1. Ronald, Noelle MS
  2. Quinn, Winifred V. PhD
  3. Reinhard, Susan C. PhD, RN, FAAN
  4. Cleary, Brenda L. PhD, RN, FAAN
  5. Hunter, Meredith Rucker MS
  6. Akinwole, Barbara S. MLS


How a national organization is helping to expand nursing education capacity state by state.


Article Content

Editor's note: This is the second in a series of articles describing a public and private collaborative effort to redesign nursing education to prepare the future nursing workforce.


The Center to Champion Nursing in America (CCNA) is a joint initiative of AARP, the AARP Foundation, and the Robert Wood Johnson Foundation (RWJF). Our mission is to ensure an adequate supply of the highly skilled nurses our country needs to provide safe, affordable, quality health care now and in the future. Our initial efforts focused primarily on increasing nursing education capacity. In 2008 and 2009 the CCNA, AARP, the RWJF, the U.S. Department of Labor's Employment and Training Administration (ETA), and the U.S. Department of Health and Human Services' Health Resources and Services Administration (HRSA) convened two national summits on nursing education capacity, in order to address the challenges in teaching sufficient numbers of nurses the skills required in the 21st century. The CCNA also provides technical assistance to individual states.

Figure. The CCNA tea... - Click to enlarge in new windowFigure. The CCNA team, from left to right: (front row) Susan C. Reinhard, Noelle Ronald, Brenda L. Cleary, and (back row) Winifred V. Quinn, Meredith Rucker Hunter, Barbara S. Akinwole, 2009 nurse fellow Carol Hall Ellenbecker, Diane Welsh.
Figure. State nursin... - Click to enlarge in new windowFigure. State nursing workforce team members share their progress in expanding nursing education capacity at one of the CCNA summits.

Technical assistance, as defined by the CCNA, is the facilitation of communication exchanges and knowledge acquisition between subject matter experts and learning parties. The technical assistance program helps bring the best practices and expertise of model state teams (exemplars), which have experienced successes in expanding nursing education capacity, to the other state teams. The program uses a variety of interactive approaches (such as Webinars and other Web resources, in-person exchanges, site visits, and multistate conference calls), as well as written information, to offer viable solutions to specific problems. The scope of this national effort is unprecedented, and the hope is that other states will be able to adapt and build on the experiences of the states that have found success.


This article is the second in a series of seven. The first, "Forging Partnerships to Expand Nursing Education Capacity," in the January AJN, described the two national summits in depth. Future articles will highlight the work of individual state exemplars. This month we discuss our efforts to support 30 geographically diverse state teams in expanding nursing education capacity.



We envisioned a national movement to increase awareness of the need to expand nursing education capacity and support the changes required for success. The CCNA began its work to support this movement by approaching nursing workforce centers in each state. First, we suggested that each state nursing workforce team strategically expand its membership, reaching out to representatives from the governor's office, the workforce development board, the state hospital association, academia, chambers of commerce, nurse employers, legislators, policymakers, state budget and finance experts, philanthropic organizations, consumer groups, and patient advocacy organizations. Second, we asked the teams to assess several factors in their states:


* the nature of the current and projected nursing shortage


* current efforts to expand nursing education capacity and the challenges encountered


* goals and objectives for expanding nursing education capacity


* the team's current level of activity and depth of strategic partnerships



We also invited the state teams to submit letters of application to attend the first summit on nursing education capacity in June 2008. In states without nursing workforce centers, we sent invitations to state workforce agencies, state hospital associations, and the governor's office.


Representatives of the RWJF, the ETA, HRSA, and the CCNA reviewed the applications and selected 18 state teams (referred to as "lead state teams") to attend the first summit and receive technical assistance: Alabama, California, Colorado, Florida, Hawaii, Illinois, Maryland, Massachusetts, Michigan, Mississippi, New Jersey, North Carolina, North Dakota, Oregon, South Carolina, Texas, Virginia, and Wisconsin. Already identified as exemplars, many of these state teams had already been working with their strategic partners to increase awareness of nursing education capacity and to address challenges in education redesign and come up with solutions. Attendance at the summit supported and supplemented their efforts and encouraged continued success.


