Journal of Nursing Education

Major Article 

Imperatives for Integrating Culture of Health Concepts Into Nursing Education

Patricia N. Scott, DNP, RN, PNP; Ashley Davis, PhD, RN; Laura E. Gray, PhD, RN, CNE; Debra A. Jeffs, PhD, RN, NPD-BC, FAAN; Leanne L. Lefler, PhD, RN, APRN, FAHA, FAAN

Abstract

Background:

In all nursing care, nurses should address the social determinants of health that make it difficult for people to lead healthy lives. The Future of Nursing: Campaign for Action recommends transforming nursing education to prepare nurses to address social determinants through building a culture of health. Our study examined integration of culture of health/population health concepts into nursing education and assessed nursing deans' and directors' perceived barriers, facilitators, and readiness to incorporate culture of health into curricula.

Method:

Modified Delphi techniques were used in two neighboring southern states through two rounds of data collection to develop quantitative surveys in each state.

Results:

Consensus emerged on the need to integrate population/culture of health concepts into nursing curricula. Deans and directors described barriers and facilitators to educational integration.

Conclusion:

Population/culture of health concepts must become a fundamental component of nursing education at all educational levels. [J Nurs Educ. 2020;59(11):605–609.]

Abstract

Background:

In all nursing care, nurses should address the social determinants of health that make it difficult for people to lead healthy lives. The Future of Nursing: Campaign for Action recommends transforming nursing education to prepare nurses to address social determinants through building a culture of health. Our study examined integration of culture of health/population health concepts into nursing education and assessed nursing deans' and directors' perceived barriers, facilitators, and readiness to incorporate culture of health into curricula.

Method:

Modified Delphi techniques were used in two neighboring southern states through two rounds of data collection to develop quantitative surveys in each state.

Results:

Consensus emerged on the need to integrate population/culture of health concepts into nursing curricula. Deans and directors described barriers and facilitators to educational integration.

Conclusion:

Population/culture of health concepts must become a fundamental component of nursing education at all educational levels. [J Nurs Educ. 2020;59(11):605–609.]

Nurses are integral to creating a culture of health (COH) by addressing the social determinants of health (SDH) that make it difficult for people to make healthy choices and lead healthy lives. The World Health Organization (2020) defines SDH as “the conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power, and resources at global, national, and local levels. The social determinants of health are mostly responsible for health inequities—the unfair and avoidable differences in health status seen within and between countries” (para. 1).

In the United States, one of the wealthiest countries in the world, 11.1% of households experience food insecurity (U.S. Department of Agriculture, 2019); 18.4% of people suffer severe housing problems (e.g., lack of kitchen or plumbing facilities, severe crowding, cost burden; United Health Foundation, 2020); and 18% of children live in poverty (Kids Count Data Center, 2019).

The Robert Wood Johnson Foundation (RWJF, 2020a, 2020b) developed the COH vision and describe it as “placing well-being at the center of every aspect of our lives. In a Culture of Health, Americans understand that we're all in this together—no one is excluded. Everyone has access to the care they need and a fair and just opportunity to make healthier choices. In a Culture of Health, communities flourish and individuals thrive” (para. 1). Along with the Rand Corporation, RWJF created the COH Action Framework that identifies the key “Action Areas” for improving health:

  1. Making Health a Shared Value,

  2. Fostering Cross Sector Collaboration,

  3. Creating Healthier, More Equitable Communities, and

  4. Strengthening Integration of Health Services and Systems.

Together, the Action Areas provide a structure and integrated approach to the SDH, population health, well-being, and equity through a set of drivers and evidence-based measures for each of the identified four areas (RWJF, 2020). The COH Action Framework offers an evidence-based foundation for community action and for nursing education at all levels.

