Strategic partners develop clinical placement system, core competencies, simulation training, and resources to support nurses.
The State of Massachusetts is a leader in health care legislation. Perhaps its best known effort is the 2006 law mandating that all Massachusetts residents have health insurance.1 Less well known is the state legislature"s funding for nursing. At the prompting of the state"s chancellor of higher education, the legislature designated $500,000 for nursing education for 20052 and subsequently authorized the same amount for each of the next two years. Impressed by how much progress had been achieved with these modest funds, the legislature doubled the allotment for 2008 and then initially allowed for another doubling for 2009. However, the economic downturn forced a cutback from $2 million to $1.39 million. For the 2010 budget, although $1 million was initially allotted, the amount was later reduced to $498,000 because of the continuing budget crisis.
While obtaining funding in the face of the economic crisis and competition from other worthy causes was a monumental achievement in itself, what was accomplished with the funds is equally important. In just a few short years, the Massachusetts Nursing Initiative has developed a set of core competencies for future nurses, created a centralized clinical placement system that has benefited both nursing education programs and health care facilities, increased access to simulation technology to help educate nurses, and provided educational and financial assistance to individual nurses.
STATEWIDE ADVISORY COMMITTEE
A committee of multiple stakeholders provides general oversight and organization for the Massachusetts Nursing Initiative. Cochairs of this committee are David McCauley, deputy commissioner for workforce development at the Massachusetts Department of Higher Education, and Karen Nelson, MPA, RN, senior vice president of clinical affairs at the Massachusetts Hospital Association.
The advisory committee meets quarterly. This partnership, which formed in 2005, initially included stakeholders from education, nursing practice, industry, workforce development, and legislation. In the five years since its inception, other stakeholders have joined, including representation from the community (AARP) and foundation resources (Tufts Health Plan Foundation) (see Figure 1).
One of the first tasks undertaken with the 2005 funding from the Massachusetts state legislature was the Nursing Education Practice Partnership Survey. This telephone survey reached all 24 publicly funded nursing schools and a variety of health care institutions, including 50 acute care facilities (about 70% of all such facilities in the state), 14 long-term care facilities, and 14 home health agencies. The survey revealed three common needs across the state:
- for faculty: increased numbers and enhanced clinical and educational competence
- for students: better preparation, with improved critical thinking skills and smoother transition into the clinical setting
- for nursing education: new curriculum approaches to meet the demands of the future, including revised, unified, and standardized models; accelerated nursing education pathways, such as from diploma-to-baccalaureate in nursing; increased use of simulation; and better coordination of clinical placements
A useful metaphor. The survey findings were conceptualized as an expanded nursing education pipeline (Figure 2). Constrictions such as faculty shortages and too few clinical placement sites shut potential students out of nursing school. Strategic planning, active partnerships, and increasing the number of faculty can build capacity. Innovations such as use of simulation technology and better coordination of clinical placement sites enhance the flow of students through the pipeline. Other initiatives, such as student retention programs and mentoring, can reduce "leaks" from the pipeline. Opening new ports into the pipeline, for example, with alternative degree options and online education, will expand the pipeline, resulting in more nurses and nursing faculty.
Another concept emerged as a cornerstone of all future work: the importance of partnerships between education and practice. All projects undertaken as part of the Massachusetts Nursing Initiative and all applications for funding must be a joint endeavor involving at least one nursing education program and one health care facility.
DEVELOPMENT OF COMPETENCIES
A major undertaking has been the development of a set of competencies to serve as a framework for a revised nursing education curriculum. The goal here is different from the goal in Oregon, which was to create a standardized statewide nursing curriculum (see Uniting States, Sharing Strategies, March). In Massachusetts the goal is to standardize the outcomes of education through a focus—across varying nursing programs—on the competencies required of future nurses.
The competency development committee was formed in 2006 and comprises representatives from all segments of nursing education and practice, including long-term and home care, faculty, staff nursing, and nursing education accreditation. The group meets for four hours once or twice a month.
Examining existing competency sets, the committee determined that the competencies for Massachusetts nurses should be based on the 2003 Institute of Medicine core competencies for all health care professionals3 and on the Quality and Safety Education for Nurses" structure of having three components (knowledge, attitudes, and skills) for each competency.4 In developing its own set of competencies for Massachusetts nurses, the committee also considered the competencies chosen by other states, accrediting bodies, practice organizations, and hospitals.
Specific competencies. By November 2007, a draft of the Nurse of the Future Nursing Core Competencies was ready for circulation. The competencies indicated the minimal expectations for those completing a prelicensure nursing education program. The draft was posted on the Massachusetts Department of Higher Education"s Web site (http://bit.ly/cm076v), and comments were solicited. The committee subsequently modified the competencies based on feedback from readers of the Web site, discussions at schools and practice sites throughout the state, and a thorough literature review.
The revised competencies will be published on the Web site in April. Each of the following 10 competencies includes numerous specific areas defined by knowledge, attitudes, and skills:
- patient-centered care
- system-based practice
- informatics and technology
- teamwork and collaboration
- quality improvement
- evidence-based practice
Novel application of competencies. A Massachusetts Organization of Nurse Executives committee is using these competencies to develop a transition-into-practice model. The underlying concept is that transition into practice begins with the first clinical placement during nursing school. By June, the committee hopes to have developed best practices.
