Iterative Learning and Program Evolution

Iterative learning and evolution of the program

Each project matured, although growth was uneven and dependent on local environments.  In some states, weak partnerships and the need for relationship development became a rate - limiting factor for progress, and in those regions this remained the focus of NPO support.   In other states, attention shifted to mechanics of program development, especially curricular design and messaging the planned transitions.  Sites with pre-existing academic progression projects moved beyond curricular design to enhance the role of practice partners and tackle challenges, especially the impact of new pathways on admissions, financial aid, and diversity.  As the project sites advanced their work, the role of the NPO likewise evolved, and role modeling shifted to greater integration of complexity science, demonstrating the importance of managing multiple inter-related systems, interconnectivity, and dynamic adaptability across all project sites.

Broadening outreach and impact

Over the second and third years of the APIN project, substantial discovery and program development occurred. The NPO served increasingly as a convener and began to broaden the community of outreach to projects outside the APIN-funded sites. A number of non-APIN states were advancing academic progression projects through the State Implementation Program (SIP), also funded by RWJF (Campaign for Action, 2015). Through cooperation with CCNA and the National Program Office of SIP, conjoined national meetings were held. Among the SIP - funded projects, work of the Minnesota Alliance for Nursing Education (MANE) in particular mirrored the process of APIN projects in development of an academic progression model (MANE, 2016).  Although SIP funding for MANE concluded in 2015, the APIN and SIP National Program Offices fostered their continued involvement with the national academic progression work. 

In addition, the APIN NPO became aware of substantive work on academic progression being done at sites without dedicated Campaign for Action funding, most notably through programs in Arizona, Colorado and Kansas, as well as through widely disseminated distance education programs such as University of Phoenix.  Each of these sites developed sophisticated exemplars of the partnership model. After identification of these programs, APIN NPO staff met with representatives of each to develop a full understanding of their work. Due to the significant synergy with the APIN projects, representatives of these programs were subsequently included in national meetings and other learning forums throughout the duration of the project.  APIN representatives also reached out to leaders from the Oregon Consortium for Nursing Education (OCNE).  OCNE was the originator of the statewide standardized nursing curriculum model and the earliest national leader in intentional academic progression pathways (OCNE, 2016).  Bringing representatives from these varied projects together with the APIN grantees expanded the learning milieu and allowed all to benefit (Gerardi, 2016). It was through this dynamic interchange that the most promising practices began to emerge (Hoffman, 2016).  

Critical role of practice partners

All participants recognized the critical role of nursing employers and other practice partners in driving academic progression and this was validated repeatedly throughout the project. Employers were found to play a vital role in driving the market for BSN prepared nurses, with more than 90% ultimately having expressed a hiring requirement or preference for the BSN (AACN, 2013; AACN, 2015b, AACN, 2016).  Among APIN grantees, Hawai’i provided a case in point for the importance of hiring practices on BSN completion. 

A temporary oversupply of nurses in that state allowed employers to strengthen BSN-preferred hiring. AD graduates were unable to find suitable employment and in many cases remained in school, which resulted in Hawai’i having one of the highest proportions of BSN prepared nurses in the nation.  Magnet recognition and the Magnet journey have had a powerful influence on hiring practices (AACN 2014). Major national employers such as U.S. Public Health service and the U.S. military have long required the BSN (AACN, 2015b; Kessler, 2016; U.S. Public Health Service, 2016). Those seeking to enter the nursing profession with an Associate’s Degree have faced diminishing options in the acute care setting (Auerbach, Buerhaus, & Staiger, 2015). This momentum for a more highly educated workforce was overall positive, but created complexities in evaluation of individual academic progression programs because these market forces varied geographically (AACN, 2013). 

The APIN NPO required project teams to develop and strengthen ties to practice. Project leadership teams each had representatives from nursing practice and these individuals were included in national meetings and dialog. NPO staff assured that the employer perspective was highlighted and reinforced consistently.  They provided intentional outreach to national nursing practice leaders through targeted publications and presentations.

