ABSTRACT Public health and nursing leaders in Iowa identified a need to increase access to health occupations education and avert a projected shortage of qualified faculty. The Iowa Department of Public Health provided a competitive funding opportunity to create a strategic plan to accomplish these goals through the use of e-learning. Federal funding through the US Department of Health and Human Services supported the development of a plan that focuses on the nursing profession. Recommendations of the plan are being implemented at the state and local level.
Key Words Strategic Plan--E-learning--Online Education--Health Care Education--Nursing Education
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STABLISHED BY THE IOWA DEPARTMENT OF PUBLIC HEALTH IN 2002, the Center for Health Workforce Planning had an important mission: to assess and forecast health workforce supply and demand; to promote the recruitment and retention of health workers, faculty, and students; to support strategies that prevent shortages at the local level; and to engage in activities to sustain a competent and diverse health workforce. In 2005, the center provided a competitive funding opportunity to develop a strategic plan to increase access to health occupations education statewide through the use of e-learning technology. Given that nursing represents the largest population of health occupations professionals, the development of the strategic plan used nursing as a focus for study. THIS ARTICLE reports on an online survey of nursing programs, faculty, and students in Iowa conducted for the development of the strategic plan. * Establishment of the Center for Health Workforce Planning was spearheaded by Iowa Senator Tom Harkin, the governor's Task Force on the Nursing Shortage, and the Iowa Council of Nurses. The center received federal funding from 2002 to 2006 administered through the US Department of Health and Human Services Bureau of Health Professions, Health Resources and Services Administration. Its work is guided by an advisory committee representing a number of stakeholders: Iowa's health workforce, including nurses and nursing assistive personnel; education and training programs; practice settings encompassing acute, ambulatory, long-term, and home health care; and public and private partners, as well as community leaders. The committee provides consultation from the field, guides the center's long-term plan and evaluation, and serves as a conduit to policy makers, legislators, and stakeholders.
Funding to develop the statewide strategic plan was granted in September 2005. Applicants were evaluated according to their ability to accomplish the following objectives:
* Research national and state-level best practice strategies to prepare health occupations students and faculty through the use of e-learning technologies.
* Recommend specific e-learning technologies to prepare Iowa's health workforce.
* Assess Iowa's capacity (financial, human, organizational) to implement a strategic plan for e-learning health occupations education.
* Identify additional capacities needed to implement the strategic plan.
* Establish partnerships among educational institutions and employers.
* Recommend organizations and stakeholders to serve in an advisory capacity.
* Recommend policy changes to assist faculty in implementing e-learning modalities and assist students in accessing e-learning opportunities.
* Identify a timeline and costs for implementation of the statewide strategic plan and assign priorities for components of the strategic plan.
* Identify modifications to the strategic plan that would broaden its applicability in education and practice settings.
* Identify strategies to increase the capability of Iowa's educational and practice institutions to provide e-learning opportunities to health occupations students and faculty.
Why E-learning? For the purposes of the strategic plan, e-learning encompasses the use of computer communications and technology to enhance learning for students and professionals. E-learning is used to varying degrees in many different capacities. Some health care facilities rely on e-learning to provide real-time training to health care professionals. In academia, e-learning opens access to education for professionals and students. It is apparent from the literature that comparisons between e-learning and traditional education, for practice and academia, indicate that there is 'no significant difference' in outcomes (1,2).
Findings by O'Neil, Fisher, and Newbold (1), along with the flexibility realized in e-learning, point to the potential to address the nurse faculty shortage while improving access to health occupations education. A recent study of 278 Iowa nurse faculty indicated that participants agreed that the flexibility of e-learning offered a potential benefit to faculty (M = 4.14, SD = 0.749) and students (M = 4.23, SD = 0.601) (3). Participants also agreed that the flexibility of e-learning can serve as a recruitment tool for faculty (M = 3.85, SD=0.601). Still another statistical analysis revealed that participants who used e-learning were more likely to teach courses beyond their contractual agreement.
