Technology and partnerships help overcome geographic isolation and reform curriculum.
The Hawaii nursing community has always encouraged cooperation among nurses on Hawaii's many islands; in so doing it has formed strategic partnerships with other communities that share similar goals. To decrease isolation and increase educational opportunities for both students and practicing nurses, Hawaii has for many years relied on technology such as distance learning and simulation. Its use of these innovations has helped Hawaii stand out as a leader in nursing education reform. Two years ago Hawaii was invited to send an interdisciplinary team to the June 2008 summit on nursing education capacity cosponsored by the Center to Champion Nursing in America (CCNA) at AARP, the Robert Wood Johnson Foundation (RWJF), the U.S. Department of Labor, and the U.S. Department of Health and Human Services. State teams that attended this summit received ongoing technical assistance from the CCNA, participated in the 2009 all-nation summit, and had other opportunities to share information nationwide (see "The Technical Assistance Program of the CCNA," Uniting States, Sharing Strategies, February).
WHAT THE DATA SHOW
In 2003 the Hawaii state legislature established the Hawaii State Center for Nursing "to address nursing workforce issues."1 One function of this group is to collect and analyze data concerning the nursing workforce. The center calculates that demand for nurses in Hawaii will grow by 28% between 2006 and 2020, while supply will increase by only 8.9%.2 The shortage of full-time–equivalent RNs will increase steadily, from a shortfall of 960 in 2006, to 1,697 in 2012, to 2,669 in 2020 (Figure 1).2
The growing shortage of nurses is a result of both an increase in demand and a decrease in supply. On the demand side, the population of older adults has been growing faster in Hawaii than in the United States as a whole.3 As for supply, more than 60% of active RNs are 40 years of age or older, and 8.4% of these are 60 or older, suggesting that many will be retiring within the next five to 15 years.4 More new nurses must enter the profession to replace those retiring and to meet the needs of an aging population.
Hawaii has eight nursing education programs; six are part of the University of Hawaii (a public system), and the other two are private institutions. Recent efforts to increase nursing education capacity are reflected in rising enrollments and graduations, especially in baccalaureate programs (Figure 2), Hawaii's most popular type of nursing education program. In the 2007–08 academic year, 65% of undergraduates earned a bachelor of science in nursing (BSN).5 Enrollment in associate's degree programs, which are offered at community colleges on all the islands, has also been increasing, whereas fewer students are choosing to become LPNs.5
Despite the need for nurses, 276 qualified applicants were turned away from undergraduate nursing programs in 2007, and 50 were denied admission to master's degree programs.5 The most common reasons given are difficulty finding faculty, too few faculty and sites for clinical placement, a lack of classroom space, and need for funding support.5
LEARNING THROUGH TECHNOLOGY
In using innovative approaches to educate nurses, Hawaii is trying to make up for faculty shortages and lack of classroom space. Distance learning and Web-based simulation enable participation in nursing education programs regardless of where the learner lives and make it possible for an educator to reach more students than through traditional classroom instruction.
Distance learning. For many years the university system has depended on technology to keep campuses connected with each other and with the public hospitals. Originally, it used videoconferencing through television hookups. Today, University of Hawaii courses are available online to residents of all the islands as well as to nursing students anywhere in the world.
The support that both faculty and students receive, especially in the beginning, has been important to these programs' success. For example, in the University of Hawaii at Manoa's online doctorate in nursing program, students meet on campus for a one-week intensive each summer for the first three years. This in-person component of the online program helps students bond with each other and with their instructors and advisors. Students also get a chance to practice with the technology they'll be using at home.
Simulation. All nursing programs in the state already use some sort of simulation in their training. But a recent joint endeavor is taking simulation to a new level.
In December 2009, four groups—the Hawaii Medical Service Association Foundation, Hawaii Pacific Health, Kaiser Permanente Hawaii, and the Queen's Medical Center—contributed a total of $1.05 million to the Hawaii Nursing Simulation Center Fund.6 The University of Hawaii at Manoa is housing and facilitating the creation of the simulation center, which will link existing simulation laboratories on university campuses and hospitals throughout Hawaii. The new center will have patient simulators, bedside computers, interactive instructional software, and realistic hospital and outpatient practice settings.
The diversity of the groups supporting the new simulation center—health care systems, nurse education programs, and a health care foundation—illustrates what's possible with a mix of strategic partnerships. This point was stressed at the 2008 and 2009 CCNA national summits, where the Hawaii team learned the importance of developing relationships with policymakers and legislators and shared it with other state teams. Hawaii's nursing community can point to its success in this regard: the state legislature funded nine faculty positions in 2005 and 17 more in 2006.4 The additional positions were among the factors that made it possible for Hawaii to increase enrollment in nursing education programs.