The Future of Nursing: Campaign for Action was formed by the RWJF, AARP, and AARP Foundation in response to the Institute of Medicine's (IOM; now the National Academy of Medicine) 2010 Future of Nursing: Leading Change, Advancing Health report that identified nurse professionals as instrumental to transforming health and health care (Future of Nursing: Campaign for Action, 2020a; IOM, 2010). The Future of Nursing: Campaign for Action encourages state Action Coalitions to fulfill the 2010 IOM report recommendations that include transforming nursing education to prepare nurses to address the SDH that contribute to poor health outcomes and to develop nurse leaders to build a COH. Nurses are well poised to build a COH that can transform health and health care because they bring a biopsychosocial, scientific process orientation, along with being trusted health professionals with the desire to serve and advocate. Successful nurse-designed models of care have been shown to use activities in the COH Action Areas to advance a COH (Martsolf et al., 2017). Nurses have begun to use the COH framework as a foundation for population-focused work, such as nonprofit hospital community health needs assessments (Day et al., 2017). Some nursing schools across the United States are integrating SDH and population health concepts into their curricula and clinical experiences. For example, the University of Birmingham at Alabama Family Nurse Practitioner students integrate SDH screening and referral into their clinical care (Buys & Somerall, 2018). The Vanderbilt University School of Nursing includes the Community Action Poverty Simulation for all enrolled students, and the University of Arkansas for Medical Sciences, College of Nursing offers an interdisciplinary 3 credit hour graduate course in COH.

However, most nurses are educated for clinically focused individual patient care and less prepared for the population-focused care that is needed to promote a COH. Nurses need to become educated about SDH and gain the skills needed to build a COH in their communities. They need to learn, for example, how to work across sectors to create changes that lead to increased access to nutritious food; safe, affordable housing; and active transportation. To this end, RWJF produced the Catalyst paper, “Catalysts for Change: Harnessing the Power of Nurses to Build Population Health in the 21st Century” (RWJF, 2017). This report considers nurses as “catalysts” to promote population health in curricula, practice, and leadership, and recommends that nurses take a population health view of health (RWJF, 2017; Storjfell et al., 2017).

In 2019, the Future of Nursing: Campaign for Action commissioned a pivotal study, Population Health in Nursing (PHIN) (Future of Nursing: Campaign for Action, 2020b), that was founded on the 2017 Catalyst paper. The PHIN study examined promising educational models, including nursing curricular revisions at several schools of nursing such as Thomas Jefferson University, Oregon Health and Science University, and Rush University. In its second phase, the study surveyed public health leaders to discover the ways in which nurses could contribute to improved health in practice. The final phase of the PHIN study offers conclusions about action steps for the next decade. These recommendations include a historical perspective with nurses at the forefront of holistic, population-focused care where nurses develop the capacity for advocacy and for leading partnerships and policy and systems changes necessary to improve health.

Prior to publication of the Catalyst and PHIN reports, Action Coalitions from two neighboring southern states developed a partnership to learn about nursing education programs in these two states to foster improvements in education about population health. The purpose of this study by these two states was to examine the current state of integration of culture of health/population health concepts into academic nursing education in these states. The study also aimed to assess nursing deans' and directors' perceived barriers, facilitators, and readiness to incorporate COH into their curricula. Collaborating study teams in each state wanted to report combined findings to disseminate our common and important results.

Method

Studies were completed separately and at different times in each state: Arkansas in 2017, and Tennessee in 2019. One of the Arkansas Action Coalition leaders moved to Tennessee in 2017 and began working with that state's Action Coalition whose members were interested in developing nurse leaders who could address SDH and inequities. Over the course of the next year, and building on the strong Tennessee Action Coalition history, members updated priorities and created a new charter in early 2019. Tennessee coalition leaders and researchers were inspired by Arkansas's work and made plans to conduct a similar study because of a shared border with Arkansas, common history and culture, comparable population health issues, and the need for a nursing workforce prepared to address SDH. Study teams included members of the state Action Coalitions and nursing faculty researchers from each state. (The Arkansas Action Coalition is now the Arkansas Center for Nursing).

