototyping of a new product requires a small-scale launch for implementation and testing. How to scale up to achieve maximum ROI should be the next question for program administrators. The Institute of Healthcare Improvement, which pioneers innovation in health care, recommended the model of “the Power of 5” (Whittington, 2012), beginning with a cohort of 5, then 25, then 125, and finally 625, with refinement of the model at each interval. With the increase in cohort numbers at each stage of “the power of 5,” new considerations for size and delivery will require those innovators to rethink the prototype and modify or innovate to meet the cohorts’ needs. By the time the program reaches an enrollment of 625, the majority of the scale considerations and needs will have been addressed.

Continually evaluate and reevaluate the program before implementation, as sometimes what you initially intended for it may not seem appropriate at a later date—do not be afraid to be flexible, make changes, and modify, as nothing should be set in stone. As Isaacson (2011) noted, “What makes great products were not previous great successes, but lessons learned from the great failures” (p. 219).

Summary

In the face of health care reform calling for new emerging roles for nurses, a national nursing shortage, a call from the Institute of Medicine to change the face of nursing through education and practice, and a call for a more a highly educated nursing workforce (Benner, Sutphen, Leonard, & Day, 2009), nursing education must address these issues through carefully planned and executed innovative program initiatives. Nursing education can take many lessons from Gladwell (2002) in understanding key tipping points for program success. Crucial steps in launching a new innovative program include a well-conceptualized idea for a program, followed by initial program exploration, a resource infrastructure investigation, and reflection on knowledge needed to garner support and maneuver the political obstacles.

References

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  • Covey, S.R. (2004). The 7 habits of highly effective people: Powerful lessons in personal change. New York, NY: Free Press.
  • Dickerson, P.S. (2012). Rocking the boat: Challenges ahead for continuing education providers. The Journal of Continuing Education in Nursing, 43, 443–450. doi:10.3928/00220124-20120815-35 [CrossRef]
  • Gladwell, M. (2002). The tipping point: How little things can make a big difference. New York, NY: Back Bay Books.
  • Hassmiller, S.B. (2011). The future of nursing Institute of Medicine report: One year later. The Journal of Continuing Education in Nursing, 42, 479. doi:10.3928/00220124-20111024-01 [CrossRef]
  • Institute of Medicine, (2010). The future of nursing: Leading change, advancing health. Washington, DC: National Academies Press.
  • Isaacson, W. (2011). Steve Jobs. New York, NY: Simon & Schuster.
  • Kelly, T. (2001). The art of innovation: Lessons in creativity from IDEO, America’s leading design firm. New York, NY: Doubleday.
  • Massoud, M.R., Nielsen, G.A., Nolan, K., Schall, M.W. & Sevin, C.A. (2006). Framework for spread: From local improvements to systemwide change [IHI Innovation Series white paper]. Cambridge, MA: Institute for Healthcare Improvement.
  • The President’s Forum, & The Council of State Governments National Center for Interstate Compacts. (2012). State authorization reciprocity agreement: April, 2012—Working draft. Retrieved from http://www.csg.org/NCIC/documents/WorkingDraft.pdf
  • Rosenbloom, B. (2011). Envisioning online learning: The disaggregated professor. Retrieved from http://onlinelearning.commons.gc.cuny.edu/2011/08/13/the-disaggregated-professor/
  • Whittington, J.W. (2012, February). IHI’s innovation methodology: Scanning. Presented at the Institute for Healthcare Improvement Innovation College. , Cambridge, MA. .

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