Mills, Mary Etta C. ScD, RN, NEA-BC, FAAN; Hickman, Linda J. PhD, MBA, RN, FACHE; Warren, Joan I. PhD, RN-BC, NEA-BC
Author Affiliations: Professor (Dr Mills); Assistant Professor (Dr Hickman), Department of Organizational Systems and Adult Health, School of Nursing, University of Maryland, Baltimore; and Director (Dr Warren), Nursing Research, MedStar Franklin Square Medical Center, Baltimore, Maryland.
Grant support was provided to the authors by the Maryland Health Services Cost Review Commission in conjunction with the Maryland Higher Education Commission. The authors declare no conflicts of interest.
Correspondence: Dr Mills, School of Nursing, University of Maryland, 655 W. Lombard St, Rm 301, Baltimore, MD 21201 (email@example.com).
Supported by visionary leadership, a unique strategic-academic partnership model was established with grant support between the University of Maryland School of Nursing, Baltimore, and 13 Maryland hospitals to prepare hospital-based staff nurses as clinical instructors. Participating hospitals gained masters’ degree–prepared nurses able to lead the achievement of clinical and organizational goals. The schools of nursing gained additional access to clinical education resources to enable increased undergraduate enrollment.
Although RN employment has increased during the current recession, substantial shortages are still expected in the next decade. An imbalance is reported between the nursing labor market and nursing education capacity.1 Recent projections of the RN workforce indicate an expected shortfall of approximately 260,000 RNs by 2025.1 The nurse faculty shortage exacerbates the ability to meet the continuing demand for RNs. Although enrollments in nursing schools have steadily increased, 3.9% (2010-2011), the American Association of Colleges of Nursing (AACN) data show that 51,082 qualified applicants to entry-level baccalaureate programs were turned away because of a lack of nursing faculty.2 According to AACN, 65.2% of schools of nursing (SONs) indicated that insufficient clinical teaching sites are a major contributing factor to limiting admissions, yet projections show that there will be a 40% increase in the need for RNs compared with a 6% growth in the supply.3 The supervision of clinical training for students usually requires a ratio of students to MSN-prepared faculty of 8:1 in medical-surgical units or as few as 4:1 to 6:1 in specialty units, making availability of MSN clinical instructor (CI) faculty critical to the ability of SON to increase enrollments.
In the State of Maryland, hospital rates for inpatient services (as defined by Medicare) and outpatient and emergency services at a hospital are set by a statewide rate commission (Maryland Health Services Cost Review Commission) as a result of receiving a Medicare waiver in 1987.4 In 2005, an innovative program established by the Commission allocated 0.1% of regulated patient revenue to a new program entitled the Nurse Support Program II.5 This yielded an availability of $10 million in grant funding for each of 10 years for a total of $100 million, which is administered by the Maryland Higher Education Commission. Under the program, acute care hospitals and SONs were invited to submit grant applications designed to increase the enrollment of students in Maryland SON for purposes of increasing the numbers of RNs for Maryland hospitals.
The University of Maryland School of Nursing, Baltimore, submitted a grant, entitled “Master’s Preparation of Staff Nurses to Expand Clinical Instruction Capacity,” specifically designed to prepare hospital-based staff nurses currently holding an ADN or BSN to complete an MSN and be prepared as CIs. Upon completion, these nurses would continue in their patient care roles while also being available to serve as hospital-based CIs. Motivating RNs to return for an advanced degree was critical to the success of the model, and as such, the proposal incorporated elements derived from previous research such as organizational incentives and support from employers and educational institutions.6
A unique strategic academic-service partnership resulting in teams was established between University of Maryland School of Nursing and 13 area hospitals. A contract was signed by the SON with each hospital participating in the grant detailing partnership responsibilities. Each of the 13 teams included the SON project directors, a chief nurse executive, SON admissions-registration specialist, and a hospital-based part-time education coordinator. Staff nurses received focused mentorship in exploring an expanded career trajectory and received on-site individualized academic advisement and support extending from the 1st informational contact through the admissions process to graduation. Course work could be completed online, and peer groups were developed whenever possible to support participants. The academic program of study included health services leadership and management, education, and advanced clinical course work. In addition to education theory and curriculum development, the nurse educator sequence of course work included a special practicum for CI educators. New job descriptions for CI/faculty roles were developed and implemented in each hospital to incorporate position requirements specific to the CI role into the staff member’s current clinical practice role responsibilities. Examples of CI expectations include the following:
* encouraging and fostering critical thinking skills through appropriate questioning;
* assigning students to patients and observational experiences and observing student performance in actual nursing situations;
* applying evidence-based practices as applicable in the clinical setting; and
* assisting students through participative experiences to apply nursing theory, the nursing process, and nursing techniques in the clinical setting.