Other Key Partnerships

Over time, the APIN NPO identified and strengthened other key partnerships, especially with the Organization for Associate Degree Nursing (OADN).  Under the guidance of Chief Executive Officer Donna Meyer, MSN, RN, OADN partnered with other national leaders in providing support for AD program participation in academic progression models.  As with the Tri-Council, OADN is a membership organization, and they likewise served a dual role, providing a voice for their membership as well as messaging back to their members about the work in progress (OADN, 2017).

Among the OADN constituency there was general support for academic progression coupled with recognition of the existing role of community colleges in nursing education nationally. As an organization, OADN provided early endorsement of education transformation, having joined with AACN, the American Association of Community Colleges, the Association of Community Colleges Trustees, and the National League for Nursing in a 2012 position statement endorsing the need for academic progression (AACN, 2012). Thoughtful leadership by Ms. Meyer and ongoing inclusive practices amplified their support, which was valuable to development of the community college – university partnerships which form the basis of the most successful structures for academic progression. 

In 2015, OADN reiterated their commitment through a Joint Position Statement with ANA, calling for all nurses to have access to seamless academic progression through accredited nursing education programs and in 2016, they created a brochure in conjunction with AACN to provide information to students about academic progression (OADN, 2015; OADN, 2016).

Other key individuals assisted in advancing the work through their content expertise and consultative services.  Heather Andersen, Ed.D., RN was invaluable in strategizing and facilitating group sessions. Jean Giddens, Ph.D., RN provided critical content on early creation of the New Mexico model, and on challenges to adapting that model elsewhere. Rhonda Anderson, DNSc, RN, and Catherine Rick, D.Sc.(h), RN provided strategic guidance and continued support from the practice perspective. Critical assistance with data assessment was provided by JoAnne Spetz, Ph.D. Pat Polansky, M.S., RN and Mary Sue Gorski, Ph.D, RN offered consistent collaboration and provided critical links to the related work being conducted through CCNA. Mary Dickow, M.P.A. assisted the APIN grantees and others with targeted expertise on sustainability planning.   Program developers in communities advancing academic progression models without the benefit of APIN funding have shown generosity and collegiality in sharing details about their programs, including Nelda Godfrey, Ph.D. RN, Margi Schultz, Ph.D., RN, Susan Bonini, M.S.N., RN,  Faye Uppman, M.S., RN, Collene Bay Andersen, MBA, and Paula Gubrud-Howe, Ed.D., RN.

Broadening the constituency of participants also helped to identify common questions, concerns, and challenges across projects. As the learning community matured, specific issues crystalized and required resolution for the common good. The APIN program staff, often in conjunction with CCNA and other representatives of the Campaign for Action, guided interventions to resolve and address the following problems of mutual interest.