Completion of this committee"s work will help finalize the mission statement identified at the end of an invitational meeting that the Massachusetts Board of Higher Education and the Massachusetts Organization of Nurse Executives assembled in March 2006: "to establish a formal coalition to create a seamless progression through all levels of nursing that is based on consensus competencies that include transitioning nurses into their practice settings."5
A major obstacle limiting student enrollment is the shortage of clinical placements. Work to address this problem in Massachusetts began in 2005, and in 2007, the Massachusetts Department of Higher Education and the Massachusetts Center for Nursing began a Web-based centralized nursing clinical placement system. The Web site (www.mass.edu/mcncps/welcome.asp) displays and manages clinical placements in four designated regions in the state: Boston, Northeast–Central, Southeast, and West. Both students and clinical faculty can access this information.
Currently, 90 health care organizations (including 80% of the acute care facilities in the state and some long-term care organizations) and 76 nursing education programs (including 100% of the bachelor of science in nursing programs, 95% of the associate"s degree in nursing programs, and 22% of the LPN programs) participate in the state"s clinical placement system.6 By late 2009, the system had handled more than 10,000 student placements and increased the availability of open clinical placements by 20%.
A unique feature of the Massachusetts clinical placement system is the development of one online orientation process for all clinical sites. Previously, students might have attended an orientation lasting up to two hours whenever they went to a new clinical site.
Because of the state budget cuts, the Massachusetts Nursing Initiative is looking for a way to sustain the clinical placement system. A fee-based proposal is currently under consideration.
Simulation projects have been a major focus of both nursing schools and hospitals across Massachusetts. In order to foster partnerships between education and practice, every application for simulation funding from the state allocation must show a partnership between a nursing school and a clinical setting.
Since 2005, the Massachusetts Nursing Initiative has awarded, on a competitive basis, 26 simulation manikins to school–hospital partnerships across the state. Nine partnerships between nursing programs and health care facilities have also received funding to develop simulation scenarios. Simulations include critical care, home care, and newborn situations; they also encompass different nursing core competencies.
SUPPORT OF INDIVIDUAL NURSES
The development of competencies, the clinical placement system, and simulation training all focus on changes at the program level. But leaders in the state recognize that the best programs will not resolve problems such as the nursing shortage if capable nurses cannot participate in them. Therefore, several initiatives reach out to individual nurses.
The Welcome Back Center uses a case management approach to work individually with legal immigrants in the Boston area who were nurses in another country but lack a license to practice in the United States. Some of these nurses have been working in health care settings, but in low-paying positions that do not allow them to fully use their skills. The main goal of the Welcome Back Center is to help these nurses obtain RN licensure in Massachusetts. A secondary goal is to increase diversity of the nurse workforce. Since this program"s inception in 2006, 121 nurses have graduated from it, and 303 are in the pipeline.
The state legislature"s budget cuts for 2010 meant loss of government support for the Welcome Back Center. However, the program will continue with grants and support from Bunker Hill Community College and the three other participating nursing programs.
Nurse Scholars is a program that the Tufts Health Plan Foundation has funded since 2008. That year, the foundation offered a total of $100,000 in scholarships for nurses pursuing doctorates, with the goal of increasing the number and diversity of faculty. Each nurse receives a scholarship of $10,000, with the stipulation that she or he commits to teach nursing for a year. In 2009, the foundation increased the funding to $250,000 and expanded the program to include nurses pursuing master"s degrees who commit to teaching nursing.
BEYOND STATE BORDERS
In 2009, the Massachusetts Nursing Initiative, with the Tufts Health Plan Foundation as the sponsoring foundation, received a Robert Wood Johnson Foundation Partners Investing in Nursing"s Future grant to develop a regional model that extends the Massachusetts model to two bordering states. Rhode Island had already started a centralized clinical placement system similar to that of Massachusetts. New Hampshire wanted to do the same, and both states also wanted to use or adapt the Nurse of the Future competencies. Together, Rhode Island and New Hampshire raised more than $100,000 to help support the regional program.
A regional coordinating council, consisting of representatives of each state and the fiscal agent, ensures consistency (but not necessarily duplication) among the three states. The Massachusetts Statewide Advisory Committee is sharing all of its materials with coordinating committees in Rhode Island and New Hampshire. These states are adapting the materials and programs as needed. For example, New Hampshire has no doctoral programs in nursing, so for its Nurse Scholars program equivalent it is funding New Hampshire residents who are doctoral students in other states and who commit to teach in New Hampshire.
Massachusetts participates with other states throughout the nation in a program to build nursing education capacity that is jointly sponsored by the Center to Champion Nursing in America, the U.S. Department of Labor"s Employment and Training Administration, the U.S. Department of Health and Human Services" Health Resources and Services Administration, and the Robert Wood Johnson Foundation (see the January and February Uniting States, Sharing Strategies). One of the 18 lead states in this initiative, Massachusetts had a team, a subset of the Statewide Advisory Committee, at both the 2008 and 2009 multistate summits. As part of its nationwide outreach, the Massachusetts Nursing Initiative also hosted a Webinar on November 18, 2009 (for related resources, go to http://bit.ly/aE34Km).