Best practices in other states provided support for development of the Iowa strategic plan. An alliance between the University of South Dakota (USD) and the Evangelical Lutheran Good Samaritan Society (a multistate, multisite provider of long-term and rehabilitation care) resulted in the development of the 'Grow Our Own-RN' program. USD provided the curriculum and structure for the associate degree for society employees who often were unable to access academic programs because of geographical or time constraints. Through this collaboration, students were able to continue their employment, often in underserved areas, while advancing professionally. In fall 2004, 43 students were enrolled in the nursing program and another 70 students in six states were taking support courses. Given the dispersed nature of this program, e-learning is a vital tool.
The School of Nursing at Indiana University has used e-learning to bring together professionals, students, and consumers in one online classroom (D. Billings, personal communication, February 7, 2006). Online Communities of Professional Practice is implemented through an online critical care course where professionals can earn continuing education credit and students can earn academic credit. The benefits of this learning environment include real-time learning that facilitates collaboration and critical thinking (4).
Health care facilities throughout the United States use the Internet to train faculty and students in computer-based medication and charting systems and to meet annual competencies. Training takes place before students reach the clinical site, decreasing the burden on development resources such as in-house staff educators and computer labs. This flexibility also allows professionals to focus on their training at times that are convenient for them (5).
The state of Oregon has developed regional simulation alliances that bring together practice and academia for the purpose of sharing scarce assets, including intellectual and financial resources. Human patient simulators, while costly, are needed by all clinical sites, large and small, to provide realistic training of staff (6).
Through the development of a statewide nursing curriculum, the Wisconsin Technical College System (WTCS) has been able to offer all didactic nursing courses online. Sixteen schools share the responsibility of offering these courses online, and because of the common curriculum, students may take courses from any WTCS school. This flexibility benefits students who have children and jobs by allowing them to avoid scheduling conflicts. These online offerings have also assisted schools with tight clinical scheduling, as many clinical sites are reaching capacity.
And, already in Iowa, an organization known as Prepare Iowa has brought together a number of universities and public health agencies for the purpose of providing e-learning in the public health arena (see http://prepareiowa.com/Public/ default.aspx). The course offerings in this program are free, and the infrastructure is flexible enough to allow for the use of a variety of course management systems (7).
Process and Findings The development of the strategic plan was driven by a multifactorial statewide assessment. Stakeholders were identified and polled to provide feedback, input, and project oversight. The main stakeholder group and advisory committee was the Iowa Council of Nurses (ICON), a heterogeneous group of individuals from professional organizations, academia, and practice. ICON invited input from regulatory entities and state agencies and was pivotal in providing key contacts for data collection. The member organizations also helped develop the assessment plan and finally the strategic plan. Other key contributors included the Iowa Association of Colleges of Nursing (IACN), Iowa Community Colleges Nursing Education Directors Association (ICCNEDA), and the Iowa Hospital Association (IHA).
Statewide assessment was conducted via individual and group interviews, electronic and paper-based publications, and survey questionnaires. Data were first collected about nursing academia in Iowa. Data were then collected on the use of e-learning in practice. The findings were analyzed for strengths and weaknesses of e-learning across the state.
ACADEMIC PROGRAMS Data were collected from 21 nursing education programs across Iowa about program structure, faculty development, partnerships, and use of technology. More than 80 percent of responding academic programs reported an increase in student enrollments in the 2004-2005 academic year, and 90 percent projected an increase in 2005-2006. Some programs were successfully using e-learning as an innovative teaching modality to maximize the use of existing faculty. Others expressed interest in technology but lacked information and resources.
The findings indicated that several technologies were in place and a variety of course management systems were being used across the state. Most of the courses being taught through e-learning focused on pharmacology, nursing theory, and nutrition. Some programs had all or most of their courses in some type of e-learning format (fully online or hybrid). Courses that build skills and clinical expertise were exceptions. The RN-BSN and MSN programs have more courses completely online than prelicensure programs. Computer and human patient simulators were used to varying degrees around the state. Computerized testing services and solutions were used to allow for tracking of student progress throughout the student's academic career.
