The One Day per Week Nursing Program: A web-assisted (hybrid) Associate Degree Nursing Program
Article Outline
- Abstract
- 1. Introduction
- 2. Methodology and design
- 2.1. Rationale and goals of the program
- 2.2. Marketing and recruiting
- 2.3. Admissions
- 2.4. Online course development
- 2.5. Nutrition: The first online course
- 2.6. Clinical courses: Web-assisted (face-to-face and online)
- 2.7. Tapes and videos
- 2.8. Use of the weekly colloquium for face-to-face interaction
- 2.9. Off-site nursing skills laboratory
- 2.10. Use of clinical and academic mentors
- 2.11. Assessment (TEAS™, ATI)
- 3. Results
- 4. Discussion
- Acknowledgments
- References
- Copyright
Abstract
Ocean County College received a New Jersey Health Initiatives grant from the Robert Wood Johnson Foundation to develop a web-assisted (hybrid) education model. By creating New Jersey's first web-assisted Associate Degree Nursing Program, the model seeks to address shortages of RNs in the hospital setting. This program allows those currently employed in the health care field to complete an RN program by attending class only 1 day per week (primarily on-site in host health care institutions) supplemented by online instruction. The initial results demonstrate a higher level of performance in the One Day per Week Nursing Program when compared with a group of students in the traditional nursing program who had nearly identical results on the entrance test (Test of Essential Academic Skills). Despite the influence of factors outside the program, the results do indicate early success and the likelihood that the program will meet its primary objectives.
Keywords: One Day per Week Nursing Program, Mentors, Hybrid nursing program, Online education, Blended courses
1. Introduction
Over the years, two Ocean County College (OCC) nursing faculty, Dr. Leah Kelly and Professor Joan Barrett, encountered ancillary health care workers who were interested in attending OCC's nursing program in both the hospital and extended care facilities. Although many had clear potential for nursing education, they often had employment and family obligations that precluded full-time study. Unfortunately, there seemed to be no viable route leading them to successfully complete an RN program.
A new partnership emerged in 2003 in which the OCC nursing faculty and the dean worked cooperatively to apply for funding that was made available through the Robert Wood Johnson Foundation's New Jersey Health Initiatives. The Call for Proposals specifically targeted the increased recruitment and retention of New Jersey nurses. Together, a proposal was crafted, which was funded by the said foundation the following September.
A recent editorial by Diane Billings (School of Nursing, Indiana University) urged the nursing faculty to “encourage creativity and thinking about new ways of addressing old problems” such as nursing shortages, cutbacks, and overworked health care staff (Billings, 2005). She suggested using “new learners, new settings, and new strategies.” The One Day per Week (ODPW) Nursing Program sought to seek out (1) new learners (individuals who were working full time in health care and could not afford to stop working to attend a nursing program), (2) new settings (have a face-to-face session and clinical experience right in the workplace and in participating health care facilities), and (3) new strategies (create an ODPW face-to-face program and present the rest of the nursing content online during the rest of the week).
2. Methodology and design
2.1. Rationale and goals of the program
The project objectives are to (1) develop online components to the didactic portions of the entire nursing curriculum, which would allow a significant portion of the course content to be taught in a web-assisted (hybrid) or blended manner; (2) organize all classroom, laboratory, and clinical face-to-face learning experiences in such a way that they will be delivered in a single day of the week in a training facility within existing hospitals. These serve as learning centers where didactic sessions, on-site nursing laboratories, and clinical instruction all occur under one roof. As designed, each center will be capable of adding 30 additional RNs per year when the program is fully implemented; (3) recruit students who are currently employed as LPNs, nursing assistants, emergency medical technicians, and the like, at participating institutions. Particular attention will be directed toward students who are considered “nontraditional” or who are members of communities that have been historically underrepresented in the nursing profession.
2.2. Marketing and recruiting
The ODPW Nursing Program was actively marketed throughout Ocean County, NJ. Two recent nursing graduates specifically marketed the program to employees in hospitals, long-term care facilities, and communities that had populations that were underrepresented in nursing. Brochures and posters were developed and distributed. A local cable station ran an advertisement several times a day. Signs, web pages, and press releases all helped the program to be successful in attracting qualified candidates (Czaja, 2004).
2.3. Admissions
Our first class was selected from more than 60 applicants who appeared to meet the admission criteria. Within this group, a number had substantial academic preparation but were very minimally exposed to health care. Several of the applicants were LPNs, and some were nurse aides. Others worked in health care settings that did not offer direct patient care experience. From the applicant pool, an initial class of 20 was selected. Although all initially claimed to have a high degree of computer skill, several required assistance. There was tremendous cooperation between students; those with higher levels of computer skills assisted those who were weaker in this area, and strong ongoing study groups were formed.