The teams in both states used a modified Delphi technique to conduct their studies. The Delphi method is effective in determining consensus among a small group of experts and in quantifying those experts' judgments but can also be modified to fit research study questions (Keeney et al., 2001; Waltz & Strickland, 2010). The technique is also useful when a lack of consensus and a need for baseline knowledge surrounding an issue exists (Powell, 2003), such as integrating COH concepts into curricula. We needed to better understand deans' and directors' perspectives to build a quantitative survey, and the Delphi method was the most appropriate means of gathering a variety of ideas that would then inform survey and consensus development. Using the Delphi technique in each state, researchers first conducted a round of qualitative interviews with the panel of experts (nursing deans and directors). This information was summarized and presented individually and anonymously back to the experts in the second phase. In the third phase, a quantitative survey was developed based on results of the first two phases and disseminated to deans and directors in each state. Studies were granted human subject protection exemption from collaborating universities' institutional review boards in each state.

In each state, the researchers recruited a convenience sample of deans and directors from all types of nursing education programs, from practical/vocational nursing to doctoral levels. The schools represented a wide range of student body sizes, geographic locations across the states, and program offerings.

In Arkansas, the research team met with all state nursing deans and directors attending their biannual meeting. Nine consented to telephone interviews in the first round of the Delphi process. Through recorded interviews, we asked each participant six questions concerning curricular content on population health, SDH, and COH. These questions focused on thoughts about integration, importance, current offerings and activities reflecting incorporation of this content in their institutions, and barriers and facilitators to integrating these concepts.

Once completed, all interviews were deidentified, transcribed, and compiled. Arkansas's research team of five analyzed the narratives using content analysis by identifying and examining common themes. A questionnaire to clarify, validate, and expand information on these themes was then emailed to the participants from round one. Six participated in this second round. From the round two responses, the team was able to validate the original themes and finalize the round three questionnaire. Original themes along with participant feedback provided basis for an 8-item quantitative survey used for the third and final round of the Delphi process. The survey items had respondents select importance of items on a 10-point Likert scale (1 = not at all important to 10 = extremely important) and asked respondents to select items that would be most applicable to the situation presented. All 43 Arkansas deans and directors were invited to participate in the final quantitative survey, and it was sent to them via email.

Two years later in Tennessee, deans and directors of nursing programs were invited to participate following an introduction to the study at a regular meeting of nursing deans and directors. The research team subsequently sent email invitations to 30 of the 45 Tennessee deans and directors representing various school sizes, state geographic locations, and program offerings. Ten chose to participate in the telephone interviews. We asked each participant to answer the same four questions concerning content on population health, SDH and COH, and reflecting experiences at each institution and nursing program. Interviews were recorded and transcribed verbatim. Interviews were deidentified, compiled, and analyzed using content and thematic analysis by our research team. These themes were then sent to the participants individually for validation, clarification, and feedback. Original themes along with clarification from participant feedback provided the basis for the quantitative survey. The survey, built using the Qualtrics® software program, consisted of a 20-question quantitative survey. Items again asked respondents to select the level of importance for statements presented and used multiple choice items as well. The final survey was sent electronically to all 45 deans and directors in that state. Table 1 provides the Delphi rounds 1 to 3 process and response summary for both states.

Delphi Rounds 1 to 3: Process and Response Summary

Table 1:

Delphi Rounds 1 to 3: Process and Response Summary

Results

Given that the surveys were similar but not identical, we reported results per state. In Arkansas, 22 deans and directors responded to the quantitative questionnaire, and in Tennessee, 23 participated, for a total of 45 deans and directors, with an overall response rate of 51%.

