California collaborative model for nursing education: building a higher-educated nursing workforce.
Developing Consensus to Build A Higher-Educated Workforce
The California Institute for Nursing & Health Care (CINHC), the state's nursing workforce center, was founded in 2001 as an independent not-for-profit organization to address California's nursing workforce issues. At that time the nursing shortage was reaching a crisis as California had the least number of RNs per capita in the nation and was on a trajectory to meet only 55% of the state's need for nurses by 2020 (Health Resources and Services Administration, 2004). Building the workforce was a priority for the newly formed organization; thus, CINHC took on the challenge of creating a master plan for the state's nursing workforce and served as the catalyst for the statewide effort to build educational capacity in partnership with key stakeholders that included policymakers, state agencies, educators, health care systems and associations, foundations, and professional nursing organizations (Jones & Leach, 2005).
Efforts to increase educational capacity paid off with educational capacity increasing by 69% since 2003 (Waneka et al., 2013). However, the need to redesign nursing education to ensure nurses were prepared to meet evolving health care needs became an important consideration. In 2006, the Gordon and Betty Moore Foundation funded CINHC for an 18-month project to engage 100 "thought leaders" representing key stakeholders in thoughtful and evidence-based dialogue about the need to change nursing education. California thought leaders and invited national experts developed a consensus-driven white paper on Nursing Education Redesign, which became Goal 3 of the California Master Plan in 2008 (Boiler & Jones, 2010; CINHC, 2004).
Seven strategic priorities emerged and became the "building blocks" for nursing education redesign in California. One of the building blocks was the Collaborative Nursing Education Model (Boiler & Jones, 2009). An early example of such a partnership occurred between Sacramento City College and Sacramento State University in 2002-2004 and was also a key feature of the Oregon Consortium for Nursing Education (Tanner et al., 2012). Ultimately, the CCMNE was launched in 2008 with broad-based consensus as the most effective means by which California could educate the numbers of BSN-prepared muses needed.
California Collaborative Model For Nursing Education
CCMNE builds on the foundation of ADN education, acknowledging the contribution community colleges make in preparing the nursing workforce. Also, as these nursing programs tend to be more financially and geographically accessible to under-represented minority students, they have a higher proportional enrollment of His panic and Black/African-American students than university pre-licensure BSN programs, providing exceptional opportunity to increase diversity in the BSN-educated workforce.
CCMNE strives to overcome barriers to the traditional RN to BSN programs available for decades through documented seamless progression from ADN to BSN by:
* Streamlining the admissions processes.
* Eliminating cumbersome processes to transfer nursing credits from one level of nursing program to another.
* Preventing duplication of nursing prerequisites and major courses.
* Shortening the time frame for an RN to obtain the BSN to a reasonable and equitable length of study.
* Increasing access to BSN education.
Purposefully designed into the CCMNE is the uninterrupted academic progression toward the BSN regardless of whether or not the ADN student obtains employment upon graduation and licensure. One reason ADN graduates reportedly do not continue their formal education is because they are waylaid by employment (Fauteux, 2013); however, the model engages their early commitment and supports their timely and uninterrupted progression to the BSN.
Because of ongoing state budget constraints in the public sector, BSN programs have limited opportunity to expand capacity in pre-licensure BSN programs to meet demand. The CCMNE provides a means through which the state-supported nursing schools can prudently educate more BSN-prepared nurses under these circumstances. This is an important consideration as public schools are significantly less costly than private educational institutions. Nevertheless, it is noteworthy that private California nursing schools increased their new student enrollments by 389% over a 10-year period between 2002 and 2012 (Waneka et al., 2012).
The CCMNE strategy evolved with the growing interest in coordination between ADN and BSN degrees. "Articulation" between the public sector California Community College (CCC) ADN and California State University (CSU) BSN programs was an expectation, driven by legislation enacted in 2002 (CA AB2314). However, traditional articulation agreements were course-to-course, not degree-to-degree, and consequently functioned as an unrecognized barrier to many RNs who sought to advance their education. At the time the white paper was initiated in 2006, 70% of the state's new nursing graduates were from ADN programs. Although these graduates were encouraged to continue their education by completing RN-BSN programs offered by many public and private universities, in 2010 only 20% of ADN nurses reported a BSN or higher nursing degree (Spetz, Keane, & Herrera, 2011).