2.4. Online course development
Experienced nursing faculty members are often in the best position to innovate, suggesting changes to the curriculum based on their close interactions with students and on their observations of learning. The National League for Nursing Accrediting Commission (2005) Accreditation Manual Policy #15 on Distance Education, which states that the faculty should have “responsibility for and oversight of distance education, ensuring both the rigor of the program and the quality of the instruction,” was closely followed. As subject matter experts, nursing faculty members are also optimally positioned to redesign the delivery methods for their curriculum, such as transitioning a traditional course to an online or hybrid delivery method. The most effective transitions from traditional to online or hybrid courses are generally made by teams that include both instructional design and technology professionals and nursing educators. (Avery et al., 2004, O'Neill, 1998, O'Neil et al., 2004).
At OCC, the ODPW team began with a small team of faculty members who met regularly with the dean and an instructional designer to discuss uniform templates and similar issues. As Avery et al. (2004) note, faculty involvement and administrative support in processes like these are crucial elements for a successful online program development (Cameron & Forger, 2004). Extensive one-to-one faculty/instructional designer meetings occurred, and these sessions were of substantial benefit in translating the traditional face-to-face course delivery to online course delivery.
2.5. Nutrition: The first online course
The first course to be developed was a three-credit Nutrition course that is now offered completely online, with five required examinations in a proctored setting. The course text remained the department-approved Grodner volume, which offered a few online resources via the publisher's site, including some diagrams and worksheets. The remaining course materials came primarily from converting and embellishing the traditional lecture slides into web page formats. The instructional designer converted the initial slides into a page template that complies with Section 508 of the Americans with Disabilities Act, using fonts and styles that typical screen readers and other accessibility tools could handle. These pages were then uploaded into the WebCT course management software, where the professor logged in and enhanced her outline text to become text-based lecture files that are more complete.
Course development for Nutrition began in Spring 2004 and was completed in time for a pilot section of the course in Fall 2004. The students who piloted these new materials were offered two bonus points on their test average if they responded to a series of four formative assessments: continuous quality improvement on layout, design, usefulness of materials, and accessibility. More than half of the enrolled students participated in this assessment project, yielding valuable feedback that directly informed course refinement in time for the official launch of the course in Spring 2005.
The Nutrition course may be taken before students are accepted into the nursing program, and whenever a Nutrition course is taught, the students in the class are a mix of nursing and prenursing students. The patterns of Nutrition enrollment were considered when the course content was placed into the online/web-assisted format. All contents of the OSOL program were made available to traditional students through the college's online portal to ensure that students taking Nutrition in a traditional format and students taking Nutrition in the OSOL format receive the exact same content. OSOL students access material for the Nutrition course through WebCT. The same WebCT material is uploaded to the college's online portal for use by traditional students. In both contexts, students may choose to read the material online, print the material for reading, and access web sites listed throughout the course.
Just as communication between the instructional designer and the faculty designer was important for the success of the OSOL Nutrition course, so is communication between the faculty teaching the OSOL Nutrition course and students taking the course. OSOL students benefit from frequent online contact with course faculty, which promotes a nurturing learning environment, and students recognize faculty presence (Diekelmann & Mendias, 2005). Announcements and other important information are added as frequently as needed to the course's home page. Student e-mails are answered on a regular (usually daily) basis. As soon as a Nutrition test is graded, those grades are posted online. Discussions with students (through a discussion page) are held frequently. Through these discussions, the faculty is able to answer the student's questions and clarify course concepts. The importance of this interaction with students online cannot be understated and has been identified as a key ingredient in online instruction (Brown, 2005, Buckley et al., 2005).
The online Nutrition students are also encouraged to interact with one another using discussions and e-mails. Through this process, students get to know one another. Student communication helps build collegiality, decreases any feelings of isolation from peers that an online student might experience, and promotes the formation of study groups.
These Nutrition students are also encouraged to have face-to-face interactions with the faculty during regular office hours. Online Nutrition students often request a face-to-face appointment via e-mail.