Arkansas

A clear consensus emerged on the importance of integrating COH concepts into nursing curricula, with respondents ranking the importance as 8.636 on the 10-point Likert scale. The baccalaureate level (82% agreement) was identified as the most appropriate educational level for integration of these concepts into curricula. Participants reported content in these areas are being taught in the courses of health promotion and prevention (64% and 82% of the time, respectively), community health (25%), written assignments on culture-related topics (22%), and clinical and service-learning experiences (14% to 18%). Eighty-six percent of deans and directors agreed/strongly agreed that nurses who understood COH concepts delivered better care. Table A (available in the online version of this article) presents all results indicating mean percent or mean score for the Arkansas quantitative survey.

Arkansas: Quantitative Survey of Population Health (PH) Concepts for Curricular Changes (N = 22)Arkansas: Quantitative Survey of Population Health (PH) Concepts for Curricular Changes (N = 22)

Table A:

Arkansas: Quantitative Survey of Population Health (PH) Concepts for Curricular Changes (N = 22)

The most common barriers to integrating COH concepts into nursing curricula were faculty time and workload, curriculum overload, and the lack of COH content covered on the National Council of State Boards of Nursing (NCSBN) licensure examinations. The top facilitators to integration of COH concepts into nursing curricula were the possibility of conferences and workshops for faculty on how to integrate the COH into the nursing curricula and the ability to integrate the COH concepts throughout their curricula as opposed to a separate course. Finally, the deans and directors ranked future conferences and workshops along with guidelines on how to integrate the COH concepts as the top needed resources.

Tennessee

Consensus surrounded the need to integrate COH concepts into nursing curricula, with 87% of respondents saying this was extremely or very important, and 95% identifying the undergraduate level as the most appropriate place for integration. Eighty-six percent of the deans and directors agreed that nurses who understand COH concepts deliver better care. In addition, 96% of the respondents agreed on the importance of teaching health promotion strategies.

Despite overwhelming support for integrating COH concepts into nursing curricula, only one of the respondents in Tennessee reported full integration of the concepts into their program. Concepts were slightly integrated in 40% of schools and not at all integrated in 10% of schools represented. Approximately half of the respondents (54. 5%) said their curricula currently reflected a health–illness continuum model rather than a health promotion model.

Barriers to integrating COH concepts into nursing curricula were grouped into academic factors and health care system factors. When asked to choose two of the main academic barriers, 38% of respondents identified the large amount of content in current nursing curricula and 21% identified the nature of content covered on the NCSBN licensure examinations. Other academic barriers included faculty knowledge deficit surrounding COH concepts (12%), faculty resistance to change (14%), and lack of student exposure to community needs (12%). A similar lack of consensus was noted in identified health care systems barriers, which included the current system's focus on disease management (29%), lack of nursing role models in current practice (19.5%), absence of collaboration and communication among components of the health care system (19.5%), lack of health promotion focus (14.6%), and economic structure of the current health care system (14.6%).

Facilitators to integration of COH concepts into nursing curricula were grouped into people-related factors and institution-related factors. When asked to choose two main factors in each group, respondents largely focused on faculty as a people-related factor: faculty buy-in for integrating COH concepts (37.5%), innovative and flexible faculty (20%), having a diverse faculty (10%), and faculty willingness to engage with students (10%). More than half of the respondents identified clinical opportunities as institution-related facilitators: clinical experiences in the community (32.5%) and having community agencies open to having nursing students (22.5%). Other institution-related facilitators included teaching economics of health care, including the benefit of prevention versus illness care (20%), and elevating practice entry-level requirements for nursing beyond the associate's degree (15%; Table B [available in the online version of this article]).