Challenges revealed and addressed

  • Inconsistent prerequisites and general education requirements created barriers for students to advance from the AD to higher levels of education.
    • NPO response:  A national workgroup was convened to seek consensus on needed prerequisite and general education coursework. 
    • Outcome:  Development of the BSN “Foundational Courses”, a standardized set of course requirements consisting of 60-64 non-nursing credits, covering general education and basic, social, and human sciences (RWJF, 2015b).
  • The potential impact of innovative education pathways on program accreditation was not clear and created concerns for academic institutions in advancing these models.
    • NPO response:  A Round Table discussion was held with leaders from the Commission on Collegiate Nursing Education (CCNE), the Accreditation Commission for Education in Nursing (ACEN), and the Commission for Nursing Education Accreditation (CNEA).  Prior to the event, questions and concerns were solicited from the developers of academic progression models, and these were presented to the accreditation agencies for response.
    • Outcome:  Development and dissemination of a Frequently Asked Questions document:  Accreditation and Academic Progression FAQ (Campaign for Action, 2015b).  Leaders from the accreditation agencies voiced their support for academic progression and acceptance of high quality innovative programs (RWJF, 2015).  Specific questions from the field were addressed. 
  • The role of nursing regulators in providing oversight to nursing education programs, especially those advancing new academic progression pathways, was unclear.  
    • NPO response:  The NPO facilitated a meeting for discussion and mutual education with the National Council of State Boards of Nursing.  As with the accreditation agencies, questions and concerns were solicited from academic progression program leaders prior to the meeting, and these were presented to the NCSBN for response and clarification (Gerardi, 2016b).
    • Outcome: Development and dissemination of a Frequently Asked Questions document: National Council of State Boards of Nursing and Academic Progression FAQ (Campaign for Action, 2016).
  • Rural partners identified unique challenges which were not being fully addressed through existing projects.
    • NPO response:  A national meeting of rural constituents was convened to identify and address concerns unique to these areas.  Selected content experts provided exemplars and group discussion elicited strategies to accelerate progress (Gerardi, 2016c).   Several months later, the APIN NPO conducted a Day of Dialog with key participants to further develop creative solutions applicable to rural and frontier areas.
    • Outcome:  Development and dissemination of a document to support the unique needs of rural and frontier communities in developing academic progression programs: The Guiding Principles for Academic Progression in Rural Communities (Gerardi, 2016c).
  • Concerns were expressed in regard to nursing education data throughout the duration of the project.  Availability of baseline information, familiarity with data sources, and reliability of available data varied from state to state.  The metrics for evaluation of the academic progression projects themselves also varied, making comparative evaluation difficult. 
    • NPO response:  A variety of strategies were advanced to address this issue.  In conjunction with CCNA and Campaign for Action consultants, the strengths and weaknesses of various data sources were reviewed in several settings - during monthly calls, at national meetings, via webinar and through individual consultation with grantees.  Several states conducted individual surveys of related matters, such as the Massachusetts and New York Employer Surveys.  There was recognition of the need to continue advancement in spite of insufficient data, and program leaders were encouraged not to allow need for data to delay important and challenging work.
    • Outcome:  Significant progress has been demonstrated in consistency of data related to nursing workforce educational levels.  For many states, strengthened relationships with boards of nursing allowed improvements in data collection and sharing.   All APIN grantees were provided with baseline data and subsequent updates from the American Community Survey.  Data reporting remains inconsistent across states, however, and there is still a need to define standard metrics of success for the academic progression programs themselves.
  • Strengthening diversity of the nursing workforce remains a concern, and the impact of innovative academic progression pathways on student diversity is not clear.   Some programs reported early evidence of decreased racial / ethnic diversity within initial cohorts in their innovative pathways.  Other project sites had anecdotal evidence their programs were enhancing diversity, but data was lacking for objective comparisons.  Many types of diversity may be strengthened in partnership models overall by inclusion of students who begin their education through the community college.  This includes a higher proportion of students from rural areas, first generation college students, and those who are disadvantaged socioeconomically. 
    • NPO response:  Intentional dialog through monthly calls and conference presentations provided strategies for recruitment, mentoring, and retention of diverse students.  APIN grantees were encouraged to track diversity of students enrolling and graduating within their new pathways.
    • Each APIN project site addressed diversity through a variety of mechanisms tailored to their site.
    • Outcome:  There is a need for better data to allow evaluation of the impact of innovative academic progression pathways on student diversity.
  • Nurse educators and practice partners who were not actively involved with their state Action Coalitions or the Campaign for Action were not well – engaged in the work, leaving gaps in outreach.
    • NPO response:  Efforts were strengthened for dissemination of information through memberships of the Tri-Council and OADN organizations.  A series of publications was conducted through the AONL bi-monthly newsletter.  Presentations were delivered at national and state nursing conferences, including the AACN Baccalaureate Conference, the AACN Deans and Directors meeting, the Western Institutes of Nursing, the AONL annual conference, the OADN annual meeting and the Community College Baccalaureate Association annual conference.  Some individual program leaders have also published and presented nationally on their programs.
    • Outcome: Outreach was strengthened, but the need for improved information dissemination across all nursing education programs remains.