Recently, the Hawaii State Center for Nursing developed a five-year plan with both short- and long-term strategies to ensure a nursing workforce adequate to meet the state's needs. The plan calls for the development of sustained statewide partnerships among education facilities, health care organizations, the business community, philanthropy, and government policymakers.4 In addition, Hawaii received one of the first 10 Partners Investing in Nursing's Future (PIN) grants from the RWJF and the Northwest Health Foundation.7 And the Hawaii State Center for Nursing partnered with the Hawaii Medical Service Association Foundation to initiate a program to address recruitment and retention in long-term care facilities.
Funding from the RWJF Executive Nurse Fellows program and the Hawaii State Center for Nursing is supporting the piloting of seven new models of clinical education. Each model is a partnership between nurse educators and nurses in health care settings, including acute care, long-term care, outpatient care, and home health care. In one model, nursing students and faculty are building a health promotion and disease prevention business plan for the Hawaii chapter of the National Kidney Foundation. In addition to improving the transition from nursing education to practice, these models may have the potential to increase nursing education capacity.
Another initiative that's focused on the transition to practice is creating partnerships to start preceptor training programs in hospitals throughout Hawaii. In this program, which is based on the model of the Vermont Nurses in Partnership,8 nurse educators, managers, and staff nurses will work in a preceptor capacity with new graduates.
With only eight nursing education programs in Hawaii, faculty at the community colleges and university programs on the islands tend to know each other. The camaraderie among faculty is especially valuable as Hawaii undertakes a major redesign of its nursing curriculum.
The goal of the Hawaii Statewide Nursing Consortium is to develop a unified, streamlined system of nursing education in Hawaii that avoids duplication of services and meets the state's needs for well-educated, culturally sensitive nursing professionals. A new curriculum design is built on the model of the Oregon Consortium for Nursing Education (see "Oregon Takes the Lead in Addressing the Nursing Shortage," Uniting States, Sharing Strategies, March).
Work on the new curriculum started, as it did in Oregon, with faculty from across the state meeting to discuss the competencies that would be the foundation of the redesigned education program. After one and a half years of discussion, curriculum development began. Faculty from five campuses—the University of Hawaii at Manoa and the Kauai, Maui, Kapiolani, and Hawaii community colleges—were actively involved. However, only the University of Hawaii at Manoa, Kauai Community College, and Maui Community College will use the curriculum when it's first phased in this fall. Wrinkles in the new system can then be worked out before the curriculum is used throughout the state.
The new education system is designed as a four-year, competency-based program culminating in a bachelor's degree. Although students can choose to leave with an associate's degree at the end of three years, if they stay in the program for four years, they'll save a full year of study; currently, if a graduate of an associate's degree program decides to go back and earn a baccalaureate, it will take two more years (five years of study altogether). All participating campuses will share the new curriculum. Most courses will be classroom courses, but the state will also rely on online courses and faculty sharing to reach the most students.
In the first year of the unified curriculum (see Table 1), students take prerequisites, including courses in natural and physical sciences, social sciences, written communication, and multicultural perspectives. The nursing curriculum begins in the second year. In addition to nursing courses, students planning to earn a BSN must take humanities courses and a health and illness course in the third year.
The first cohorts at the two community colleges will be eligible to transfer to the senior-year curriculum at the University of Hawaii at Manoa in the fall of 2012, and the first students to earn baccalaureates will graduate the following spring. Whether more students will choose to continue after receiving their associate's degree than might otherwise have been the case remains unknown. When Oregon implemented a similar unified curriculum, only 25% of the first cohort continued on for a bachelor's degree, but 40% of the second cohort did.9
Although the new curriculum won't be formally introduced for several months, some faculty members have already been trying new teaching strategies. These include active learning strategies such as problem solving and case-based instruction. For example, an instructor might ask students to research various ways to handle a case and then have them explain which approach is best.
The new approach to education may be challenging for some instructors. To increase faculty understanding and acceptance, the statewide consortium included faculty from several campuses in developing the curriculum and has organized faculty development seminars. Funding from the Hawaii State Center for Nursing and the Carl D. Perkins Vocational and Technical Education Act supports travel for faculty development.
Hawaii has already increased nursing education capacity with strategies such as distance learning and faculty sharing. It's uncertain whether the revised curriculum, which relies in part on these same strategies, will further increase nursing education capacity, although that's certainly the hope. Developers are confident that the redesigned, unified curriculum will be a more efficient educational program that prepares nurses to meet the evolving health care needs of all Hawaiians.