Following the publication of the white paper, the commitment to develop a new model for advancing nursing education was underwritten by two private foundations, along with the State Chancellor's Office for California Community Colleges, to provide funding to launch CCMNE demonstration projects (CINHC, 2012). In 2008, $3 million was committed to begin the work: $2 million from private foundations (Kaiser Permanente Health Education Fund and Foundation for California Community Colleges) and $1 million through special state-funded grants. Through CINHC, the foundations sent out a request for proposals (RFP) to all 132 California nursing programs to create Collaboratives and apply as demonstration sites to develop the CCMNE. Five Collaboratives representing 23 nursing programs received implementation grants. Grant recipients were expected to meet the requirements described in the RFP, identify barriers to seamless nursing education progression, and develop processes to overcome these barriers.
Grant applicants were encouraged to tailor Collaboratives to local/regional needs while being required to meet the following criteria:
1. A "seamless" transition from the ADN to the BSN program, without a break in education or the need to reapply for admission to the partnering university.
2. The BSN academic portion to be completed in no more than 12 months, or three semesters, following the ADN portion.
3. Equivalent to the BSN degree offered by nationally accredited baccalaureate nursing programs.
4. Commitment from the administrative leadership of collaborating education institutions to support the model for long-term sustainability.
5. Description of how the Collaborative operationalized the following required elements: integrated curriculum, sharing faculty among programs, incorporation of dual admission into the process, BSN completion within 1 full year post-ADN study, and permanence and sustainability.
The proposals also needed to describe how the faculty would be engaged in the process, how the university's capacity to educate BSN-prepared nurses would be expanded, and how academic progression would be promoted to students. Evaluation of the Collaborative's success by the partnering schools included setting goals and progress toward meeting targets of ADN graduates expected to obtain the BSN. Through this initial work, the operational definition of the CCMNE Core Components evolved. In 2012, CINHC was awarded a $250,000 grant from Kaiser Permanente Community Benefit to provide technical assistance to emerging Collaboratives throughout southern California, and was also awarded a $300,000 grant through the Academic Progression in Nursing (APIN) project (Robert Wood Johnson Foundation [RWJFj] to launch a regional Collaborative in the greater Los Angeles area.
The Impact of State Legislation And the IOM Report on California's Journey
Coincidentally, soon after the 2009 launch of the CCMNE demonstration projects, the California state legislature passed Assembly Bill 1295 (AB1295) that required the two state public education systems--CCC and CSU--to streamline nursing education progression by the fall of 2012. The bill called for developing "articulated nursing degree pathways" that removed nursing course duplication and licensure content repetition from the ADN-BSN curriculum and removed repetition of prerequisite nursing courses. AB1295 accelerated the public education system's institutionalization of transparent ADN-BSN academic progression, facilitated development of standardized CSU nursing prerequisites, and provided opportunity to award university credit for pre-licensure nursing content completed in the ADN program (CSU CO Executive Order 1084). Outcomes for post-licensure BSN students include decreased time to BSN completion, decreased associated costs, and accessible ADN-BSN academic program pathways and requirements (CSU-CCC "ADN-BSN Roadmaps").
The Institute of Medicine (IOM) (2011) "The Future of Nursing" report raised the importance of academic progression as a mandate in preparing for health care reform and called for 80% of nurses to be BSN educated by 2020. Both AB1295 and the IOM report further emphasized the significance of the ongoing CCMNE work.
CCMNE differs from AB1295 and the IOM recommendation for academic progression in that the California model focuses on concurrent ADN-BSN education rather than post-licensure ADN-BSN education. By so doing, the model recognizes and encourages collaboration between the community college and university nursing programs to leverage the resources of both. The CCMNE effectively decreases time to obtain the BSN degree because boundaries between community college and university programs are breached; nursing curricula are organized purposefully and transparently, are interdependent, and clearly establish similar entry into practice outcomes for both the ADN and BSN and unique outcomes for the BSN.
The following three CCMNE Core Components exceed what is required by AB1295 or described in the IOM recommendations:
* Dual admission to, and concurrent enrollment in, both ADN and BSN programs to hasten and institutionalize ADN student academic progression to BSN.