Arrangements to place students with a staff nurse–CI are made through the hospital nursing education coordinator. The coordinator, in concert with the nurse manager or director of the patient care unit on which access for students is being sought, identifies whether the unit can release the instructor to work with students for the necessary timeframe. There are times when patient volume or staffing levels preclude the release of the instructor. Often, the hospital may extend the availability of the instructor to a school as a professional exchange without an associated cost. Any financial arrangements or supplementary income for the CI is at the discretion of the hospital and school.
The partnership has yielded a greater number of MSN-prepared staff who are value-added participants in assessing, planning, implementing, and evaluating patient care services and systems. Because graduates of the program are already employed as staff, there are no direct or indirect orientation costs for CI faculty by the organization. The staff nurse–CIs are already authorized users of the clinical information system and do not need special access accommodations. By supervising students on their own patient care unit, the staff nurse–CIs are knowledgeable regarding patient care needs for the identified populations and protocols, thus reducing disruption and inconvenience of other staff in accommodating students.
All participating hospitals in the project offered tuition reimbursement to nurses pursuing graduate education. Many of the hospitals provided additional tuition support beyond the usual reimbursement benefit for staff willing to undertake the preparation necessary to become a CI. Tuition and fee support exceeding $5,250 are taxable to the employee but can be claimed as a business expense deduction by the employer. This level of tuition support if given for each year of a 5-year part-time plan of study would equal $26,250. Following graduation, the cost of backfilling staff to cover for a CI was $12,000 on average based on the CI providing 120 hours annually of preceptor time for 2 years at an average salary of $50 per hour. Adding tuition reimbursement and staff coverage costs equal $38,250, an average of $5,464 per year over the 7 years of combined education and CI practice. Graduates of the program have had less than 10% turnover in 7 years. According to the 2013 National Healthcare and RN Retention Report,7 the national average annual turnover rate for nurses is 13.1%, yielding a projected rate of 91.7% in a 7-year period. Based on an annual salary of $80,000 with a 30% benefit factor, a nurse prepared at the master’s level would incur a salary expense of $104,000.8 Assuming recruitment and orientation replacement costs of 75% of this amount ($78,000), the average per year for each of 7 years equals $11,142, thus yielding an average cost savings for the hospital of $5,678 per year in return for developing and retaining these advanced prepared nurses as CIs.
Over the past 7 years, the program has admitted 202 staff nurses into the MSN specialty of health services leadership and management with additional focus on education. The final project goal has a target of 250 staff nurses from 13 hospitals by the end of 2014. Nursing staff–CIs have maintained their regular full-time positions while completing the academic program on a part-time basis. The entire program of study is offered online except for practicum courses. At present, 89 students have graduated from the program, and others will be completing the program over the next 3 years.
The availability of hospital-based CIs has led to increased SON enrollments and opportunities for clinical rotations of groups of undergraduate students. For example, 1 hospital increased clinical usage from 125 requests from a combination of 10 SONs to 146 requests for a total of 580 students. SONs accessing clinical rotations at partner hospitals increased their number of enrolled students by an average of 13.2% compared with schools not seeking clinical rotations at grant partner hospitals.
A survey of 69 program graduates resulted in 50 responses (72.6%). Of the respondents, 92% (n = 46) are performing a nursing leadership role as senior clinical nurse, clinical educator, or nurse manager, and 94% (n = 47) are additionally participating in a variety of organization and unit-wide committees and activities as a member or a leader as well as CI.
The creation of a dual-role staff nurse–CI position is value added for hospitals and the SON. Similar partnership models may be replicated by working with hospital leadership to support preparation of additional CI faculty enabling SONs to increase undergraduate student nurse enrollments through enhanced clinical education opportunities. Since the CIs are already hospital employees, they bring both academic and experiential knowledge to the student experiences, thus enhancing the care delivered by students. This collaborative program also benefits the hospital employers by increasing the numbers of nurses with advanced degrees. Other organizations may be able to replicate similar programs on smaller scales with private or grant sources of funding.
The authors thank the Maryland Health Services Cost Review Commission and the Maryland Higher Education Commission for grant and administrative support that made the project possible. Special recognition is given to Ms Vicki Krohn and Ms Tricia Fronczek, who assisted in the implementation of the staff nurse–CI role.
1. Buerhaus P, Auerbach D, Staiger D. The recent surge in nurse employment: causes and implications. Health Aff. 2012; 28 (4): 657–668.
2. American Association of Colleges of Nursing. New AACN data show significant enrollment increases in Baccalaureate, master’s and doctoral nursing degree programs. www.aacn.nche.edu
. Accessed January 26, 2013.
3. American Association of Colleges of Nursing. New AACN data show enrollment surge in Baccalaureate and Graduate programs amid calls for more highly educated nurses. March 22, 2012. www.aacn.nche.edu/news/articles/2012/enrollment-data
. Accessed January 26, 2013.
5. Maryland Health Services Cost Review Commission. Health services cost review commission initiatives and hospital performance: Nurse Support Program II. www.hscrc.state.md.us/
. Accessed January 26, 2013.
6. Warren JI, Mills ME. Motivating registered nurses to return for an advanced degree. J Contin Educ Nurs. 2009; 40 (5): 200–207.