Tennessee: Quantitative Survey of Population Health (PH) Concepts for Curricular Changes (N = 23)Tennessee: Quantitative Survey of Population Health (PH) Concepts for Curricular Changes (N = 23)Tennessee: Quantitative Survey of Population Health (PH) Concepts for Curricular Changes (N = 23)

Table B:

Tennessee: Quantitative Survey of Population Health (PH) Concepts for Curricular Changes (N = 23)

Discussion

We examined the current state of integration of COH and population health concepts into academic nursing education curricula in two southern states and found a paucity of this content throughout the 45 schools of nursing that participated. The National Advisory Council on Nurse Education and Practice (NACNEP, 2016) and the American Association of Colleges of Nursing (AACN, 2013) recommend that public health nursing and/or population health content are included in curricula. AACN shares information on their website about a 2013 population health supplement to The Essentials of Baccalaureate Education for Professional Nursing Practice (AACN, 2013). Several schools across the country also share information on this website about curricula threading, developed courses, and service-learning experiences in their schools. It is clear in this supplement that the AACN shares similar recommendations to the data from the deans and directors of nursing that we found in this study. That is, 21st century practice should be health focused rather than illness focused, and that schools of nursing should be integrating this content throughout their curricula. Similarly, the National League for Nursing (NLN) calls for integrating SDH into nursing education (NLN, 2019), and for strengthening nursing education for engagement in global health issues (NLN, 2017).

Results from this study also found that deans and directors of schools of nursing share in the perceived barriers and facilitators for incorporating this content into their curricula. From our results, there is a clear need to implement faculty training for population health and COH concepts and on how to integrate these concepts throughout curricula. Only one school surveyed fully integrated these concepts into the curricula. Our results found that deans and directors in these two southern states recognized this need and were amenable to integrate this content but needed guidance and resources on where and how to include the content into an already overcrowded curriculum. Others agree that there is an expectation that nursing students learn a constantly expanding amount of content in their education programs to be prepared to care and treat in the 21st century (Brussow et al., 2019). Finally, we found that because this was relatively new content in our rapidly changing health care environment, faculty and staff need continuing education regarding these concepts to feel confident in teaching it. Consensus indicated a need for research, development and dissemination of curricular guidelines, and faculty development in COH.

Limitations

Limitations of this study include different study questions and survey approaches in each state. The time difference between the studies in each state is also a limitation in that by 2019, deans may have become more aware of the need to incorporate COH into curricula. We did not examine institutional information such as faculty education, class sizes, workload, and specialty areas that could influence a school's ability to integrate new concepts or redesign curricula. Data that reflect perspectives of these deans and directors may not necessarily reflect those of nursing faculty in their own programs or of deans and directors and faculty throughout the United States. A future study of faculty perspectives of COH integration in the curricula would offer a fuller picture of nursing education needs.

Conclusions

We believe these findings validate the recommendations of the IOM, the Catalyst paper, and the PHIN study. Deans and directors in each state reported the importance of integrating COH concepts into nursing curricula. They agreed that population health is part of evidence-based practice and should be a focus throughout all nursing education at all levels from practical/vocational through doctoral nursing education. Barriers included faculty time, knowledge and workload, absence from licensure examination blueprints, and curriculum overload. Facilitators included faculty buy-in and faculty development through workshops and conferences that would be helpful in increasing faculty capacity in teaching COH concepts. Next steps for these collaborators include follow-up events that bring together faculty, deans, and directors from each of our states and across the United States to create ideas and test best practices in integrating COH into nursing and health professions education.

References

Delphi Rounds 1 to 3: Process and Response Summary

RoundArkansasTennessee
1Scripted interviewsScripted interviews
Nine deans and directorsTen deans and directors
Six open-ended questionsFour open-ended questions
2Clarification of themes from round 1Clarification of themes from round 1
Six deans and directors from round 1 respondedFive deans and directors from round 1 responded
3Quantitative survey based on themes and feedbackQuantitative survey based on themes and feedback
Twenty-two (51%) of the 43 state deans and directors responded to the eight-question surveyTwenty-three (51%) of the 45 state deans and directors responded to the 20-question survey

Arkansas: Quantitative Survey of Population Health (PH) Concepts for Curricular Changes (N = 22)