* Purposefully sharing faculty across community college and university programs to promote robust, efficient, effective alliances to increase student access and success.
* Curriculum design that supports completion of the BSN within 1 year of ADN graduation to more closely align with the traditional 4-year pre-licensure BSN academic plan.
Neither AB1295 nor the IOM report contains these specific provisions. Rather, both focus on post-licensure ADN to BSN progression and avoidance of repetitive nursing and prerequisite content. The CCMNE core components also focus on collaborative strategies to advance and sustain academic progression, building upon the foundation provided by the community college nursing programs.
Both CCMNE and AB1295 stimulated the state's educational systems to recognize the limitations of the existing formal "articulation agreements" between CSUs and CCCs, which remained a structural barrier to implementing seamless nursing degree progression. For the ADN-BSN transfer population, general education requirements for both systems were not coordinated nor were the nursing prerequisites and degree requirements synchronized. The result for the ADN to BSN student was increased time to degree, increased associated costs, and excess accumulation of units not applicable toward the BSN degree. Nursing programs seeking to implement the CCMNE had to address such issues to meet the required CCMNE core components. The results of these CCMNE discoveries and subsequent negotiations hastened the ability of the CSU and CCC to design corrective measures as part of the AB1295 mandate.
CCMNE Core Components
The five core components and operational definitions (see Table 1) are followed by discussion of the intent and rationale for each and examples of approaches across California. It is noteworthy this framework continues to evolve, is sufficiently flexible to accommodate a variety of strategies that meet the intent of each core component, and can be implemented at local, regional, or state levels.
Integrated curriculum. The purpose is to achieve authentic, transparent, seamless ADN-BSN progression. Systematic vetting and alignment of all components of both ADN and BSN degrees provides the opportunity to accomplish this goal. With a guiding framework (e.g., AACN Baccalaureate Essentials, Nurse of the Future Core Competencies), nursing faculty can effectively design degree progression that builds on existing nursing curriculum structures and clearly identifies BSN outcomes that differ from and/or add to ADN outcomes (Hall, Causey, Johnson, & Hayes., 2012; Landry, Orsolini-Haine, Renwanz-Boyle, Alameida, & Holpit, 2012). Alternatively, collaborating programs may decide to develop an entirely new "common" curriculum (Tanner et al., 2012). All nursing prerequisites, general education, statutory, and institution-specific degree requirements need to be examined and coordinated to support the progress made by integrating the nursing curricula. This process can also identify nursing courses that could simultaneously meet both nursing major and other degree requirements.
Two general approaches have emerged in California. Piloted in 2000, the Sacramento City College and CSU Sacramento Collaborative simultaneously admitted students to the ADN and BSN programs and obtained board of nursing approval for the pre-licensure curriculum to be taught in two separate nursing schools. The Sonoma State University Collaborative (Collaborative Nursing Education Continuum Model, 2008) refined the post-licensure BSN curriculum based on existing ADN content so that required university coursework consists only of upper-division nursing and upper-division general education.
Shared faculty. The primary goal is to purposefully work together to clarify both educational paths. Obstacles to cross-employment such as different faculty unions do not preclude the intent of "sharing" faculty. Frequently, clinical faculty already teach across programs and adding joint professional development, structured joint faculty and/or advisory board meetings, Collaborative curriculum committees, and content-specific work groups encourages an esprit de corps that maximizes all nursing program faculty resources.
The San Francisco State University Collaborative with City College of San Francisco facilitated a full faculty retreat and subsequent meetings where discoveries about each other's curricula, teaching methodologies, and learning activities generated a sense of enthusiasm, understanding, and respect for what both institutions brought to the student nurse's trajectory. Educators eliminated content repetition to achieve seamless ADN-BSN transition (Landry et al., 2012). CSU Los Angeles partnered with eight area community colleges to implement their CCMNE with APIN/RWJF grant funding; community college nursing faculty also teach university nursing courses. Sonoma State University and five community college nursing programs joined together in 2008 and publicly strengthened their existing alliance as nurse educators all on the same path--educating the nurse of the future.