Most programs offered some type of faculty development related to computers and e-learning. However, most faculty development focused on operating e-learning tools, for example, setting up an electronic grade book, putting a PowerPoint presentation on the Internet, or creating learning activities. These programs tended to lack training in the pedagogy needed to implement and manage e-learning effectively.
NURSING STUDENTS In order to provide a profile of nursing students to help stakeholders better understand how to use e-learning, data were collected from 1,334 undergraduate nursing students at a variety of institutions across Iowa. Pre-licensure baccalaureate and master's students accounted for 55 percent of the sample: community college (associate degree) students accounted for 45 percent.
Data analysis revealed that the mean age of the entire student nurse sample was 25.6 years (SD = 7.8). The mean age of community college students (M = 29.3, SD = 9.04) was higher than the mean age of baccalaureate nursing students (M = 21.59, SD = 3.19). Overall, 32 percent of students had children (60 percent of community college students and 6 percent of prelicensure BSN students). The total mean for hours worked was 14.97 (SD = 12.36).
The differences found between the two populations of students were significant. Community college students were considered more likely to practice in high-need areas such as long-term care. Making the educational process more flexible and accessible for this group of students is a concern of Iowa stakeholders.
PRACTICE Data were acquired from 42 health care delivery units in Iowa ranging in size from 25 to 6,500 employees. These included acute care, long-term care, independent living, and home health agencies. Data were also gathered from a variety of professional organizations, including those representing the elderly, acute care, nursing leaders, and staff development educators.
A major theme of the strategic plan has been to analyze ways in which practice and academia can, and do, collaborate and how e-learning may better facilitate cooperation. Smaller health care delivery units (HCDUs) have voiced interest in working more with academia through training students and providing continuing education for staff.
The data analysis reveals that about 40 percent of HCDUs in Iowa reported some type of collaboration with academia. Some of this collaboration was in the form of precepting students and continuing education. Training for preceptors was being done mostly in face-to-face settings; however, 10 percent of HCDUs used e-learning for preceptor training.
A few clinical facilities used computer simulation and human patient simulators. While a few academic institutions also use these technologies, there was no report of collaboration between academia and practice.
A variety of course management systems were being used for staff education in the state. Staff educators were able to receive training through professional organizations and by attaining academic degrees. There were no reports of staff educators in Iowa receiving training in e-learning.
Strategic Recommendations The Strategic Plan to Increase Access to Health Occupations Education in Iowa Through the Use of E-Learning was completed based on data analysis anti stakeholder feedback. The plan includes a statewide assessment of e-learning used in a variety of health occupations venues and recommendations for action steps to actualize the plan.
Given the importance of faculty development in the successful implementation and use of e-learning, the first recommendation is to create a collaborative faculty development program in e-learning. This training program will emphasize the pedagogy needed to use e-learning to improve the quality and flexibility of nursing education. The program will be structured to include face-to-face seminars and online training courses that use the course management systems of the participating nursing programs.
The second recommendation is to facilitate collaboration between rural clinical sites and nursing education programs. Students, using e-learning, will be placed for clinical experiences in sites that are normally out of reach of the academic institution. E-learning will facilitate close monitoring by faculty. better support for clinical preceptors, and training for all parties involved. The result will be that smaller, isolated facilities will actively collaborate with academia.
The third recommendation is to create an online assistant nurse educator program in which professional nurses in practice serve as teaching assistants in nursing education programs. To alleviate the challenges of scheduling and location, the teaching assistant will join the class via e-learning. Given the national faculty shortage, this option may not only improve nursing education, but may also alleviate the strain on current and future nurse faculty.
The fourth recommendation focuses on training staff development personnel in the use of e-learning. Staff development educators would receive training on the use of technologies such as course management systems and simulation technology. In a similar vein, the fifth recommendation covers clinical preceptors. Preceptor training is important, for new hires in a facility and for students at affiliated schools of nursing. E-learning would allow for collaborative projects that provide high quality training for preceptors in both environments.
A statewide, seamless community college nursing curriculum is the sixth recommendation. The expectation is that collaboration could occur through the use of e-learning if community colleges were to develop a similar curricular structure. With nursing courses offered online, students across the state would be afforded more flexibility in achieving their academic goals.