QuestionScaleaValue Scored
How important is integrating PH concepts into nursing curricula?10-point Likert8.6

Top reasons integration is beneficial to your program?% rated item as “most important”
  Nurses to understand better the population that they serve.86.4%
  Nurses understand better the barriers to health care.86.4%
  Helps nurses to provide holistic care.81.8%

Rate beliefs in teaching PH, SDH, COH concepts10-point Likert top ranked
  Understanding patients' barriers encourages more effective treatment.9.0
  Teaching these concepts is part of teaching evidence-based practice.8.8
  Understanding these concepts helps us provide holistic care.8.8
  Changes in health care require nurses to know about these concepts.8.8
  These concepts could be integrated in small pieces throughout the curriculum.8.5

Rate perceived barriers to integrating PH, SDH, COH into curriculum10-point Likert top ranked
  Faculty time/workload6.9
  Curriculum overload6.6
  Absence from NCLEX® Blueprint5.8

Rate perceived facilitators to integration10-point Likert top ranked
  Conferences/workshops on how to integrate COH, PH, SDH8.1
  Concepts can be broken down and integrated throughout the curriculum7.9
  Change agents within the program needed7.5

Needed resources10-point Likert top ranked
  Faculty workshop/conferences8.4
  Guide needed to include major topics8.4
  Examples of assignments/lectures8.4
  Template/sample curricula needed8.2

How/where is it currently being taught?% of total
  Community Health course24.6%
  Culture-related topics, written assignments21.5%
  COH, PH, SDH clinical experience(s)23.1%
  COH, PH, SDH clinical assignment(s), care plans16.9%
  Incorporation of health promotion model10.8%

Where do topics need to be included?% selected
  Undergraduate, Bachelor's Degree81.8%
  Undergraduate, Associate's Degree68.2%
  Graduate, Master's and/or Doctoral54.5%
  Practical/vocational36.4%

Tennessee: Quantitative Survey of Population Health (PH) Concepts for Curricular Changes (N = 23)

QuestionScaleValue Scored
How important is it for nursing students to receive content on culture of health concepts (i.e., population health and the social determinants of health) in their programs?% rated item by importanceExtremely Important 64% Very Important 23%

When should nursing programs start introducing culture of health concepts (i.e., population health and social determinants of health content) into curricula?% selected1st year UG 45% 2nd year UG 18% 3rd year UG 32% LPN 4.6%

How important is it that nursing curricula include content on health promotion strategies?% rated item by importanceExtremely Important 82% Very Important 14%

Does your nursing program's curriculum primarily reflect a health-illness continuum model or a health promotion model?% selectedHealth-illness continuum 55% Health promotion/wellness 45%

Nurses who understand the culture of health concepts are positioned to deliver better nursing in clinical practice% rated item by agreementStrongly agree 57% Agree 29%

Which TWO of these factors BEST distinguish nursing's role in translating culture of health concepts into practice? Please choose only two answers.% selected
  Nurses have a holistic perspective of care41.5%
  Nurses are in a unique position to improve population outcomes.41.5%
  Nurses can reduce health disparities9.8%
  Nurses are leaders in health care4.9%

Which TWO factors would you rank as the main academic barriers to integrating culture of health concepts into your nursing curricula?% selected
  Amount of content in current nursing curriculum38.1%
  Nature of content covered on the NCLEX®21.4%
  Faculty knowledge deficit surrounding culture of health concepts14.3%
  Faculty resistance to change11.9%
  Lack of student exposure to community needs11.9%

Which TWO factors would you rank as MAIN health system barriers to integrating culture of health concepts into your nursing curricula?% selected
  Current health care system focus on disease management29.3%
  Absence of collaboration and communication among health care system19.5%
  Lack of role models set by practicing nurses19.5%
  Lack of health promotion focus in the current health care system14.6%
  Economic structure of the current health care system14.6%