Dual admission. The major purposes are to engage the ADN student in BSN progression and shorten the overall time to BSN completion. Additionally, dual admission supports organization of system resources such as financial aid, academic advising, and application procedures to decrease duplicative efforts. The major obstacles to dual admission with enrollment in a sequential pattern include increased costs to students and challenging financial aid coordination. Major obstacles to enrollment in a simultaneous pattern include challenging clinical and theory schedule coordination between programs and increased student workload.
Some California Collaboratives (CSU Los Angeles [CSULA], Sonoma State University [SSU]) have instituted "sequential" dual admission/enrollment in BSN coursework during summer when ADN students are not enrolled in ADN coursework. This pattern avoids the difficult challenges of lecture and clinical schedule coordination and increased student workload characteristic of "simultaneous" dual enrollment while preserving the overall goal of streamlining progression to the BSN. "Simultaneous" dual admission/enrollment is supported by overlapping nursing curricula and has been successful in both decreasing time to degree and encouraging ADN-BSN progression (CSU East Bay and CSU Fullerton).
BSN attainable in 1 year. The goal is to reasonably align the post and pre-licensure BSN degree programs so the ADN-BSN curriculum plan meets but does not inadvertently exceed requirements for the BSN. If an ADN program contains similar nursing prerequisites, general education courses and nursing coursework to meet licensure requirements, has an "articulation agreement" with the university, and optimally takes 3 years to complete, then logically no more than 1 year should be required to complete a BSN. Unfortunately, existing system problems such as course-to-course articulation agreements (not degree articulation agreements), unclear university transfer and general education requirements for the ADN population, and the "ADN-BSN Conundrum" (Close, 2013) historically rendered the actual time frame post-ADN being closer to 2 or more academic years. Effective corrective strategies used in California include arrangement for current ADN students to begin required post-licensure BSN coursework while completing their ADN; removal of duplicative nursing content from ADN and BSN curricula; standardization of nursing prerequisites for program admission; clear identification and coordination of ADN and BSN degree requirements; and provision of the option for awarding university nursing credit for NCLEX-RN (CSU Executive Order 1084 is an example).
A variety of approaches are present across the state. CSU Fullerton's RN-BSN program can be completed in 1 calendar year of full-time enrollment following completion of the ADN through the utilization of both simultaneous and sequential enrollment patterns for nursing and upper-division general education courses and utilization of an upper division nursing portfolio course series. ADN-BSN academic plans for San Francisco State University and SSU include award of up to 20 units of university nursing credit for NCLEX-RN which facilitates completion of the remaining 30 units of university credit in two to three academic terms following ADN graduation. SSU and CSULA also utilize sequential dual enrollment (summers) during the ADN program to complete initial BSN courses. CSU Channel Islands has variously utilized sequential and simultaneous enrollment to achieve BSN program completion within 15 months of ADN award.
Permanence and sustainability. The intent of this component is to assure continuing availability of the ADN-BSN program. Institutional permanence between CCCs and CSUs is supported by ongoing faculty collaborative work, commitment to curriculum redesign/integration, and official transparent and comprehensive degree "articulation agreements" between the institutions. Published ADN-BSN "roadmaps" that guide pre-nursing community college students through the ADN and completion of the post-licensure BSN were a direct result of the California legislative mandate AB1295 (subsequently chaptered in state education code). Importantly, the CCMNE enhances seamless progression by the expectation for dual admission, integrated curriculum, and completion of BSN within 1 calendar year of ADN completion.
CCMNE program sustainability in the public sector is influenced by state budget allocations, which renders long-term planning for ADN-BSN viability challenging. Various fiscal models need to be examined fully if a demand-driven increase in ADN-BSN educational capacity is desired. The CSU campuses may, within strict guidelines, use self-support program design or elect to decrease enrollment in other nursing department tracks (such as pre-licensure BSN or MSN) and redistribute the limited funding toward the ADN-BSN track. Increasing and sustaining ADN-BSN capacity requires focused nursing faculty and administrator discussions regarding intended and unintended consequences of choosing one or a combination of any potential options.
The California Collaboratives have employed a variety of approaches to assure sustainability including models that allow qualified ADN students to enroll in required BSN courses through approved state and self-supported mechanisms either independently or in a blended fashion. San Diego State University utilizes several approved nontraditional approaches to provide ADN student access to BSN coursework prior to university admission to the BSN program (without guarantee of admission attached to enrollment); the BSN degree is then completed through regular university admission and part-time enrollment. CSU San Marcos and CSULA offer their RN-BSN programs utilizing a self-support model.
