Baccalaureate Nursing in Rural Oklahoma: Strategies for Success

Link to MinorityNurse.com

by Anne W. Davis, PhD, RN, Deborah L. Flowers, PhD, RN, and Judy Goforth Parker, PhD, RN

Providing baccalaureate nursing education in a culturally diverse rural setting affords unique opportunities and challenges for faculty, administration and students-especially when that education is delivered via interactive television. This article will describe how East Central University (ECU) and Southeast Oklahoma State University (SOSU) joined resources to offer a distance learning extension of ECU's baccalaureate nursing program at SOSU.

ECU@SOSU nursing students Karen Holiday, Dana Danderson, Sabrina Durant and Brandie Gray participate in a clinical day at the Choctaw Nation Health Care Center in Talihina, Oklahoma.

For more than 30 years, ECU has been the only baccalaureate nursing program serving southeastern Oklahoma and north Texas. Both ECU and SOSU are situated in southeast Oklahoma, which is home to the Chickasaw and Choctaw Nations' tribal headquarters. ECU's service area consists of 22 counties, 20 of which are federally designated as medically underserved. Approximately 35% of the university's nursing majors self-identify as American Indian and a high percentage of nursing majors are first-generation college attendees. There is a higher percentage of American Indian students enrolled in nursing compared to the average percentage of American Indian students enrolled on both the ECU and SOSU campuses in other academic majors.

In the mid 1990s the Oklahoma State Regents for Higher Education urged academic institutions to work collaboratively to preclude program duplication. The presidents of both ECU and SOSU enthusiastically supported this concept and directed their respective vice presidents of Academic Affairs to proceed with establishing the ECU baccalaureate nursing program at SOSU. The goal of our joint project has been to provide a quality baccalaureate nursing educational experience to students enrolled on both campuses. Another major goal has been to enhance cultural experiences for our nursing students, with an emphasis on American Indian culture.

First of Its Kind

This project was unique in that there were no similar collaborative programs in Oklahoma at the time. Prior to this, a number of academic institutions in the state had delivered courses and programs electronically to other institutions.

However, the difference between our project and other existing collaborative programs is that ECU placed a program coordinator from its faculty, Dr. Deborah Flowers, on-site at the SOSU campus. Other unique aspects of the collaboration were signing an articulation agreement with SOSU to accept its general education and science support courses in ECU's program, agreeing to financial aid arrangements and having ECU award the degree.

Establishing the nursing program extension was technically challenging, because the ECU courses needed to be reformatted for live electronic delivery over the State Regents' One-Net system of two-way interactive digital television (ITV) and enhanced with WebCT. Since the nursing faculty had no previous experience in distance education, ECU administration supported their efforts to attend conferences in order to learn these skills. In addition, laboratory space and equipment and clinical experiences had to be planned.

To fund the project, the Oklahoma State Regents for Higher Education provided ECU with a continuing special appropriation of $250,000 (now reduced by budget cuts to about $225,000) and provided SOSU with a one-time $100,000 allocation to build and equip an ITV classroom and office space. Additional funding was achieved through a U.S. Department of Health and Human Services, Health Resources and Services Administration grant funded through the Division of Nursing's Basic Nursing Education and Practice program (BNEP). The grant, Extending Baccalaureate Nursing Education to Rural Oklahoma, was funded in 2000 for approximately $800,000 over three years. A second grant, Nursing Education with Enhanced Retention Activities (NEW ERA), is now in progress.

Community support to establish and retain the cooperative program has been outstanding. Local health care employers seek our nursing graduates and have actively supported our program. Clinical facilities and the Chickasaw and Choctaw Nations have funded professorial chairs to assist with faculty salaries.

Two clinical facilities assist with part-time clinical faculty salaries. In addition, the Chickasaw Nation donates two textbooks to each entering sophomore student: R.E. Spector's Cultural Diversity in Health & Illness (Sixth Edition) and Twiname & Boyd's Student Nurse Handbook: Difficult Concepts Made Easy (Second Edition).

Setting the Stage

Once the full-time on-site program coordinator was designated, we needed to create a name for the distance education nursing program that would be acceptable to both schools. This required some political sensitivity, because for many years a rivalry had existed between the two institutions. After a certain amount of discussion, the name chosen for the program was ECU @ Southeastern Department of Nursing (ECU@SOSU).

The next step was the development of the distance education site. Specific activities we needed to accomplish included:

Developing a liaison between ECU and SOSU and establishing relations with key persons and departments at SOSU.
Designating space for the new department, staffing it, and equipping it.
Developing policies and procedures relating to require-ments for general education, nursing prerequisites, course substitutions, transference of financial aid, student registration and enrollment, and student transfers between campuses, as well as adapting existing ECU Department
of Nursing policies and procedures for ECU @ Southeastern nursing students.
Developing and implementing a media plan for recruitment of a qualified student applicant pool.
Establishing clinical sites in the surrounding area and hiring clinical instructors.
Ensuring equal access to quality nursing education for students at both schools, including access to campus resources, student support services, student nursing organizations and faculty advisement.

The ECU @ Southeastern Department of Nursing was placed under the auspices of the SOSU Department of Biology, a division of the SOSU School of Arts and Sciences, with the chain of command beginning with the chair of the Biology Department. We held meetings with the various department personnel with whom the ECU@SOSU program coordinator would be working. Qualified Department of Nursing office personnel were hired and the department's computer, basic skills and physical assessment laboratories were fully equipped to replicate ECU's laboratories. The SOSU Telecommunications Department oversaw the installation of two state-of-the-art ITV classrooms.

To ensure adequate numbers of qualified prospective students from which to select a nursing class, the ECU @ Southeastern Department of Nursing advertised to the SOSU catchment area, using a recruitment/media plan developed with input from an American Indian consultant and the ECU public relations director. The program coordinator, Dr. Flowers, met with nursing administrators to select qualified clinical sites; contracts were signed as per ECU protocols. Locating qualified clinical faculty in this rural setting was a challenge, but having available ECU graduates in the area has been an asset.

An articulation agreement between ECU and SOSU was developed, delineating the specific responsibilities each university would assume in the education of the ECU@SOSU students. Both university presidents signed the agreement.

All of these activities took place over approximately 18 months while the distant site became operational. The first cohort of 11 students to graduate from the ECU @ Southeastern Department of Nursing did so in 2002.

Focusing on Retention

While our first HRSA grant project focused on initiating a baccalaureate nursing program at SOSU, the current project is focused on student retention and successful graduation. Because of concern that the new nursing department's retention rate was not as high as anticipated, we developed the second project with the goal of increasing retention in order to increase the workforce of culturally competent professional nurses who would be able to serve the area's diverse communities. Nursing faculty and students in the ECU@SOSU program are involved in a variety of retention activities. Some activities are didactic, others emphasize student orientation and advisement.

From the beginning, students are introduced to retention activities as part of their program acceptance packet. In an effort to communicate college expectations to students and their families, the department holds a "Back to School Night" for students and their significant others. The event is conducted in the first few weeks of the sophomore-level course and is transmitted via ITV with some nursing faculty at each site. The department chair welcomes students and guests, explains the program and underscores the students' study time expectations. Each faculty member is introduced and the respective department sites are open for tours. This event also provides an opportunity to introduce and explain specific retention activities, particularly the Individual Observational Experience and the department's friendly "invasive advisement."

Invasive advisement is a proactive advising approach that the department has adopted. Following each unit exam, the project retention coordinator communicates with each student via the course Web site. Students are sent notes, which vary in content based on their test grades. Students in academic jeopardy are asked to make an appointment with the course coordinator or faculty to discuss issues that may be impacting their performance. The students are asked to identify work hours, study techniques and any other factors that may be affecting their academic success. Then faculty members assist the students in planning interventions, including referrals to university services, such as counseling for test anxiety, support services for study and test-taking skills, and tutoring arranged by ECU's Native American counselor. The faculty document each advising session.

Individual Observational Experiences (IOEx) are offered to each sophomore-level student enrolled in the first clinical course. Students participate in a four-hour clinical observational experience in their choice of clinical settings.

Four local clinical agencies generously pair staff nurses with students, most of whom have never worked in a hospital setting. The goal is to offer a realistic look at nursing from a "real" nurse's perspective. The project director coordinates IOExs in concert with the Human Resources or nursing office staff at the participating health care facilities.

In addition, faculty have designed in-class activities, called Teaching-Learning Cultural sessions (TLCs), which promote student retention. TLCs are concentrated, lively 10- to 15-minute weekly sessions that cover a multitude of topics, such as health promotion, stress reduction and how to form an effective study group. For example, students may be asked to complete a schedule of their week, evaluate quality study time and determine realistic study goals. The schedules become the basis for TLC class discussion about time management. TLCs can also incorporate cultural or pathophysiologic topics relevant to the class lecture material.

Plus, clinical cultural sessions are held monthly during post-conference in most major clinical junior- and senior-level courses. Students from both the ECU and SOSU campuses attend these sessions to discuss cultural aspects of nursing care.

Clinical faculty develop the sessions and facilitate discussion, which is held via ITV. For example: Students assess their assigned patient's traditional health beliefs or home health practices, then share this information with their student colleagues. As part of the discussion, students also share their own family's traditions. Additional clinical topics include beliefs related to the dying process, diabetic care and cultural or ethnic assessment findings. The textbooks by Spector and Twiname & Boyd serve as a springboard for both TLCs and clinical cultural sessions.

A culminating senior-level cultural experience occurs in the Community Health course. Students plan, implement and evaluate health career fairs and health assessments at local elementary and secondary schools that have a high percentage of American Indian students.

Bridging Boundaries

Developing and implementing this technologically complex collaborative project was often challenging, but the results we have achieved together have been more than worth it. Our first grant project's goal of bringing baccalaureate nursing to rural southeastern Oklahoma has been successfully met: We have a vibrant extended nursing department which is flourishing in the distance education environment.

NCLEX-RN® pass rates are consistent across the two campuses and exceed the national average. This fall semester, the senior class will be the largest we have ever had, with 60 students. This represents a two-year average increase of over 10 students. The junior class has retained 71 of the original 74 students. Preparation of a new ITV classroom is in progress to accommodate the larger ECU campus site class size. We continue to maintain a higher enrollment of Native American students in the nursing program than the overall average percentage on both the ECU and SOSU campuses.

We have bridged many boundaries to build the ECU @ Southeastern Department of Nursing, not the least of which was the longstanding rivalry between the two educational institutions. Initially the two campuses had separate student nurse organizations, but now the two organizations are merging. Most clinical agencies in the area have been eager to accommodate ECU@SOSU nursing students and faculty.

By extending ECU's program to a sister university with an equally diverse student population, we have increased the accessibility of a baccalaureate nursing program that is well established and fully accredited. We continue to maintain a philosophy of providing quality nursing education to all students regardless of which campus site they attend. Faculty physically travel to ECU@SOSU to originate at least 25% of didactic class sessions. The instructors' sensitivity to promoting distant students' class participation has been integral in achieving inclusiveness.

Classroom and clinical activities are designed to enhance student interaction across both campuses and to increase cultural sensitivity. Every junior-level student has at least one clinical day at the Chickasaw Nation's Carl Albert Indian Health Facility. ECU campus senior students travel to the ECU@SOSU campus for selected class activities. The program's clinical cultural sessions and TLCs receive positive evaluations from the students.

An important benefit of this project is that we are helping to alleviate minority health care disparities in our area by reaching out to surrounding diverse communities to recruit our nursing students. We also conduct clinical activities in predominantly Native American secondary schools. In one of these schools, our senior Community Health students have conducted physical assessments and health career fairs for six years; the high school students look forward to the nursing students' activities. Altogether, approximately 200 grade school and high school students per year participate in activities planned by our nursing students. At least one of these pre-college students has indicated that she plans to enroll in our nursing program when she graduates.

Most of the nurses we prepare at ECU and at ECU @ Southeastern remain in the area after graduation. Thus, our project has increased the numbers of culturally diverse professional nurses in the rural Oklahoma health care workforce. As more baccalaureate-prepared American Indian students continue to graduate from our program and embark on nursing careers, they will be able to provide enhanced culturally sensitive care to underserved populations who urgently need it.

Authors' Note

The authors gratefully acknowledge the U.S. Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Professions, Division of Nursing for its financial support of this project. We also wish to express our gratitude to the administrations at ECU and SOSU, and to the ECU Department of Nursing's faculty, staff and students.

Dr. Anne W. Davis is a professor of nursing at East Central University (ECU) in Ada, Okla., and serves as project director for Nursing Education with Enhanced Retention Activities (NEW ERA). Dr. Deborah L. Flowers is program coordinator of ECU @ Southeastern Department of Nursing and an associate professor of nursing at ECU. Dr. Judy Goforth Parker is a professor of nursing at ECU and is retention coordinator for NEW ERA.