Which TWO of these people-related factors would you rank as most influential in facilitating integration of culture of health concepts into your nursing curricula?% selected
  Faculty buy-in for integrating culture of health concepts37.5%
  Empowering students to embrace nursing's unique potential to change health care17.5%
  Having a diverse faculty10%
  Faculty willingness to engage with students10%
  Having a diverse student body5%

Which TWO of these institution-related factors would you rank as most influential in facilitating integration of culture of health concepts into your nursing curricula?% selected
  Extending the time frame of the nursing curriculum2.5%
  Nursing program setting that is close to communities with evident need7.5%
  Clinical experiences set in the community32.5%
  Having community agencies open to having nursing students22.5%
  Teaching economics of health care, including cost benefit of prevention verses illness care20%
  Elevating practice entry level requirements beyond the associate degree15%

How important is it for schools of nursing to develop community partnerships to build a culture of health?% rated item by importanceExtremely Important 80% Very Important 20%

What TWO partnerships will help students BEST understand culture of health concepts?% selected
  Local health departments40%
  Housing and transportation services (homeless shelters, housing and land development planning commission)17.5%
  Service organizations (YMCA, local community centers)12.5%
  Health care organizations (Hospitals, health centers, nonprofit clinics)15%
  Early childhood centers, schools, and after-care programs7.5%
  Faith-based organizations (churches, temples, mosques)7.5%
  Local businesses0%

How would you rate your nursing program on incorporating culture of health concepts into the curriculum% rated by choices
  Fully integrated5%
  Moderately integrated45%
  Slightly integrated40%
  Not at all integrated10%

In what ways are culture of health concepts already integrated into your curriculum?% selected
  Community health/public health courses24.6%
  Clinical experiences and/or simulation labs23.1%
  Written assignments21.5%
  Care plans16.9%

Choose all that apply to the institution that houses your nursing program% selected
  Public school26.3%
  Private school21.1%
  Religious affiliation23.7%
  Teaching focused26.3%
  Research focused2.6%

How many undergraduate students are in your nursing program?% selected
  200 or fewer65%
  200–50030%
  501–10005%

How many graduate students are in your nursing programs?% selected
  50 or fewer50%
  50–1006.3%
  More then 10043.8%

How would you characterize the environment in which your nursing program is set?% selected
  Primarily rural30%
  Primarily urban30%
  A combination of urban and rural40%

How would you best characterize the faculty at your institution?% selected
  Majority with more than 5 years of teaching experience36.6%
  Majority with fewer than 5 years of teaching experience9.8%
  Majority with Master's degree29.3%
  Majority with DNP12.2%
  Majority with PhD2.4%
  An even mix of DNP and PhD-prepared faculty9.8%
Authors

Dr. Scott is Consultant, Tennessee Department of Health, Dr. Gray is Assistant Professor of Nursing, Belmont University, Nashville, Tennessee; Dr. Davis is Executive Director, Arkansas Center for Nursing, Dr. Jeffs is Academic Nursing Education Manager, Arkansas Children's Hospital, and Dr. Lefler is Associate Professor, University of Arkansas for Medical Sciences College of Nursing, Little Rock, Arkansas.

This work was supported by the Robert Wood Johnson Foundation. The authors thank participating Arkansas and Tennessee nursing deans and directors for sharing their thoughts and keen insights; for their dedication to their students, faculty, and schools; and for making this work possible. They also thank Belmont University nursing students Jordan Porter, DNP, FNP; Brianna Pendergrass, MSN, FNP; Brady Franklin, MSN, FNP; and Corbin Davidson, MSN, FNP, for helping to collect and organize the Tennessee data.

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

Address correspondence to Patricia N. Scott, DNP, RN, PNP, Consultant, Tennessee Department of Health, 2101 Thistlewood Drive, Nashville, TN 37216; email: pattinscott@comcast.net.

Received: April 05, 2020
Accepted: June 08, 2020

10.3928/01484834-20201020-02

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