Learning from the Past And Looking to the Future
One significant lesson learned is the critical need for a Collaborative to employ a dedicated program director. The coordination of all university and community college nursing degree requirements, nursing faculty, educational counselors and academic advisors, student financial aid staff, registrar offices, and myriad other essential operations between and within each of the partners demands a single "point person." The necessity for a program director was also validated by the Oregon Consortium for Nursing Education (Tanner et al., 2012) with one of their key findings being the pivotal and multifaceted nature of that role to support program integrity and sustainability.
An important technical assistance need that emerged throughout this journey relates to the reality that, as state-funded institutions, the CSUs cannot simply increase numbers of BSN students at a time when nearly all campuses and programs are impacted. Reasonable options for shifting priorities within departments and universities as well as non-state-funded financial models must be vetted for CSU nursing programs to increase ADN-BSN capacity. In designing any self-support budget, the Collaboratives must assure reasonable student enrollment fees and sustainable operational funding while meeting strict guidelines for program expansion.
Currently, 6% of all ADN students in the state are dual enrolled in public sector CCMNE ADNBSN programs. Several CCMNEs that began dual enrollment in 2011 demonstrated a doubling of post-licensure BSN graduates in 2014 from their respective universities attributable exclusively to the CCMNE. There has been a 44% increase in BSN graduates from all types of California-based post-licensure BSN programs since 2012 (see Figure 1). The CCMNE provides an additional path to increasing workforce BSN diversity that reflects the overall contribution of the post-licensure BSN degree trajectory to which the CCMNE makes an important contribution (see Table 2).
This journey challenged California nurse leaders to address the BSN degree in its entirety, engage faculty across all programs, and commit to streamlining the entire process while maintaining quality and meeting national accreditation standards. The CCMNE continues to exceed the expectations of increasing access to and timely seamless completion of the ADNBSN pathway. A serendipitous and empowering outcome has been the evolving "cultural shift" to an expectation that most ADN graduates will progress to achieve the BSN rather than the current situation in which most do not.
There are now 11 California State University and 50 California Community College nursing programs enrolling ADN students through the CCMNE. With recent additional funding from Kaiser Permanente, CINHC will continue providing technical assistance to southern California CCC-CSU partnerships and also to University of California and private nursing schools to promote seamless academic progression in all California nursing programs.
Boiler, J., & Jones, D. (2009). Nursing education redesign for California: Goal 3 education redesign white paper and strategic action plan recommendations. Oakland. CA: California Institute for Nursing & Health Care. Retrieved from http://cinhc.wp engine.netdna-cdn.com/wp-con tent/uploads/2009/12/5_Nursing-Ed Redesign.pdf
Boiler, J., & Jones, D. (2010). Change California? Reflections on leading statewide collaboration in nursing education redesign. Nurse Leader, 8(2), 40-46.
California Assembly Bill 1295, Postsecondary education: nursing degree programs. Chapter 283, Statutes of 2009-2010 (2009).
California Assembly Bill 2314, Nursing education. Chapter 1093, Statutes of 2001-2002 (2002).
California Institute for Nursing & Health Care (CINHC). (2004). A master plan for California's nursing workforce. Oakland, CA. Retrieved from http://cinhc.wpengine.netdna-cdn.com/ wp-content/uploads/2009/12/5_Nursing-Ed-Redesign.pdf
California Institute for Nursing & Health Care (CINHC). (2012). California collaborative model for nursing education. Oakland, CA. Retrieved from http://cinhc.wpengine.netdnacdn.com/wp-content/uploads/2012/ 06/Statewide-Survey-of-Collab oratives-May-2012.pdf
California State University (CSU) Executive Order 1084. (2013, January). Systemwide nursing policy. Long Beach, CA: Office of the Chancellor, CSU. Retrieved from https://www.calstate.edu/eo/EO-1084.html
Close, L. (January 24, 2013). The shared curriculum model (SCM): Part one Leveraging the best of both worlds; Part two--Unpacking ADN-BSN seamless progression. Promising Education Progression Models Video Series, Campaign for Action, Center to Champion Nursing in America. Available from http://champion nursing.org/ video/promising-education-progression-models-videoseries-shared-curriculum-modelsem-part-one and http://champ onnursing.org/video/promising-education-progression-mo dels-videoseries-shared-curriculum-modelscm-part-two
Collaborative Nursing Education Continuum Model. (2008). Retrieved from http://www.sonoma.edu/nursing/bsn-post/cnecm.html
Fauteux, M. (2013). The case for academic progression. Charting nursing's future, Issue 21. Princeton, NJ: Robert Wood Johnson Foundation. Retrieved from http://www.rwjf.org/ en/library/research/2013/09/cnf-thecase-for-academic-progression.html
Hall, V.P., Causey, B., Johnson, M., & Hayes, P. (2012). Regionally increasing baccalaureate-prepared nurses: Development of the RIBN model. Journal of Professional Nursing, 28(6), 377-380.