2.6. Clinical courses: Web-assisted (face-to-face and online)
Simultaneously, other professors were working with the instructional designer in a similar process to convert their existing materials for Nursing I, a nine-credit course now offered in a hybrid format, into an ODPW format with clinical experiences on Wednesdays and into didactic information that is now offered in the WebCT course management system. In addition to the elements included in the process used for Nutrition, the faculty collaborated with several other colleagues in the Nursing Department to record audio and video lectures and demonstrations. These audio and video files were edited with a Media Services specialist who also contributed to the project, and the instructional designer eventually uploaded these files into the WebCT course management system for student access as well. Throughout each course, students were surveyed about their use of the various learning tools available to them, including traditional textbooks, audio and video resources, WebCT lectures, student study groups, academic mentors, and faculty office hours. Survey data revealed that most students employed their WebCT materials at least as often as their textbooks, suggesting that each tool set proved to be equally valuable from the students' perception.
At the time of this writing, the development of Nursing III, Nursing IV, and Contemporary Nursing courses was nearing completion, following processes similar to those employed in the Nutrition and Nursing I courses. As O'Neil et al. (2004) discuss in their collection of best practices, the nursing faculty discovered that remaining flexible throughout the course design and delivery process proved to be a valuable practice. For example, several faculty developers discovered that the textbook publisher made only some of their illustrations and diagrams from the textbooks available for use online. In such cases, alternative material was sought or alternative ways for students to access the materials in compliance with copyrights was sought.
Similarly, where student feedback indicated that the main method for organizing each unit's instructions (Unit 1, Unit 2, etc.) was less helpful than a more descriptive method (Cardio Unit, GI Unit, etc.), the faculty made “midcourse corrections” to respond to that valuable feedback and redesign aspects of the course to better meet student needs. This emphasis on responding flexibly to student feedback reinforced the findings reported by O'Neill (1998) in her study of Contemporary Nursing at the State University of West Georgia as well as those practices in ongoing evaluation discussed by O'Neil et al. (2004).
2.7. Tapes and videos
The original multimedia plan had envisioned a strong video component that was initially planned to reside online where students would have immediate access to video clips of skills to be mastered. Research has shown that small video clips combined with online content can promote more realism in the practice environment, enhance learning outcomes, and promote safe patient care environments in clinical practice (Jefferies, 2005, Mills, 2000). An “error” section was also planned, where students could review common errors and learn from mistakes. It was hoped that individual skill videos would reside on the server and be accessible from the web. This proved beyond the capabilities of the web server, and currently, the skill videos are being mastered to DVD for individual distribution. One multimedia innovation completed for the fundamentals course involved multimedia clips of the individual techniques of therapeutic communication. This required not only digital video production but also that the instructional designer load the individual clips in the appropriate content areas of the online content. Students were able to use this resource online and did consult the techniques sections both in the fundamentals course and in the psychiatric component of the second semester.
2.8. Use of the weekly colloquium for face-to-face interaction
The colloquium was a 2-h seminar that was planned each week to discuss and refine the online content and served as a face-to-face forum for clarification and explanation of the different concepts and areas of study. This was done in a flexible fashion in the first semester as both student groups were in one hospital and a room was always available for learning. Students responded well to this forum, established strong relationships with peers and with faculty during this time, and generally were able to ask questions and discuss new content. Faculty used this time also to deal with complex content, to role-play therapeutic communications, and to test students on content mastery to prevent any potential problems with online test administration. Generally, students knew in advance what would be covered and would bring questions or would be expected to work through case studies to demonstrate both learning and confusion about the content. Faculty had the time to refine knowledge, emphasize points, and explain difficult concepts in depth. Students engaged in case study work and were placed in cooperative work groups as the lecture content was covered both online and in the taped lectures.
The psychiatric experiences took place at separate hospital sites, and colloquium had to be held on campus, in a room dedicated and available for the students. This brought the students on campus and reinforced their identity as OCC students.
2.9. Off-site nursing skills laboratory
Development and utilization of the Nursing Skills Laboratory for the ODPW students required planning, time, and personnel. The off-site nursing skills laboratories were set up in two regions of the county: Ocean Medical Center in Brick, NJ, and Southern Ocean County Hospital in Manahawkin, NJ. The laboratory supervisor and academic mentors worked to provide synchronized services on a continuing basis to meet student needs. The planning stage began with identifying nursing skills, which were needed to be demonstrated in a simulated environment, prior to the clinical experience. Necessary equipment for simulation was then identified, ordered, and received for each site.
2.10. Use of clinical and academic mentors
2.10.1. Academic mentorsAcademic mentors provide reinforcement of subject matter, laboratory skills, and encouragement. Professors can refer a student for remediation of clinical skills, including documentation, which may be scheduled at any site that has availability, and students may self-refer as well.
Academic mentors also interact with the students online. Through e-mail and the discussion page, academic mentors may answer a question, facilitate a discussion, or schedule a face-to-face appointment. Providing prompt guidance in a distance-learning format saves time and decreases anxiety.