The final recommendation would expand the use of human patient simulators. Modeled after simulation alliances in Oregon, this recommendation promotes potential alliances in Iowa that would increase access to the high fidelity simulators and the sharing of resources. When properly used, human patient simulators provide high quality training for practitioners and students, an especially important factor when clinical training sites are in short supply.
Future Directions The strategic plan was presented at a one-day, statewide conference hosted by the Iowa Hospital Association on June 14, 2005, in Des Moines. The conference, entitled 'Imagine a Future ... E-Learning--A Bridge for Practice and Academia,' had two main purposes. The first was to present information on the use of e-learning in nursing practice and academia. The second was to solicit feedback about the preliminary draft of the strategic plan from a broad audience.
In keeping with the collaborative nature of the strategic plan, the conference provided an unprecedented opportunity for nurse educators and practitioners to explore collaborative initiatives that promote engaged learning in the online environment. Of the 95 participants, approximately half were from practice and half were from academia. The enthusiasm generated by the conference prompted the Center for Health Workforce Planning to distribute the strategic plan to all Iowa nursing programs and hospitals and to provide additional competitive funding opportunities to implement the recommendations in the plan.
In September 2005, new competitive funding awards were announced by the Iowa Department of Public Health to support the development and expansion of e-learning opportunities for nurses and nursing assistive personnel. Through August 31, 2006, these awards supported the following projects:
* Academic courses for online delivery to students enrolled in health programs
* Expanded capacity for student clinical experience through the use of simulation technology
* Provision of a state-approved online nurse aide curriculum to meet the unique needs of learners preparing to enter the long-term care workforce
* Faculty development in the use of e-learning with students provided through conferences, online training courses, and curriculum modules for program use.
These and other e-learning initiatives are providing the assistance requested by Iowa's nurse educators and practitioners. They accommodate growing enrollments in a rural state in which more than 80 percent of full-time faculty members are 45 to 54 years of age and where an increasing number of nursing faculty vacancies in the areas of medical, surgical, pediatric, obstetric, mental health, geriatric, community health, and critical care nursing are reported each year.
References
(1.) O'Neil, C. A., Fisher, C. A., & Newbold, S. (2004). Developing an online course: Best practices for nurse educators. New York: Springer Publishing.
(2.) Vroeginday, B. J. (2005).Traditional vs. online education: A comparative analysis of learner outcomes. Dissertation Abstracts International, 66(10), 3559A. (UMI No. 3193436).
(3.) Bristol, T. (2005). Perceptions of e-learning in Iowa nursing faculty. Unpublished doctoral dissertation, Capella University, Minneapolis, MN.
(4.) Billings, D. M. (2003). Online communities of professional practice. Journal of Nursing Education, 42(8), 335.
(5.) Dumpe, M. L., Kanyok, N., & Hill, K. (2007). Use of an automated learning management system to validate nursing competencies. Journal for Nurses in Staff Development, 23(4), 183-185.
(6.) Oregon Simulation Alliance. (2006). Background to the Oregon Simulation Alliance Initiative. [Online]. Available: www.oregonsim.org/profile/ history.htm.
(7.) BristoI, T. (2006). Evidence-based e-learning for nurse educators. Des Moines, IA: Iowa Department of Public Health. [Online].Available: www.idph.state.ia.us/hpcdp/common/pdf/ workforce/elearning_2006.pdf.
Tim J. Bristol, PhD, RN, was a faculty member at Moraine Park Technical College, Fond du Lac, Wisconsin, during the preparation of this manuscript. He is now director of nursing, Crown College, St. Bonifacius, Minnesota. Eileen M. Gloor, MSN, RN, was executive officer of the Center for Health Workforce Planning, Iowa Department of Public Health, Des Moines, during the preparation of this article. She is now bureau chief for the Bureau of Professional Licensure, Iowa Department of Public Health. The development of the strategic plan described in this article was made possible by grant number 6 R24HP04104-00 from the Bureau of Health Professions, Health Resources and Services Administration, US Department of Health and Human Services. For more information, contact Dr. Bristol at tim@nursetim.com.