Health Resources and Services Administration. (2004). What's behind HRSA's projected supply, demand, and shortage of registered nurses? Retrieved from www.ohiocenterfor nursing.org/pdfs/nursingwork force/HRSAbehindshortage.pdf
Institute of Medicine. (2011). The future of nursing: Leading change, advancing health. Washington, DC: National Academies Press.
Jones, D., & Leach, L.S. (2005). A master plan for the California nursing workforce goal I: Building educational capacity in California schools of nursing. Oakland, CA: California Institute for Nursing and Health Care. Retrieved from http://cinhc. wpengine.netdna-cdn.com/wpcontent/uploads/2009/12/2_Master PlanCase.pdf
Landry, L.G., Orsolini-Haine, L., Renwanz-Boyle, A., Alameida, M., & Holpit, L. (2012). The nursing educational highway in action: Results of a needs assessment and the formation of a collaborative workgroup. Nursing Education Perspectives, 33(4), 274-277.
Spetz, J., Keane, D., & Herrera, C. (2011). 2010 survey of registered nurses. Sacramento, CA: California Board of Registered Nursing. Retrieved from http://www.rn.ca.gov/pdfs/forms/sur vey2010.pdf
Tanner, C.A., Herinckx, H., Delmar, A., Munkvold, J., Spencer, A.G., Gubrud-Howe, P., ... Andersen, H. (2012). Redesigning nursing education: Lessons learned from the Oregon experience. Retrieved from http://www.rwjf.org/content/dam/ farm/reports/reports/2012/rwjf73090
Waneka, R., Bates, T., & Spetz, J. (2013). 2011-2012 annual school report: Data summary and historical trend analysis. Sacramento, CA: California Board of Registered Nursing.
Deloras Jones, MS, RN, and Liz Close, PhD, RN, detail the California Collaborative Model for Nursing Education.
DELORAS JONES, MS, RN, is Former Executive Director, California Institute for Nursing & Health Care; and currently, Nursing and Health Care Consultant, San Rafael, CA.
LIZ CLOSE, PhD, RN, is Professor and Former Chair, Sonoma State University Department of Nursing, Rohnert Park, CA.
Table 1. Core Components of the CCMNE Core Component Operational Definition Integrated Nursing courses, nursing prerequisite, and general Curriculum education courses and degree requirements are coordinated between the ADN and BSN degree programs without inadvertent repetition. Shared Faculty Qualified community college and university faculty collaborate on nursing curriculum development, delivery, and evaluation. Dual Admission Current ADN student is admitted to, and sequentially or simultaneously enrolled in, post-licensure BSN ("RN-BSN") program. BSN Attainable BSN is achievable within 1 calendar year of full-time Within 1 Year study after completion of the ADN. Permanence and All components of the CCMNE are institutionalized at Sustainability collaborating community colleges and universities to ensure continuing program viability. Table 2. Diversity in California Nursing Workforce and BSN Programs Distribution Rate in Enrollment Enrollment California Rate in Rate in Nursing Pre-Licensure Post-Licensure Workforce BSN Programs BSN Programs Population (2013) (2014) (2014) Hispanic/Latino 6.6% 16.2% 20% African American 4.9% 3.5% 8% Figure 1. Student Completions in California Post-Licensure BSN Programs 2012 1,268 2013 1,600 2014 1,826 Note: Table made from bar graph.
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|Author:||Jones, Deloras; Close, Liz|
|Date:||Nov 1, 2015|
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