Contribution of external evaluation to the learning process

RWJF engaged the TCC group to provide formative and ongoing evaluation of the APIN initiative, which strengthened learning for all (RWJF, 2012c; RWJF, 2013).   The TCC Group conducted independent site visits to each of the APIN-funded sites to assess implementation of programs and evaluate outcomes. Their representatives presented updates from their ongoing evaluation at each annual APIN meeting, with a focus on advancing the work of APIN grantees as well as identifying strategies from APIN-funded projects which might assist other project sites in advancing academic progression nationally.  Consultants from TCC assisted APIN grantees in developing and utilizing logic maps as a tool to build project management capabilities.  TCC identified elements for a successful APIN project and noted substantial overlap with those elements identified by the APIN NPO, reinforcing the importance of key points.  Critical elements identified by TCC included:

  • Substantive infrastructure including assigned roles for specific functions within the team, such as visionary, convener, organizer.
  • A strong coordinator who was able to hold others accountable (the highest priority recommendation from TCC).
  • Access to data and the ability to understand same.
  • Action orientation including willingness to move forward without perfect data.
  • Ability to message skeptics.
  • Close links with practice partners and nursing employers; acknowledgement of Magnet impact.
  • Consideration of the entire spectrum of nursing education, rather than only on RN-BSN education.
  • Not being overly focused on determining the specific financial support for nurses to go back to school.
  • Strong relationships including with their state Action Coalition.

                               Source:  TCC Group, 2014. (Link pending)

RWJF funded and the IOM conducted a follow up study to the original Future of Nursing report. 

Twelve reviewers provided a collective overview of academic progression work nationally and disseminated the information through a new publication, Assessing Progress on the IOM Report The Future of Nursing.  In their findings, the reviewers validated the benefit of community college programs in providing entry into nursing for disadvantaged and underrepresented populations (National Academies of Sciences, Engineering and Medicine (NASEM), 2015).   They noted overall growth in BSN programs, with some APIN states reporting higher levels than national averages, while acknowledging the uneven outcomes across the nine project sites (NASEM, 2015).  Reviewers found that “New models of education, such as partnerships between community colleges and 4-year universities, show promise for increasing the percentage of baccalaureate prepared nurses” (p 81) and recommended promulgation of these models (NASEM, 2015).  There was acknowledgement within the report of the important role played by practice partners in driving change in nursing educational levels, and the reviewers recommended that new programs should be monitored for quality through the accreditation agencies (NASEM, 2015).  This report provided independent validation of important learnings developed through the APIN program, especially the importance of community college – university partnerships.

Stretch goals:  A unique challenge

Leaders of academic progression projects were uniquely challenged by the inherent unlikelihood of fully reaching identified goals.  The size of the existing nursing workforce and the likelihood that nurses near the end of their careers would not choose to advance their education coupled with the time required to develop academic progression pathways made the goal of an 80% BSN – prepared workforce nationwide by 2020 exceedingly challenging.  The original authors of the IOM Future of Nursing report presented a truly elegant solution to a conundrum which had plagued nursing for decades and they provided an exciting and motivating goal.  However, the sheer volume of the nursing workforce results in national metrics which are slow to respond to shifting patterns of education in spite of substantial progress.

APIN leadership recognized the impact on grantees of a likely inability to fully meet goals.  They provided honest appraisal and intentional conversation to avoid negativity and in some cases shifted project goals to more realistic objectives.  The NPO emphasized the nature of rapid-cycle change and group learning, and became the advocate for creation of an infrastructure which would carry the work forward and allow accelerating progress toward the larger objective over time.