The second summit on nursing education capacity took place in February 2009 and was open to teams from all states. Exemplar state teams that participated in the June 2008 summit shared their progress, best practices, and new knowledge about expanding education capacity in their states. They also mentored the newer state teams.


After the second summit, state teams were encouraged to apply for ongoing technical assistance. Twenty additional state teams applied. The application review process incorporated a five-point numeric scale to determine the relative strength of all submitted applications. Selection criteria included having a broad range of strategic partners beyond the nursing community; a strong strategic plan to increase nursing education capacity, indicating goals and strategies to achieve them; and documented progress toward increasing nursing education capacity. Based on the results, reviewers from the RWJF, the ETA, HRSA, and the CCNA selected 12 additional state teams to participate in the CCNA technical assistance program: Georgia, Idaho, Indiana, Kentucky, Louisiana, Nebraska, New Mexico, New York, Ohio, Rhode Island, Washington, and West Virginia. These states joined the original group, for a total of 30 states eligible to participate in the technical assistance program.



To help ensure clarity and focus, each of the 30 state teams signed a memorandum of understanding with the CCNA, which specified the general technical assistance that was available to all states and asked each team to provide the following:


* two strategies for increasing education capacity or redesigning nursing education


* the specific technical assistance tool most likely to support the team's efforts


* an achievement to share with other state teams in a mentoring capacity



The memorandum of understanding also required state teams to provide baseline nursing school enrollment data across all prelicensure RN programs. Similar data would be required for fall 2009 and fall 2010 enrollment. This would help us measure the effect of our technical assistance on increasing enrollment.


Responses provided in the memorandum of understanding were incorporated into the CCNA technical assistance program. For example, five state teams indicated a need for asset mapping, a form of strategic planning. One of these teams, from South Carolina, arranged for a consulting group with strategic planning expertise to facilitate an asset mapping session for the team and obtained funding support from the Duke Endowment. The South Carolina team invited the team from North Carolina to attend the session. When they told us about this, we obtained permission from the session planners to include the teams from the other three states that had expressed an interest in asset mapping. The CCNA provided 50% of the funding for the session, and covered the costs of travel and meals for the attendees from outside the region.



The technical assistance the CCNA provides relies upon the recognized best practices and expertise of exemplar state teams and other experts in nursing education and other relevant areas, such as asset mapping. The aim is to help advance the efforts of states newer to the process of increasing nursing education capacity. Three specific types of technical assistance are designed to support the needs of all 30 state teams. Because the teams are at varying stages of progress, they have varying needs for assistance.


Targeted technical assistance is available to those teams most likely to successfully increase education capacity or redesign nursing education in their states, based on a strong history of progress toward that goal. Examples of targeted technical assistance include site visits to places that have already achieved success. Teams committed to or already implementing education redesign and increasing education capacity have made site visits to Mississippi and Oregon. Those teams committed to implementing or regionalizing simulation learning made a site visit to the Smart Hospital at the University of Texas-Arlington.


Targeted technical assistance also includes learning communities, which are self-selected groups with similar strategic priorities. One learning community focuses on education redesign, including the development of evidence-based core curricula and new partnerships between community colleges and universities. Another learning community, on technology, covers innovations such as automated clinical placement systems, online learning, and clinical simulation. The learning communities connect via an extranet accessed through the CCNA Web site.


Active technical assistance is available to all 30 state teams and facilitates the transfer of knowledge from state exemplars. Conference calls and Webinars are scheduled for the fourth Wednesday of each month on topics requested by state teams. Topics have included state support (policy, regulation, and funding) for nursing education, federal and philanthropic funding opportunities, the effect of the economic downturn on the supply of and demand for nurses, strategic partnerships, and the Massachusetts education redesign model. During these conference calls and Webinars, exemplar state teams and experts on the topics share their solutions, best practices, and lessons they've learned and facilitate postpresentation discussion.


Although teams benefit from grant-funding support for their work, the CCNA doesn't have the capacity to develop and write grants for individual teams. For those state teams that want to write grants but lack the benefit of university-based grant-writing partners, we contracted for the services of a seasoned grant writer and reviewer. The state team drafts a response to the request for proposal, and the contracted grant writer assists with formatting the grant submission and reviewing its content.


Passive technical assistance aims to raise awareness of issues related to education capacity. The public pages of the CCNA's Web site ( are the major source of passive technical assistance. The Web site offers an analysis of challenges and evidence-based solutions and related resources such as published articles, white papers, videos, and links to other useful Web sites.



Information and feedback gathered from surveys, one-on-one conversations with team leaders, and participation in state team meetings feed the continuous quality improvement process and help streamline the technical assistance program.


In December 2008 we conducted an evaluation of the 18 lead state teams that had attended the June 2008 summit on nursing education capacity. For the evaluation, the teams provided updated information on the makeup of the team, listed new strategic priorities they had identified, and reported any team activities or updates of their efforts during the previous six months. We recognize that some of the work that the states reported may have already begun before the June summit, but it was difficult to determine an exact starting point for some ongoing efforts.


Given the structure and definition of our technical assistance, an obvious achievement was the peer-to-peer information sharing among the state teams. Accomplishments of individual states included the following:


* adding questions on faculty compensation to the annual school of nursing survey


* identifying requirement barriers for associate's degree faculty, such as duplication of course work


* establishing online programs for progressing from an RN diploma to a master's degree


* establishing regional teams within the state


* receiving private grant funding for specific purposes, such as conducting workforce research or collecting data on outcomes of clinical simulation


* gaining state legislative support for specific initiatives, such as repayment of faculty loans and establishment of dedicated education units (hospital or other care delivery units prepared and equipped to provide high-quality patient care while educating and increasing the skill sets of new and student nurses)


* conducting a survey on attrition in associate's degree programs


* developing a single portal for nursing school applications in a region or state



Among the 18 lead state teams, 13 expanded to include new strategic partnerships, 11 implemented online clinical placement systems, and 11 reported that their state nursing schools were sharing resources. Nine teams reported progress toward education redesign that included reaching agreement on competencies, conducting research on components of a core curriculum, developing seamless curricula between associate's degree and baccalaureate programs, and developing dedicated education units. Ten groups planned to introduce legislation to improve nursing education capacity in their states and to seek new funding to support ongoing efforts. Unfortunately, because of the economic downturn, 13 states reported budget cuts that affect nursing education in their schools. However, 12 teams reported new funding sources for education capacity, including private sources.


Another evaluation of the effect of technical assistance is in the planning stages and will include all 30 states receiving technical assistance from the CCNA.



One type of technical assistance is help with communications, in order to increase awareness of the activities of state teams and to encourage exchange of information among the states.


Media outreach. The CCNA developed a targeted media outreach strategy, primarily to help with state team events. One example was the February 2009 summit, where we targeted both national and state-based media. At the national level, we stressed the opportunity to tell health care and nursing trade publications about the collective work of the state teams. As a result, stories appeared in health trade publications such as the American Hospital Association's AHA NewsNow and nursing trade publications such as Advance for Nurses.


To help increase awareness of the summit and education capacity challenges and solutions in the states, the CCNA asked a public relations firm employed by the RWJF as a resource for its grantees to create a "swiss cheese" press release template. This format provided general information about education capacity challenges and included space for a state team to highlight its successes and solutions. With the aid of this template, stories about the summit appeared in 23 media outlets, reaching over 1 million people. In addition, the CCNA supplemented press coverage of the summit with a "radio tour," including radio networks such as CNN Radio and the Wall Street Journal Radio Network. State and national spokespeople participated in 23 radio interviews in 16 markets, reaching more than 16.5 million listeners.


Web-based communications. State teams participating in the technical assistance program can make use of the CCNA's interactive Web-based communications. The CCNA Web site is a dual-access environment, with a public site and an extranet for state teams only. The public site offers timely, relevant information about nursing in America, including news, public policy, nursing research, and videos of nursing models of care.


The extranet is an internal site that the state teams can use to share documents. It also offers interactive modules for the 30 teams. The first modules support the two developing learning communities (focused on education redesign and technology in learning) with Web-based offerings such as Webinars and interactive discussions among experts and state teams.