2.10.2. Clinical mentorsA clinical mentor network was created within the college's partner institutions to support this new program. The faculty trained and worked closely with staff mentors who assisted in the growth of the nursing student. The mentors were trained to teach and tutor the nursing students on site. This increased the exposure of the student to professional nursing and provided a 1:1 tutorial situation for all. The staff has become increasingly invested in students, made a significant contribution to the educational process, and increased their own competencies. Clinical mentors receive benefits on the career ladder needed to advance in the institution as well as a stipend from grant funds to compensate them for their work with students. This established an excellent level of collaboration between education and service.
2.11. Assessment (TEAS™, ATI)
The framework for assessing outcomes and practices in web-based courses in nursing was based largely on the pioneering work of Billings (2000). The concepts of her model include outcomes, educational practices, faculty support, learner support, and the use of technology. With respect to outcomes, we are utilizing the Assessment Technologies Institute (ATI) Test of Essential Academic Skills (TEAS™) and ATI's Assessment Driven Review Program (the Content Mastery Series).
As those who have followed the “No Significant Difference” phenomenon in distance learning have noted, hundreds of studies ranging from single-course comparisons to multisection, multi-institutional large-enrollment studies have tended to show no significant difference among the learning outcomes and student satisfaction in online versus traditional course delivery formats (Phipps & Merisotis, 1999, Russell, 1999). However, as most scholars have noted, much of this research is flawed in its design, largely because researchers cannot adequately control for extraneous variables, most use self-selected (students opt to enroll in distance learning or not by choice) rather than random research subjects, student outcome and satisfaction instruments suffer several reliability and validity weaknesses, and most do not control for reactive effects (such as the “John Henry” and “Novelty” effects); students and faculty may undergo because they are aware that they are participating in a tested environment. Nonetheless, the research design for this 1-day program has included some comparisons, most of which replicate the No Significant Difference phenomenon and which are also subject to its inherent flaws.
3. Results
The study is comparative in design. Quantitative analysis provided a description of various demographic characteristics. In addition, the admission criteria and end-of-semester standardized examinations are reviewed. The sample consisted of 109 students—20 admitted for the Spring 2005 semester as Cohort 1 of the ODPW Nursing Program and 89 students admitted into one of the traditional classes of the on-campus nursing program for the Fall 2005 semester. The students are similar in that they met admission criteria standards set forth by the Nursing Department. The instrument used for initial demographic information is the standardized form adapted by the OCC Nursing Program for student statistics. This information is obtained anonymously and utilized each semester for college and program statistical reporting.
Admission to the program was determined by the revised criteria for admission into the nursing program, which include successful completion of the TEAS™ test (ATI Incorporated), a current grade point average (GPA) of 2.7 or higher or 1,200 on the SATs, and completion of required prerequisite studies (anatomy and physiology, English, and psychology). In addition, the ODPW students needed to complete three essays to determine program eligibility and needed to study in this unique program. A rubric was utilized to select the students most suitable for the program, and an admissions committee scored the essays. The students whose scores were among the top percentile were then admitted into the ODPW program.
Letters of invitation to participate in the study were submitted to the students to obtain consent for data collection during the implementation of this new program. Demographic data sheets are completed anonymously by all students during the first weeks of class. The total sample consisted of 20 ODPW students and 89 traditional (on-campus) students. The demographic characteristics for the groups (Table 1) were obtained and were noted to be comparable in student status (full time >12 credit hours or part time <11 credit hours), number of dependants, and previous degrees obtained. Significant differences were noted with the increase in male students in the ODPW program (19% vs. 11% in the traditional program) as well as work status (80% of ODPW students work full time and 20% work part time, as compared with 20% of traditional students who do not work at all, 57% work part time, and 22% work full time). One of the goals of the ODPW Nursing Program was to attract individuals who were from populations underrepresented in nursing, such as African Americans and Latinos, and 25% of the students admitted to the ODPW program were from these communities—twice the number present in the county population as a whole. Both the traditional program and the ODPW program were heavily represented with adult learners. The average age of the ODPW students was slightly older (37) than the traditional students (31). A requirement of the ODPW program was that students must have regular computer access; 21% had dial-up access and 79% had cable or DSL.
