In this issue of Educational Pathways we focused, in a general sense, on how three schools of nursing built and expanded their online degree offerings, and on what kind of teaching and learning approaches they have implemented. We looked at three private institutions offering nursing programs at a distance: Excelsior College, University of Phoenix and Walden University. Phoenix and Walden are for-profit institutions. Excelsior is a non-profit institution. We did not get into the management of the face-to-face clinical and practicum requirements that are obviously important parts of nursing degree programs. Nor did we talk much about the many student services that accompany such programs. But, suffice it to say, all three of these institutions have very strong infrastructures for program management and production on all these levels.

Need For Nurses Fueling Growth
Nursing programs, in general, are growing in numbers. Phoenix, Walden and Excelsior say that online enrollments are definitely on the rise. Part of this increase is due to a strong job market for nurses. According to the Bureau of Labor Statistics, job opportunities for registered nurses are growing much faster than average for all occupations through 2014. The median age of registered nurses is rising, creating a large number of impending nurse retirees and a growing need for replacements. Couple that with a growing aging population that needs nursing care, and nurses are projected to comprise the second largest number of new jobs among all occupations.

The Bureau of Labor Statistics also notes that the need for nursing faculty is increasing as more instructors in the field reach retirement age.

Much of the job growth for nurses is expected to occur in nursing care facilities, as hospitals discharge patients sooner, and in outpatient care centers, where more sophisticated medical procedures that used to be limited to hospitals move to ambulatory and surgical and emergency centers.

Excelsior College
Excelsior College is an interesting case in point in the world of nursing programs offered at a distance. Among its most notable accomplishments is its associate degree program, which has roots dating back to the early 1970s when Excelsior was known as Regents College. Today students can choose from one of two associate-level nursing degrees: the Associate in Science (AS) or the Associate in Applied Science (AAS). Both prepare students to take the NCLEX® exam and require successful completion of 67 semester credits, including 31 in general education and 36 in nursing.

Students admitted into these two associate-level programs must have some kind of prior health care experience. “Most of the students are LVNs or LPNs,” says Suzanne S. Yarbrough, associate dean for nursing. “Although we admit paramedics, respiratory therapists, and other groups of people. They are not going to be successful if they don’t have some kind of health care background.”

Learning Resources or Courses?
Most of the requirements for the AS and ASS programs may be met through Excelsior College Examinations and Excelsior College courses that prepare students for the exams. At the associate’s level, most of the courses are actually called Nursing Learning Resources because they are not courses per se, although they do have a faculty facilitator. “We don’t call them courses because they don’t have a grade associated with them,” says Yarbrough. “But they can be considered a course in a traditional sense.” These learning resources can include on-site workshops at various locations across the United States, pre-examination teleconferences for performance examinations, pre-examination advisement appointments with nursing faculty, or pre-examination online conferences for specific theory and performance examinations. The online conferences are a relatively new development started last year. “For every exam that we offer, we now have an eight-week online guided learning offering,” says Yarbrough. “We really don’t teach the content as much as we facilitate student learning inside conferences. We don’t offer credit for taking these. The student has to pass the exams to earn credit.”

BS Program
The associate-level programs eventually led to offering a Bachelor of Science (BS) in Nursing in the mid 1970s. To qualify for admission into the BS in Nursing program, a student must be currently licensed as an RN in the United States and must have successfully completed an associate degree or diploma nursing program.

Distance courses were eventually added at the BS level and today are offered in three formats: WebCT (a "virtual classroom"); web-based, where students learn at their own pace within the course term; and instructor-led CD-ROM.

Online Capstone
Yarbrough mentions a newly introduced online capstone course in the BS curriculum called the Professional Socialization and Role Performance Requirement. “Students enroll in this course once they have completed all of their other requirements,” she says. The capstone focuses on synthesizing theories, principles, models, and skills from nursing, other disciplines, and the arts and sciences. Students integrate knowledge gained throughout the curriculum to operationalize core concepts (critical thinking, communication, research, role development, caring, and cultural competence) while functioning in roles of baccalaureate nursing practice. “There are some clinical requirements,” she adds. “They do a small community assessment in their home community. They also do a service-learning project in their home community.”

Adjunct faculty facilitate this capstone, following an Excelsior syllabus. “They (faculty) direct the discussions according to the way we designed them, and the grading is done by graders.” Both faculty and graders in the BS program must have earned a minimum of a master’s-level degree in nursing.

“We’ve designed a curriculum that moves students from the associate’s degree into the bachelor’s degree,” says Yarbrough. “It makes more sense technically and educationally. And students have found better success this way.”

A Recognized Leader with a Large Student Body
The Excelsior School of Nursing has also found success, enrolling more than 15,700 students in its AS, AAS and BS nursing programs in 2005. It has the largest number of associate degree nursing students in the country.

Plus, in September last year the School of Nursing was designated a 2005-2008 National League for Nursing (NLN) Center of Excellence in Nursing Education. This recognition was first awarded by the NLN in 2004 with three schools receiving the award. In 2005, four more schools, including Excelsior College, received the designation. In order to apply for the designation, a school must be accredited by the National League for Nursing Accrediting Commission (NLNAC). There are approximately 1,700 NLNAC-accredited nursing programs in the U.S.

MS Programs
In the early 1990s, Excelsior launched its online Master of Science (MS) in Nursing (Clinical Systems Management) program, which includes a RN-MS option that allows students to work toward an MS while completing their BS. The MS program enrolled 328 students in 2005.

The MS is more of a typical online graduate-level program. The faculty are Ph.Ds, and the courses are conducted similar to the BS capstone in that they consist of discussion boards, assignments and assessments. For the most part, the MS courses are heavily assessment oriented. “There are (grading) rubrics attached to the discussion boards, and there are (grading) rubrics with regard to every assignment,” says Yarbrough. “We maintain an allegiance to our philosophy that it’s not where you learned it, or how you learned it, but what you learned. We still base what we do on objective assessments. And that has consistently applied for all students across the curriculum.”

Certificate Programs
A Nursing Management certificate program and a Health Care Informatics certificate program are the most recent additions to the Excelsior School of Nursing online offerings. Both are also part of the School of Health Sciences. Both went live during the 2004-05 academic year. Nursing management is a 14-month certificate program, developed under a Congressional award through the U.S. Department of Education. Applicants for the full program must currently be licensed RNs. The program was designed to help students acquire the skills related to budgeting, finance, human resources and ethics, and it consists of five credit-bearing courses that give students a complete framework of knowledge about the field. Each course is 15-weeks long and requires participation in online discussions and the completion of team assignments.

The Informatics certificate program is 17 credits and is open to any health care professional with a bachelor’s degree. At its core is an “Informatics Project,” which allows students to apply informatics concepts to their particular health care disciplines. Students who successfully complete the program earn 12 credits toward the MS in Nursing degree.

Courses in the informatics certificate program are set up as 15-17 week courses for cohort groups of up to 20 students. Cohort courses include a faculty-facilitated learning experience with the group. There are discussion questions and team exercises related to the course content. Most courses also include a final assessment in the form of a research paper project.

In addition, the Informatics certificate program has online seminar courses that are approximately 12-13 weeks in length and are like seminar courses on a traditional campus. Students participate in faculty-facilitated discussions with up to 20 other students and are expected to participate in the online discussions on a weekly basis.

Overall
Excelsior’s Interim Provost and Chief Academic Officer Chari Leader explains that “there is a lot of rhetoric right now about the need to be more innovative in nursing education so we can put more nurses in the pipeline, particularly since the average age of nurses is somewhere in the early 50s/late 40s. Those nurses are going to be retiring. So one of our strategies is to reach out to them to further their education with MSNs so that they can become faculty.”

In addition, Leader says that, in general, trying to be innovative in a highly regulated health care education environment comes with its unique set of challenges. “We find that many nursing boards are still looking at nursing education in a very traditional way.” Especially at the associate’s degree level, issues related the number of supervised clinical hours and seat-time in a physical classroom come into play. “Certainly Excelsior is doing lots of interesting things to create a dialogue around such topics in terms of competency-based education,” says Leader.

In the meantime, more innovative programs are starting to develop at Excelsior. In the School of Health Sciences, for instance, an End of Life Care certificate program is now being offered. The certificate is designed for nurses and other health care professionals such as social workers, chaplains, respiratory therapists, physical therapists, and occupational therapists that are involved in end of life care in different settings, or other professionals who are interested in learning more about end of life care. “They have done some things culturally, like how to be a hospice nurse, or how to be a public health nurse in different cultures, dealing with different cultural perspectives, including gay, lesbian and transgender,” notes Leader. “So, there is really a lot happening in our schools of nursing and health sciences.”

University of Phoenix
The University of Phoenix is another large provider of online nursing degree programs, with about 4,600 students enrolled in its online BS in Nursing program and another 3,500 in its online MS in Nursing programs, which includes concentrations in health care education, integrative health care, business administration and health care management, and health administration. Phoenix also provides an online BS in Health Administration, a Master of Health Administration, and a Doctor of Health Administration program.

Students in these programs are typically between 35 to 45 years of age, married with children, working full time with an income somewhere between $45,000 and $80,00 depending on where they are in the country, explains Beth Patton, associate dean and director of the College of Health and Human Services. They have successfully completed at least an associate’s degree and have decided to continue their education. “They are career and goal minded. They have a career pathway that they are after.”

Patton adds that the health care education component (which launched two years ago) “is catching on, and I think it will grow because of faculty shortages. I think there will be more nurses who want to get out of the bedside, or get out of the environment they are in, and use their knowledge and skills to teach others."

“Practitioner” Faculty
As is customary with most University of Phoenix programs, the nursing and health care programs hire what is referred to as “practitioner” faculty, meaning many of the faculty are working in their respective fields/specialties and teach online as part-time adjuncts. “We are not like traditional schools that hire full-time faculty members,” says Pam Fuller, associate dean of the College of Health Science and Nursing. Fuller adds that at least 51 percent of University of Phoenix faculty teaching in its graduate-level nursing programs have doctorates. “Our faculty model really lends itself to learning and teaching. What they do best is bring the world’s experiences to the classroom so they can be talked about, analyzed, and then applied back to their work settings.” Patton adds that “a lot of nurses want to keep their full-time day jobs, but they also enjoy teaching. This gives them the opportunity to blend both.”

Training and Mentoring Faculty
All new faculty are required to go through a four-week online training program and a mentoring arrangement held during the first class they teach. The training and mentoring “teaches them how to use our model of delivery so that they see what the students and faculty see, they understand when and how to post grades, and how and with whom to communicate with,” Patton explains. “They learn about our teaching model, which is an (career/job) applicable model; they learn about adult education and how to build teaching strategies. They have a mentor (in their first online class) that lurks in the course. If at any time the new faculty member seems to be getting off track, the mentor will communicate with them. By the time they made it through the mentoring course, these faculty feel very confident that they can continue to teach.”

Simple Course Delivery Model
The content of University of Phoenix online courses is identical to its on-ground courses. “Students are expected to have the same outcomes,” says Fuller. “If a ground-based group is doing a community assessment for their community course, the online students must do a community assessment as well. If a ground-based group is doing a face-to-face presentation inside a classroom, the online group will do an online PowerPoint presentation with their presentation notes attached.”

Fuller adds that, overall, the delivery model is not complex or complicated. “Once a student gets a grasp for how courses are delivered online, I want to say it’s relatively easy, and I think it should be, because you don’t want it to be so complex that they lose sight of the content within the course.”

Curriculum Development
When asked how the University of Phoenix keeps up with the latest developments in the health care industry, Patton explained how faculty contribute substantially to curriculum development through official monthly teleconferences. Regular communications between colleagues and students, plus focus group initiatives and data culled from course surveys, also contribute to the curriculum development process. “They (faculty and students) are our eyes and ears for curriculum," says Patton. "So when we hear that there is a movement toward gerontology, we look at how we can engage that into our curriculum. We also have focus groups within our communities to get a feel for what it is that a new graduate is expected to know. What does the industry want our students’ skill sets to be and at what level of knowledge? (In addition), I think the advantage we have is that our faculty and our students are working adults, so we get lots of data in course surveys related to what the needs are in the health care and nursing fields. Then we try to build our course work from that.”

As an example of how a focus group was conducted, Patton points to a recent project in which she helped to revise the BS in Health Administration by inviting a group of health care experts, who were identified by faculty, to attend a day-long brain-storming and information-gathering session in Phoenix, AZ. A total of 25 attended. “We talked about what employers want to see,” says Patton. “What are their key issues? What would they be looking for in a graduate?”

Course Creation
So, with all this give and take and collecting of information, how are online courses ultimately created? “Everything is a centralized curriculum,” says Patton. “It’s curriculum development managers working with faculty who are content experts.” All the data and information that has been collected goes into an online system. “We pull all this up and look to see what the trends were, what were the negatives, what were the positives about a course. And we continuously ask our full-time faculty to go back to our part-time faculty and ask them what works best. Is it time to do a major revision, or is there just a couple of things that need updating?” On average, entire curriculums are revised every two to three years, and it takes anywhere from four to six months to create a course.

Addressing the Education Needs of Future Nurses
When looking at the big picture of online nursing education, Fuller explains how the past apprehensions of nursing schools to move curriculum to online modalities have “gone to the wayside.” And the challenges now being faced revolve around whether or not nursing schools have built the infrastructure to effectively support an online teaching and learning environment? “If you don’t have a great infrastructure built in to help faculty with the IT questions, and to help them communicate effectively with students, then your courses will not be as strong as they can be,” she says.

Walden University
Walden University, which was acquired by Laureate Education, Inc., formerly Sylvan, in 2001, has one of the newest online MS Degree in Nursing programs in the country, started in September 2004. And it can safely be said that Walden, through Laureate, has a very strong infrastructure supporting all of its online teaching and learning efforts. In the Fall of 2005, Walden added a pre-entry to the MS Degree in Nursing program curriculum, called the “R.N. Track,” for RNs who do not have bachelor’s degrees. Both of these programs, combined, have already enrolled 800 students.

The Walden MS Degree in Nursing program features specializations in education and in leadership and management. The R.N. Track does not confer an undergraduate degree. Instead, it requires applicants to have graduated from associate and diploma nursing programs and be licensed as registered nurses. These students may be accepted into the MS program provided they fulfill the general education requirements. Once applicants meet these requirements, they are admitted to Walden and begin taking foundational courses. Students then progress onto the MS program core curriculum and finally the specialization courses.

Program Development
Marion Anema, faculty chair of the MS Degree in Nursing, explains how developing the program was a “great team effort” that started in 2003 with focus groups of nurses and nurse leaders from around the country. “We had nursing faculty and nurse administrators participate, and we asked how will this program really make a difference. What would you expect of a master’s prepared nurse going into nurse management or administration? What’s needed for nurse educators?” For the R.N. Track, Walden enlisted educators from nursing associations involved with associate degree and diploma education and asked them what such undergraduate students have and need to be prepared for master’s-level work. “This is how we built the foundation courses over a period of several months,” says Anema. She adds that paying close attention to standards established by the American Nurses Association, the National League for Nursing, and a guide published by the American Association of Colleges of Nursing titled “The Essentials of Master's Education for Advanced Practice Nursing” were also important elements utilized in building Walden’s MS Degree in Nursing.

Innovative Learning Model
The learning model that came out of this program-development process is one in which MS Degree in Nursing students build on prior knowledge. Basically, this is a student-centered approach whereby, for each eight-week course in the program, students are first asked what they already know about the subject being taught. Since students are actively working in health care, their knowledge and input to the course is respected and valued. “The weekly content then moves on to say, ‘okay here’s some new knowledge. Think about this in a new way,’” says Anema. “And then each week ends with asking ‘how are you going to apply this to your current practice?’”

Connecting Students to Real-World Examples through Video
An important element of the student-centered approach entails the development of course materials that connect students to the best expertise available, and to real-world examples of theory being put into practice by others. To accomplish this, Laureate invests heavily in video production that brings faculty, industry experts, and practitioners into the Walden curriculum for students on a week-to-week basis.

For example, in a “Promoting and Preserving Health in a Diverse Society” course, Laureate’s instructional design and media staff created a DVD featuring an example of a rural American population in Spirit Lake, North Dakota on the Dakota Sioux Indian Reservation. The video shoot included both scenes in the local hospital (Mercy Hospital, Devil’s Lake, North Dakota) and interviews with regional experts and spokespeople, including a Tribal Chairman who talked about health workforce issues, several professors, administrators and research analysts addressing rural health issues, as well as employees of Indian health service facilities commenting on relevant issues.

Anema refers to these DVDs as “nurse leader presentations to make students aware of where we are today, in nursing and health care and patient care, and where we should be going. It’s very futuristic, and these types of comments and presentations are interspersed throughout each course.” On a weekly basis students hear and see nurse leaders through the DVDs, in addition to participating in the typical readings, discussions and assignments of an online course. “And all of that comes together at the end of the week to say ‘here is what I really learned, and it is going to make a difference in my practice because now I can do something that will be cost-effective, or I am going to work with my nurses association to look at changing something in health care.’ So there is this group experience, and they are each going to come away with something different that is applicable to their setting.”

Keeping Up With The Times
In order to keep pace with the changing trends in health care, Walden relies on its faculty from around the country as well as its students. “The students bring a lot to the program,” says Aneama. For example, a course may include a segment that addresses how a new piece of medical equipment, such as a respirator, is used in health care, and the students and faculty will share their experiences for selecting and purchasing a new respirator, as well as how to deal with the equipment vendors who sell them. Or, for another example, students might enter into a discussion about the ethical and cost issues related to electronic medical record keeping. “So our students do come out of the program with a great deal of knowledge and focus and ability to use technology to improve practice and to adopt new things in their settings.”

And overriding everything, Anema adds, is an emphasis on creating positive social change in the field of nursing that is embedded throughout the program. "That means that the graduates are going to improve human and social conditions. All the courses have that thread in them. The students have to ask ‘how is this going to make a difference in what I am doing?”