With its variety of resources, the geographical dispersion of its workforce, and the rich diversity of clinical and research expertise in federal medicine, distance modalities can be used as the approach of choice for training and education. Distance education, as used here, refers to the application of electronic technology to teaching and learning. It also includes any educational activity in which students are separated from faculty and peers.1 Distance education affords flexible opportunities to quickly target groups in any geographical location and has the ability to access subject matter experts from across the country, exposing students to diverse opinions, theories, and applications of knowledge.2 One of the earliest and arguably one of the most successful distance learning programs for health care education was the Department of Veterans Affairs (VA)/ Department of Defense (DoD) Post-Master's Certificate Program for Adult Nurse Practitioners. The lessons learned from this program offer valuable data to public and private sector managers who are planning distance education initiatives.
In 1997, the VA and the DoD entered into a unique educational collaboration that resulted in the development of a national first, a clinical nursing curriculum taught entirely through distance education but equal in academic rigor and clinical intensity to the traditional, campus-based program at the Uniformed Services University of the Health Sciences (USU) Graduate School of Nursing (GSN). Even today, few schools offer clinical degrees taught solely through the medium of distance education.
The impetus for the program came from the VA's radical reorganization from an inpatient health care system to one based on primary care, with an emphasis on ambulatory care delivery. This shift created the need for a projected 200% increase in the number of primary care providers employed by the VA. Nurse practitioners would figure prominently in the VA's new care scheme, and securing additional nurse practitioners would be critical to the success of this organizational transformation.
At the same time, VA Headquarters' Nursing Strategic Healthcare Group (NSHG) was aware that a shortage of nurse practitioners existed nationwide. VA facilities reported difficulties in hiring these nurses and reported that local nurse practitioner programs frequently had lengthy admission waiting lists. VA nurse executives also began to note that the reorganization to primary and ambulatory care was resulting in certain clinical nurse specialists and other advanced-practice nurses being displaced from their inpatient practice; not all of these nurses had the skills to move to primary care assignments. Faced with these facts, the NSHG determined that one approach for increasing the number of nurse practitioners would be to educate existing clinical nurse specialists as nurse practitioners through a postmaster's certificate program. Because the nurses were located across the country and local nurse practitioner programs could not admit all qualified students who applied, a distance learning program seemed to be an ideal approach.
The natural partner for this VA nursing initiative was the USU GSN, which already sponsored an accredited, successful, family nurse practitioner program. The VA's proposal for an adult nurse practitioner program was greeted enthusiastically by Dean Faye Glenn Abdellah and the faculty of the GSN, and they approached the challenge of designing an additional curriculum and providing it through a new medium with keen interest.
Concluding that existing curricula or lesson plans can simply be transferred to a distance modality can lead to cost inefficiencies and high levels of dissatisfaction among students. The GSN dean and faculty were well aware that, although they could use existing courses as a foundation, the design and implementation of the new curriculum must be specific to distance transmission. Faculty members would also be challenged to initiate and sustain communication that transmitted content while stimulating student participation.3
The new program design began with a myriad of questions, Can clinical skills be taught via distance technology? How can safe practice be ensured? Many more questions were also posed. From the beginning, there were skeptics, individuals certain that clinical skills could never be taught in any setting other than a traditional classroom.
The major question, namely, whether clinical skills could be taught via distance education, was pivotal. As a result, it was decided that the program would begin by pilot-testing the Basic and Advanced Health Assessment course, referred to as Phase I. The course would be taught using synchronous (live) video teleconferencing. Continuation of the program, Phase II, would be contingent upon a positive evaluation of the course and successful skill attainment by students. The project directors were a USU professor with extensive experience in technology, who would oversee curriculum implementation, and a VA project director (the author) from the NSHG, who would guide administrative implementation and act as liaison to the VA staff.
Two medical centers participated in Phase I. Each had a need for nurse practitioners and one had advanced-practice nurses being displaced through reorganization of inpatient activities. Eleven master's degree-prepared clinical nurse specialists, including one active duty Army nurse, took part in the Phase I instruction. Class content was presented through a weekly 2-hour lecture, followed by a 1-hour laboratory experience supervised by a preceptor at the hospital site. Students also took part in defined clinical activities at the medical centers, as structured by the clinical preceptor. The clinical support system designed for Phase I was key to the pilot program. The VA project director selected sites with experienced clinicians who were committed to serving as student preceptors and ambulatory care managers who were committed to using nurse practitioners.
The purpose of Phase I was to develop and evaluate technical capabilities and teaching strategies and to identify the most appropriate and compatible media for teaching via teleconferencing techniques. The success of Phase I led to the decision to implement the full curriculum or Phase II, which was initiated in autumn 1997 at 10 VA facilities.
When implemented, the Adult Nurse Practitioner Program was an 8-course, 28-credit program with 560 hours of clinical practice, based on the National Organization of Nurse Practitioner Faculty guidelines. Designed to accommodate working nurses, it was taught over a 20-month period, with all classes scheduled from 4:30 to 6:30 p.m. Eastern Time, after working hours for most participants.
Successful distance education requires superior technology. Research has shown that students are distracted and frustrated by poor technology that is inadequate to support course content and presentation. Furthermore, technology failures can quickly lead to student dropout.
During Phase I, classes originated from an electronic classroom in the National Naval Medical Center. In this classroom, as the instructor taught, a technician controlled all incoming and outgoing transmissions. VA nurses were located in electronic classrooms that were equipped with video teleconferencing dial-up equipment, television monitors, and "smart" cameras that adjusted angle and focus on the basis of sound. The program used synchronous video teleconferencing that was dialed through the VA National Telephone Service (VANTS). Before Phase II implementation, several computer and educational technologies were immediately required to ensure the success of the project. Requirements included an upgrade of the file server at the VANTS hub in Martinsburg, West Virginia; establishment of a video teleconferencing unit at USU; and confirmation of video conferencing capabilities at each site. All required steps were accomplished.
Not all students will or can succeed in a distance learning format. The successful student is vested in using the knowledge to be acquired, works well in an unstructured environment, and is willing to commit the time and effort necessary for successful program completion.
Student selection criteria included highly satisfactory job performance, a supervisory recommendation, and completion of a master's degree in nursing with a clinical specialty. Preference was given to individuals whose current positions might be eliminated through reorganization and for whom the new skills would enable transfer to a needed role. Original guidelines made ineligible nurses not currently employed in clinical areas. From the first, however, these nurses expressed extreme interest in the program. As a result, they were evaluated on an individual basis, to determine whether they had the requisite clinical skills and background to succeed in the program. Students referred by VA were then required to meet all GSN admission requirements.
As part of the collaboration, VA agreed to hire two faculty members to support the distance learning program. One faculty member was a VA nurse practitioner who had extensive experience in VA utilization of nurse practitioners. The second faculty member, a nurse practitioner and clinical nurse specialist, came from an academic setting and had extensive experience in distance education. This pairing, as might be expected, proved ideal. These individuals were responsible for course coordination and site-based teaching activities; they also engaged in clinical practice at a VA medical center. In addition, faculty members from the GSN and the Graduate School of Medicine, as well as VA clinicians, served as guest lecturers, teaching classes within their expertise. As the distance program became more integrated into the GSN, VA faculty members served on GSN committees and participated in strategic planning activities.
Although nurses across the country were eager to participate in the program, VA medical centers first had to apply to be teaching sites. If clinical practice locations and administrative endorsements were in place, then the site was approved to begin soliciting students.
To be selected as teaching sites, VA medical centers were required to identify an administrative coordinator and a lead preceptor. Administrative coordinators were responsible for securing on-site resources, administering tests, and generally acting as sponsors for the students. The lead preceptor was a nurse practitioner responsible for identifying and securing clinical practice sites and clinical preceptors. The lead preceptor ensured that each class was followed by corresponding clinical demonstrations and practice. This individual also collaborated with individual student preceptors to assess student clinical abilities and to determine a passing or failing grade for the clinical component of the class.
Before Phase II and throughout the program, all lead preceptors and administrative coordinators attended an annual orientation program at USU. Training topics included curriculum overviews and essentials of assessing and grading clinical performance. In addition, the faculty developed comprehensive training guides for both positions. Further site support and project assessment occurred as the VA project director, the GSN nurse practitioner department chairperson, and a VA faculty member visited each site to verify that practice standards were being adhered to, that necessary resources were in place, and that administrative documents were consistent with accreditation standards. This team met with hospital administrators, preceptors, and students, to identify both learning needs and successful practices that might be replicated. Demonstrating the flexibility of distance education, when faculty members had teaching responsibilities for the distance learning program while on a site visit, they simply joined the students in their classroom and initiated the class from that VA site.
Clinical supervision posed the greatest challenge for the distance learning program. VA and GSN administrators and faculty members were committed to there being no difference in the quality of instruction between the on-site and distance programs. To that end, extensive development and planning went into preparation for clinical supervision. Clinical standards were identified by faculty members and communicated to both students and preceptors. Students completed extensive case studies, and lead preceptors met with individual preceptors and students on a regular basis.
The major determinant of successful completion proved to be the student's commitment to acquiring new clinical skills. Those who had not engaged in an active clinical practice before class admission were as likely to finish the program successfully as were their clinically active counterparts, although some said with harder work. Students spoke of their difficulty in returning to a novice role and dealing with unfamiliar content and practice patterns. Some experienced significant life events and elected to drop out of the program; more found that their studies and their classmates offered support as they experienced these events. Two graduating students were diagnosed and treated for life-threatening illnesses during their studies, and one received her doctoral degree from a local university while maintaining an outstanding grade point average in the distance learning program.
As the program progressed, it became apparent that computer literacy was a criterion for student success. Computer literacy subsequently became a requirement for admission. The majority of individuals in the first class, all of whom were highly successful clinicians, became frustrated when required to use computer skills that went beyond those typically required in the practice setting. Students were expected to prepare PowerPoint presentations, to initiate data searches, and to access documents from the USU World Wide Web site. Therefore, subsequent classes were informed of the computer skills they would need for their studies and were encouraged to complete VA-sponsored classes or tutorials before beginning the program. Although future distance learners can reasonably be expected to be more at ease with computer use, it should be remembered that a somewhat different skill set is required for academic presentations and completion of course work. Requiring preparatory classes or tutorials can reduce stress and enable participants to fully engage in class activities sooner and with less difficulty.
In distance education, those designing and implementing curricula should be prepared to critique and grow with new technology. The faculty made increasing use of World Wide Web-based materials to support and enhance instruction while reducing administrative costs. Students used chat rooms to work on joint projects, took part in Internet-based instruction, and initiated their own video or audio conferences. Materials that were first express-mailed to class sites were later posted on the World Wide Web. Testing also moved from hard copies mailed to each site to World Wide Web-based applications accessed through password-protected sites.
Because this was a national program, faculty members consistently reviewed content and, if necessary, made modifications to remain consistent with clinical practice and to satisfy nurse practitioner curricular guidelines for the various states. Faculty members also made ongoing use of student feedback. Not all innovations received positive reviews, however. During one semester, pathophysiology was taught by using a series of videotapes that students viewed independently, followed by discussion with faculty members. Students found this approach unsatisfactory, and the practice was not used with subsequent groups.
Use of Human Simulated Patients
In April 2000, USU opened the National Capital Area Medical Simulation Center, a center housing virtual-reality technology, computer-controlled mannequins, and human simulated patients. With access to this facility, the distance learning faculty pilot-tested the use of human simulated patients to teach health assessment skills. Students were able to interview patients and critique physical examinations performed in the studio. To our knowledge, this use of simulated patients in a distance learning format was also a nursing education "first."
As reported in the literature, faculty members found that a significant cost of distance learning was time. It took approximately 6 hours of preparation for 1 hour of distance learning instruction, compared with 2 hours of preparation commonly attributed to classroom instruction. It is estimated that transferring 1 hour of instruction to the World Wide Web can take from 6 to 8 hours.4
Because there are specific challenges in teaching through distance education, the faculty developed guidelines for guest lecturers that presented ways to minimize confusion to distant students and stressed the importance of interacting with the entire class by asking questions and switching camera action from site to site. It also became critical to stress that guest faculty must adhere to class timelines. It was calculated that the costs for lectures running overtime were approximately $100 per minute; this included the cost of overtime pay for staff members overseeing the dial-in at the VANTS bridge.
Report to Congress
Throughout its operation, the distance learning program was the object of keen and positive interest from Congress. In response to a legislative directive, USU and VA prepared a report on the Phase I and II activities of the program. The VA/DoD Post-Master's Adult Nurse Practitioner Distance Learning Program: From Concept to Graduation is an inclusive roadmap for implementing a distance learning program, making available the program curriculum, learning strategies, assessment methods, and transmission methods to others interested in distance learning and health professions education.5
The model implemented for clinical supervision proved successful. Clinical practice took place in ambulatory care and mental health clinics in VA medical centers and in health departments and local hospitals when VA facilities could not provide the required clinical experiences. When rated by preceptors, the clinical skills of the distance learning students were consistently observed to be equal to or better than the skills of local nurse practitioner students from traditional programs that the preceptors had supervised. Both preceptors and students rated the process as highly satisfactory. This clinical success was attributed to the close contact between faculty members and the lead preceptors, the training materials provided, and on-site observation of clinical training. Students particularly valued the use of familiar clinical sites.
When the project was initiated, it was difficult to estimate or determine costs, because USU and VA incurred both indirect and direct costs. Although there was no existent benchmark for budgeting, VA could estimate projected equipment costs and the cost of transmitting to facilities across the country. USU could estimate the number of faculty members required for the program, although the extent of required administrative support was unknown. A demonstration of the strength of the commitment between these organizations was that both agreed to initiate Phase I using their own existing resources. The Phase I implementation became the platform for generating cost estimates, with VA agreeing to supply two faculty members and support administrative costs, which included student library use, development and distribution of class materials, and GSN faculty involvement. In addition, USU shared the services of two doctorally prepared experts as consultants in media production and education technology and used a newly created video teleconferencing classroom without incurring start-up costs. At its inception, the estimated program cost was approximately $13,450 per VA student, compared with an estimated average tuition of $24,000 per student for a select sample of public and private institutions offering similar programs.
In their white paper on distance education, the American Association of Colleges of Nursing raised the concern that ". . . reliance on educational technology poses questions about the relationship of the learning milieu to the social and behavioral skills needed in a humanistic, practice-oriented discipline."6 This element of role socialization was given careful consideration throughout the program, with faculty members initiating clinical experiences, case studies, and interactive group assignments to ensure that graduates would be cognizant of and comfortable with the nurse practitioner role. The results of such efforts proved successful. Using the same evaluation tools as their campus-based counterparts, students indicated that they were highly satisfied with the program, believed they were well prepared to function as nurse practitioners, were pleased with the use of technology, and had mastered course requirements without the intrusion of the technology. During site visits, students consistently pointed out the differences between their previous clinical nurse specialist roles and that of the nurse practitioner, whereas VA administrators often mentioned the well-organized approach to classroom and clinical activities and indicated strong support for the program and the abilities of the students.
Distant Education Policy
In November 2001, the USU president approved a comprehensive distant education policy (PPM-004-2001). The guidelines apply to certificate- and degree-based courses and activities for distance delivery and require that courses meet the recommendations of the Middle States Association of Colleges and Schools and five other accrediting groups for distance education (http://www.ncahigherlearningcommission.org/resources/ electronic-degrees) and be guided by policies established by USU. The policy includes identification of the responsibilities of all who are involved in distance education at USU.
The VA/DoD Post-Master's Certificate Program for Adult Nurse Practitioners clearly proved the effectiveness of distance learning technology in clinical education. Classes were admitted in 1997, 1999, and 2001, graduating in 1999, 2001, and 2003, respectively. A total of 70 nurses from VA facilities across the United States, Puerto Rico, and the Virgin Islands graduated from the program. An active duty Army nurse graduated with the class of 1999 and a U.S. Public Health Service Nurse graduated in 2003, demonstrating that the program is applicable to others in the federal sector. New students were not admitted in 2003 because the VA's need for nurse practitioners was no longer as acute and because a significant number of nurse practitioner education programs had opened since 1999, providing VA nurses with greater access to accredited programs.
In 2001, the GSN family nurse practitioner program and the VA/DoD distance learning program were reviewed by the National League for Nursing Accrediting Commission and received a maximum 8-year term of accreditation, an indicator of program quality. The Commission on Collegiate Nursing Education also reviewed the GSN programs and granted a maximum 10-year term of accreditation. The Commission on Collegiate Nursing Education, however, does not include post-degree certificate programs within its scope.
Students, VA, and the GSN gained a number of benefits from this novel program. VA gained a cost-effective method of securing additional nurse practitioners at a time when local nursing schools had insufficient capacity to admit all qualified applicants. In addition, course content and clinical experiences highlighted conditions unique to the veteran population. Faculty members gained skills through teaching in a prototype distance education program, and teaching aids could be replicated for other academic programs. Students benefited from classes taught at the work site, clinical experiences designed to capitalize on their existing skills, faculty members and preceptors committed to their success, and acquisition of a new skill set. The success of the VA/DoD program led the GSN to implement two additional distance education programs, namely, family nurse practitioner and certified registered nurse anesthesia.
In May 1999, the first distance learning students took part in a final program hallmark, a virtual graduation. The graduation, which took place through live video teleconferencing, was appropriate for a group that had accomplished so many firsts through distance technology. Students were addressed by the Chancellor of Education of the DoD and received congratulatory remarks from VA and USU leaders. The virtual graduation became a distinguishing tradition of the program that allowed the students in each graduating class to share their distance learning experiences and their achievements with those most important to them.
Completing a complex clinical education program via distance education is not an easy task, especially when the students are employed full-time. Perhaps the best summation of the experience comes from those involved.
"The experience is sort of like Mount Everest-the view from the top is definitely worth the trip." Anonymous graduate, class of 1999.
I acknowledge the substantial contributions made to this project by Dr. Faye Glenn Abdellah, Dean Emeritus, and the faculty of the USU GSN.
© 2005 Association of Military Surgeons of the United States Provided by ProQuest LLC. All Rights Reserved.
Source: Military Medicine