Table 1. Student demographics, ODPW Nursing Program students versus traditional nursing program students
| Demographic data comparisons | Traditional students, n = 89 (%) | ODPW students, n = 20 (%) |
|---|---|---|
| Gender | ||
 Male | 11 | 20 |
| Female | 89 | 80 |
| No. of dependants | ||
| 0 | 47 | 14 |
| 1 | 20 | 38 |
| 2 | 20 | 29 |
| 3 | 13 | 14 |
| 4+ | 0 | 5 |
| Race/Ethnicity | ||
| White | 79 | 75 |
| African American | 7 | 20 |
| Hispanic | 6 | 5 |
| Asian | 4 | 0 |
| Native American | 4 | 0 |
| No. of hours worked | ||
| 0–10 | 32 | 0 |
| 11–20 | 16 | 10 |
| 21–30 | 30 | 5 |
| 31–40 | 22 | 35 |
| 40+ | 0 | 50 |
| LPN licensure | 2 | 10 |
| Foundation trust status | ||
| 12+ Credits | 31 | 20 |
| Receiving financial aid | 34 | 15 |
| Other degrees attained | ||
| Associate | 9 | 5 |
| Bachelor | 20 | 35 |
| Master | 1 | 10 |
A group of 16 students in the ODPW program (Group 1) was compared with a single class (29 students) in the traditional program (Group 2). The two groups had nearly identical TEAS™ test results: 79.6 and 79.85, respectively. This was the test taken before they were admitted to the nursing program. The most significant findings are noted upon comparison of the end-of-semester standardized examination for Fundamentals in Nursing (ATI Incorporated). This compared the two groups' knowledge of nursing fundamentals at the end of the first semester in the nursing program. The ODPW (n = 16) students' group mean of 76.8% with a program percentile rank of 97 (see Fig. 1) was significantly (P <. 01) different from the traditional students' (n = 29) group mean of 71.6% with a program percentile rank of 68 (see Fig. 2). The Group Percentile Rank-Program refers to the proportion of groups of test takers from the associate degree nursing programs (within a specified sample from the national ATI data pool) whose group composite scores are the same as or lower than our group's composite score.
Fig. 1.
ODPW Nursing Program group performance profile for Fundamentals of Nursing proctored assessment given near the end of the first semester. Graphic courtesy of ATI, LLC.
Fig. 2.
Traditional nursing program group performance profile for Fundamentals of Nursing proctored assessment given near the end of the first semester. Graphic courtesy of ATI, LLC.
There was a significant difference (P <. 05) between the two groups with respect to age. The mean age of the ODPW group was 37.00 versus 30.66 for the traditional nursing program group. Likewise, with respect to GPA, there was a significant difference (P <. 05) between the two groups entering the program, with the ODPW group having a mean GPA of 3.50 versus 3.19 for the traditional group.
4. Discussion
The initial success of the ODPW students may be attributed to several factors. The stringent admission criteria, previous health care experience, and utilization of creative teaching design through the use of online instruction and weekly colloquium enhancement discussions may be a strong contributing factor and can be recommended for further research. Availability of academic and clinical mentors may also influence student achievement. To date, one student has left the program due to health reasons and three students were clinical failures. Those failures occurred during skills practicum, and the rate of failure is congruent with the rate seen in the generic face-to-face students. Overall success and attrition rate could not be determined at the time of submission of this article.
Current students in the program make very positive comments about their experience and often mention the fact that they would not have been able to obtain the nursing education any other way. Nearly all of them believe that it is extremely challenging and find it difficult to balance their studies and their other responsibilities of family and work, which is consistent with other research (Barakzai & Fraser, 2005).
If successful, this program can be expanded in multiples of 10 students at a time for maximum efficiency and, hence, continue to meet the demands of the region's acute care hospitals and other health care facilities. A class of 40 students has just been admitted for January of 2006, which will be expanded to 60 students for January of 2007. This unique model has the potential to be duplicated elsewhere both at the state and at a national level and may reach a previously untapped source of highly motivated students interested in pursuing a nursing education.
Acknowledgments
We would like to thank Sandra Howell-White, PhD, Senior Research Analyst at the Center for State Health Policy, at Rutgers, The State University of New Jersey in New Brunswick, NJ, for her assistance with the project research design, assessment, and evaluation.
We would also like to thank our colleagues Professor William Rickert and Dean Carolyn Showalter of the OCC Department of Mathematics for their help with our data analysis.
Additionally, we would like to thank Carolyn Lafferty, the Assistant Vice President for Learning Outcomes for her assistance with the project's assessment and evaluation.
A debt of gratitude is extended to Beth Muller, who is the tireless Nursing Program Office Manager, who provided many hours of extra service to make the ODPW Nursing Program a success.
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PII: S1557-3087(06)00003-5
doi:10.1016/j.teln.2006.02.002
© 2006 National Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved.