CULTURAL CHARACTERISTICS OF A NURSING EDUCATION CENTER OF EXCELLENCE: A NATURALISTIC INQUIRY CASE STUDY BY ©2011 TONA L.LEIKER Submitted to the graduate degree program in Nursing and the Graduate Faculty of the University of Kansas in partial fulfillment of the requirements for the degree of Doctor of Philosophy. Chairperson Leonie Pallikkathayil Marjorie Bott Helen Connors Sarah Forbes-Thompson Mary Zimmerman Date Defended: April 14, 2011 ii The Dissertation Committee for TONA L. LEIKER certifies that this is the approved version of the following dissertation: CULTURAL CHARACTERISTICS OF A NURSING EDUCATION CENTER OF EXCELLENCE: A NATURALISTIC INQUIRY CASE STUDY Chairperson Leonie Pallikkathayil Date approved: April 14, 2011 iii Abstract Nursing education is at a crossroad today. Stressors in nursing programs include expanding enrollments to meet growing workforce demands for more registered nurses, demanding workloads with low average nursing faculty salaries compared to practice peers, and growing numbers of faculty retirements. The purpose of this study was to identify the cultural characteristics of a nursing education center of excellence. The primary research question was: What important factors constitute the culture of a nursing program previously determined to be a high-performing environment? Using naturalistic inquiry methods, one nursing program case study designated as National League for Nursing (NLN) Centers of Excellence in Nursing EducationTM was examined through an extended immersion experience. Following voluntary informed consent, data collection occurred over several months through prolonged immersion including six study visits, multiple observations, formal/informal interviews, and artifact/document collection and review. Data collection began with entry into the field and continued throughout the research experience. Data analysis began with the first immersion experience and continued throughout the iterative reflexive process of naturalistic inquiry case study. This process provided understanding of the factors that constitute the cultural characteristics of a nursing education center of excellence. The most significant finding of the study was the importance of creating intentional caring relationships with key stakeholders while maintaining focus upon the mission and values of the profession, student-centered nursing program, and institution. A graphic representation emerged from the three themes and 12 patterns. This study‘s results and representation, ―The Right Fit: Harmonious Alignment‖, will inform deans, policy- makers, and key stakeholders about the factors that constitute the culture of a high-performing academic nursing program designated as an NLN Center of ExcellenceTM in nursing education. iv Acknowledgements The desire to be a life-long learner is a gift from God. Channeling the gift into something meaningful for society became my life-goal. My parents as my first teachers: Myron and Darlene Veh might have said ―she lives in a dream world‖ because I loved to look, read, and think. As someone desiring understanding of the whole within the detail a qualitative dissertation became a meaningful learning process. Several nursing faculty mentored me in this journey: Dr. Eleanor Sullivan who suggested a PhD was ―the right fit‖; Dr. Michael Bleich, my academic advisor and initial dissertation chair; Dr. Sarah Forbes-Thompson and Dr. Veronica Rempusheski, my qualitative research professors who mentored me far beyond the classroom to develop my research skills. And, thanks to my dissertation committee: Dr. Leonie Pallikkathayil, Chair; Dr. Marge Bott, Dr. Helen Connors, Dr. Sarah Forbes-Thompson, and Dr. Mary Zimmerman. Each has generously shared their expertise and time in continuing my formation. I am most grateful for this opportunity and the guidance of Dr. Pallikkathayil. Thank you to the case study nursing program, administrators, faculty, staff, and students for contributing to nursing education research and my educational endeavors. Thank you to the National League for Nursing. Your assistance with access to the NLN Centers of ExcellenceTM data was appreciated. Thank you to my family. To Ron, my spouse and soul mate, thank you for your ongoing support of my professional growth. You‘ve always been there for me. To Hauna and Kyle, our children, I am so proud of you. Dad, thank you for your unconditional caring. And, Mom, although you have passed, you wanted me to achieve this goal. I remembered your strength of discipline when doctoral scholarship was difficult. Thank you for being an exemplary educator. v Funding Sources: Sigma Theta Tau International Epsilon Gamma Chapter-at-Large #121 Novice Research Award 2007 $375.00 National League for Nursing Foundation for Nursing Education Doctoral Dissertation Research Award 2007 $2500.00 vi Table of Contents Abstract iii Acknowledgements iv Funding Sources v Table of Contents vi List of Tables and Figures ix CHAPTER 1 The Problem and Its Relevance 1 Three Factors Influencing Nursing Education‘s Crisis 5 Growing Shortage of Professional Registered Nurse Faculty 6 Overwhelming Nursing Faculty Workloads with Low Average Faculty Salaries in Comparison to Practice Peers 9 Aging Nursing Faculty Workforce 12 Relevance of the Current Data to the Problem and This Study 14 Research Problem and Its Significance 15 Purpose of the Study 16 Research Question 16 Secondary Research Questions 16 Assumptions 17 Definition of Terms 17 Summary 19 CHAPTER 2 A Review of the Research Literature 20 ANCC‘s Magnet Hospital Designation Outcomes Research 21 Transforming Nursing Education NLN Centers of Excellence in Nursing EducationTM Founding Research 31 Organizational Culture in High-Performance Organizations 35 Discussion 41 Summary 42 CHAPTER 3 Case Study Research 43 Naturalistic Inquiry 43 Study Population and Case Study Selection 43 Data Collection 45 Case Study School Setting 45 Researcher as the Instrument 46 The Field Experience 48 Observations 49 Researcher‘s Field Notes 50 Interviews 50 Sampling 51 Artifacts 52 Data Analysis 52 Coding in Case Study Research: An Iterative Process 54 Establishing Quality in Naturalistic Inquiry 57 Trustworthiness 58 Credibility 58 Dependability and Confirmability 60 vii Ethical Considerations 62 Limitations 63 Summary 63 CHAPTER 4 Results 64 Narrative Summary 64 Immersion Visits 64 Observations 68 Interviews 69 Selected Artifacts 71 Patterns and Themes 72 A Graphic Representation 72 The Primary Research Question 73 The Right Fit: Harmonious Alignment 77 Theme One: A Firm Foundation 78 Heritage 79 Mission and Values of the Institution and Nursing Program 79 Theme Two: Nursing Program Transparency 80 Trust 81 Respect 82 Integrity 84 Theme Three: A Vibrant Academic Nursing Community 85 Student-Centered 85 Empowering Leadership 87 Internal and External Partnerships 89 Community of Learning 91 Sound Management Processes 93 Professional Role Socialization 95 Diversity Advocacy 96 Summary 98 Secondary Research Questions 98 Question 1 98 Question 2 101 Question 3 104 Discussion of Results 105 Nursing Education Crisis 105 Transforming Nursing Education 110 Organizational Culture in High-Performing Organizations 116 Summary 121 CHAPTER 5 Summary, Recommendations, and Conclusions 124 Summary 124 Recommendations from This Study 128 Implications for Future Research 129 Implications for Nursing Programs 129 Solving the Nursing Faculty Shortage 130 Creating Academic Leadership Development Opportunities 130 Developing Local, Regional, and National Nursing Faculty Policies 131 viii Conclusions 131 References 134 Appendix A NLN Centers of Excellence in Nursing EducationTM Program Purpose, Goals, Eligibility, Criteria, and Procedure in 2007 155 Appendix B Center of Excellence in Nursing EducationTM Designees by Category and Recognition Year(s) 160 Appendix C Participant Interview Guide 161 Appendix D Follow-up Interview Suggested Probes 163 Appendix E List of Observations by Immersion Visits 164 Appendix F Consent Form 166 Appendix G Sample Researcher Observations with Reflexive Notes 170 Appendix H List of Artifacts and Photos 172 Appendix I List of Documents 173 Appendix J Iterative Data Analysis Process – Mid-Point 175 Appendix K Iterative Process – Initial Linear Coding 178 Appendix L Iterative Data Analysis Process – Outcome 180 Appendix M Case Study Nursing Program Norms 185 Appendix N Case Study Nursing Program Metaphors 186 Appendix O Individual and Institutional Metaphors 187 Appendix P Sample Coding of Data Analysis Supporting ―The Right Fit 188 ix List of Tables and Figures Tables Table 3.1 The Case Study Summary 55 Table 4.1 The Immersion Visits 65 Table 4.2 Case Study: Themes and Patterns 74 Figures Figure 4.1 The Right Fit: Harmonious Alignment 76 1 Cultural Characteristics of a Nursing Education Center of Excellence: A Naturalistic Inquiry Case Study Chapter 1 The Problem and Its Relevance Nursing education is once again at a crossroad of complex workforce development issues. Historically, the profession has experienced periods of workforce shortage, however, none as great as is anticipated in the next two decades. The supply of U.S. registered nurses (RNs) continues to tighten and is anticipated to decline as demand is expected to exceed to growth (Department of Health and Human Services, 2006; Bleich et al., 2003). To meet this practice issue, nursing education has responded for the last six years with nursing education enrollment growth (Fang, Wilsey Wisniewski, & Bednash, 2007a). The practice demands for more RNs are two-fold: a) expanding healthcare needs of persons with complex health care problems (Cleary & Rice, 2005; Larson, 2006); and b) anticipated loss of RN workforce because of an aging workforce (DHHS, 2006), shorter career cycles of young adults (Griffin, 2004), and novice nurses leaving nursing before career establishment (Griffin, 2004). Griffin (2004) postulated that up to 60% of new registered nurses leave their first position within six months related to workplace issues and stress. As student enrollments grow, the pressure on practice environments to create meaningful student clinical experiences increases. Novice nurses may be asked to preceptor student nurses before feeling confident in the nursing care they are providing. Caring for clients with complex health conditions produces high stress levels in RNs with less than one year experience (Craig, 2007). Yet, quality situated teaching and learning of particular cases, with active coaching by engaged faculty, develops the reflective practitioners needed for today‘s complex clients 2 (Benner, 2006; The Carnegie Foundation for the Advancement of Teaching, 2006). Not only is there a shortage of nursing professionals in general, there is a noticeably higher shortage of baccalaureate and graduate-prepared nurses in practice, administration, and research positions (Fang et al., 2007a). Nursing education‘s crisis builds on this contemporary practice workforce supply and demand problem. In the practice settings and as noted above, novice nurses may be asked to mentor novice nursing students while struggling to learn their own role; the academic parallel is that novice faculty is given courses to teach with minimal faculty role preparation (Benner, 2006; Malone, 2007a). Three academic-specific workforce issues that exacerbate the nursing faculty shortage include: (a) overwhelming workload demands (Kaufman, 2007; Malone, 2007a), (b) salaries substantially lower than professional practice peers (Fang, Wilsey Wisniewski, & Bednash, 2007b; Malone, 2007b; National League for Nursing [NLN], 2005a; Rollet & Lebo, 2008), and (c) an aging workforce at the door of academic retirement (NLN, 2005a). As noted, parallels exist between practice and education related to supply and demand issues. There are not enough nursing faculty to prepare RNs to meet practice environment demands (Hornberger, Hess, & Thompson, 2003; Larson, 2006; Valiga, 2002). Nursing faculty workloads are greater than other disciplines in higher education, and both the novice and experienced faculty work long hours each week, adding to the heavy reliance on staff nurses in clinical settings to assist with student learning (Benner, 2006). The shortage of qualified staff nurses and other burdens being shifted to bedside nursing role have added to the complexity of faculty burden, limiting the number of excellent clinical placements for future nurses in need of situated learning environments (Benner, 2006). These multiple and intersecting stressors require 3 clear and purposeful attention to the recruitment and retention of nursing faculty, which is the pipeline to registered nursing preparation. As Dr. Beverly Malone succinctly wrote, ―At this time when the nation faces a looming shortage of both RNs and nurse educators we can ill afford to ignore conditions that have the potential to greatly undermine faculty recruitment and retention‖ (Malone, 2007a, p. A35). The factors stressing academia today are not uniquely different from the nursing shortage in hospital environments of the 1970s and ‘80s (Aiken, Clark, Sloane, Sochalski, & Silber, 2002; Bleich et al., 2003; Cleary & Rice, 2005; Ironside & Valiga, 2007). At the time the Magnet hospital recognition program was originally developed some 25 years ago, the supply of RNs was adequate in spite of the fact that the demand for RNs in acute care settings was still unmet at a 20% vacancy rate (McClure, Poulin, Sovie, & Wandelt, 1983). The Magnet Recognition Program® resulted from hospitals whose ‗Magnet‘ cultures defied those vacancy rates, serving as what Sternin referred to as positive deviants (2002). In recent years the Magnet program has been revitalized and it recognizes organizations whose culture supports the highest level of nursing excellence in health care organizations (Aiken, 2002; Mee, 2006; Morgan, Lahman, Hagstrom, 2006). Worldwide today, more than 280 health-care facilities hold this designation (The Commission on Magnet Recognition Program®, 2007). Ongoing research supports healthier work environments in Magnet organizations. These organizations repeatedly succeed in attracting and retaining well-qualified nurses, at times with slightly lower average salaries and increased benefits (Mee, 2006; Ulrich, Buerhaus, Donelan, Norman, & Dittus, 2007). Research evidence also supported Magnet cultures of excellence improved patient outcomes when the original goal was to create work environments that encouraged and rewarded professional nurses (McClure & Hinshaw, 2002a, 2002b; Morgan et 4 al., 2006). These studies provide support for the importance of exploring culture in high- performance organizations. In September 2003 the NLN Board of Directors approved the National League for Nursing Centers of Excellence in Nursing EducationTM (NLN COE) designation. Similar to the Magnet recognition in the practice setting, the NLN COE designation was designed to support the transformation and recognition of innovative nursing education programs and cultures support risk-taking, creativity, and excellence. (Malone, 2007b) could be acknowledged. This formal recognition and award system is designed to recognize nursing programs seeking an additional level of recognition for their ongoing commitment and work toward excellence and innovation in academic nursing education. The program has seven goals, of which one is specifically related to faculty recruitment and retention, similar to the Magnet outcome. In the first four years of the program eleven schools of nursing achieved this designation. Unlike the Magnet studies in practice, there has been no published research on these nursing programs to date (National League for Nursing [NLN], 2007). Adding pressure to build evidence around academic culture research, the Institute of Medicine (2003) issued Health Professions Education: A Bridge to Quality. This document recommended a ―major overhaul‖ of health professions education, which it states has not remained current with contemporary health care environments. This document stated health professions education ―lacked evidence-based teaching methods and curricula‖ (p. 38). Exemplifying this in nursing is Tanner‘s reference to case study approaches to education not unlike those developed in the 1930s by Goodrich (Diekelmann, Tanner, Waters, & Ironside, 2007). 5 Today, United States‘ universities and colleges are being held to higher levels of accountability. Secretary Spellings (2006), U.S. Department of Education, called to action colleges and universities to create cultures where students succeed at earning a degree in a timely manner. Spellings (2006) based these comments upon data that our nation is falling behind in the percent of college graduates available for employment when compared to other socialized countries in the world. These needs for higher accountability are initiating change; however, it is unknown whether these identified needs for reform have created or will create a sustainable change (Commission on the Future of Higher Education Report, 2006; Basken, 2007). Rahn & Wartman (2007) suggested organized approaches to resolving the health care workforce shortages within colleges, health-science centers, and healthcare organizations at local, regional, and state levels, but stated that the current crisis requires attention at ―our nation‘s highest levels‖ (p. B15). Three Factors Influencing Nursing Education’s Crisis Amidst these multiple and intersecting complex issues, nurse leaders and policy makers are increasingly aware of the importance of the academic environment and nursing faculty issues. Schools of nursing have been asked by policy makers, providers, and others to increase the output of basically prepared registered nurses. The discussion of the nursing faculty workforce shortage described in the next section further will address the magnitude of this problem as a local, regional, and national issue. In addition, it becomes more difficult to recruit faculty in economic markets where demand exceeds supply (Bleich et al., 2003; Cleary & Rice, 2005). Academic nursing administrators and directors, hereafter, referred to as deans, and policy-makers are addressing three critical faculty themes that emerged from the review of the 6 literature: (a) the growing shortage of graduate-educated nurse faculty within expanding clinical placements (Fang et al., 2007b; Larson, 2006; Malone, 2007b), (b) overwhelming nursing faculty workload expectations coupled with salaries below the competitive practice market (Fang et al., 2007b; Kaufman, 2007), and (c) an aging faculty workforce (Fang et al., 2007b). The three problems facing the faculty shortage noted above and the lack of research in recognizing the role of culture-sensitive information about high-performance academic environments provided the platform for this study. To be more explicit, the faculty shortage is well documented as evidenced in the following sections of this chapter. Growing Shortage of Professional Registered Nurse Faculty The current supply and demand of registered nurses in the United States is a shortfall where analysts seem to widen the gap of projected need annually. In 2002, the projected gap for the year 2020 between supply and demand was -29% (Department of Health and Human Services, n.d.; DHHS, 2006). Most recently Stanley, Capers, & Berlin (2007) reported the projected shortfall of registered nurses increasing to 36% by 2020. Since the 1940s nursing has been unsuccessful in increasing the percentages of nurses with advanced academic degrees (4%), within or outside of nursing and at the master‘s or PhD levels (Roberts, 1954, Brown, 1940; Meleis, 1988; Committee on Nursing and Nursing Education, 1983; Spratley, Johnson, Sochalski, Fritz, & Spencer, 2000). In 2008, there are 108 doctoral programs in nursing (Fang et al., 2007a). However, degree completion for these programs remains incredibly low at 12.8% as the age of current students and graduates continues to rise (Fang et al., 2007a). The most recent national RN survey in 2004 again suggested that one percent of the U.S. registered nurses possess an earned PhD and only five percent possess an earned degree at the master‘s level (DHHS, 2006). 7 As stated by Long (2007), ―the development of additional new doctoral programs has not been an effective or efficient strategy for producing more nurses with doctoral degrees‖ (p. 262). The American Association of College of Nursing again supported these findings in the 2006- 2007 annual survey of doctoral nursing programs (American Association of Colleges of Nursing [AACN], 2007b). The numbers of doctoral (research) students have increased over the last five years (+203 average per year change), yet the average per year change of graduates has declined (-1) (Fang et al., 2007a). During the five-year trending of nursing doctoral preparation, an alarming note is that the average age of PhD prepared nurses continues to climb to 55 years, the highest in nursing‘s history (Fang et al., 2007a). Even with the increasing age of PhD prepared nurses, the new PhDs tend to already be in faculty roles and if anything, move out to more lucrative employment when finished rather than remain in academia (American Association of Colleges of Nursing [AACN], 2004). Today‘s nursing faculty shortage is of tremendous societal magnitude as this single aspect of the nursing shortage controls the formal educational opportunities for future registered nurses and graduate nursing students (Fang et al., 2007b; Long, 2007; Stanley et al., 2007). Although the number of graduate programs and types of degrees for registered nurses has grown over the last 50 years in the United States, access to these programs remained limited until the early 21st century with the rapid emergence of learner-centered options such as online, accelerated, and alternative education. While the numbers of master‘s and doctoral prepared nurses within nursing have grown, the percentage of nurses with these degrees has not changed over the last 75 years. Adding tension to this failure to increase the percentage of nurses with terminal degrees in nursing are the growing career opportunities for PhD prepared nurses in 8 clinical and research fields. Layered upon these additional career choices are the attractive corporate and practice income and benefit structures not typically available to academicians. The lack of nursing faculty to teach undergraduate, graduate, and doctoral level nursing students creates pipeline-access problems of monumental proportions. This crisis is well- articulated by faculty members, deans, organizational leaders, and policy activists each noting the often missed but significant factor in educating tomorrow‘s nurses: the growing nursing faculty shortage across the United States (Stanley et al., 2007; Southern Regional Education Board Council on Collegiate Education for Nursing, 2000, 2001; Douglas, 2002; American Association of Colleges of Nursing [AACN], 2003; Bonnel & Starling, 2003; Tri-Council for Nursing, 2001; Hornberger et al., 2005). A major part of this crisis in the United States is the growing nursing faculty workforce shortages. An insufficient number of faculty has been cited repeatedly as a reason for limiting additional new students into nursing programs (Berlin, Stennett, & Bednash, 2003; Hornberger et al., 2005; Stanley et al., 2007). Berlin et al. (2003) reported that 41.7% of responding schools cited nursing faculty shortages as a reason for not accepting all qualified applicants. In Kansas, 92% of private and 89% of public universities reported intent to hire additional nursing faculty in the next three years (Mosbaek, 2007). In addition, to meet the current workforce shortage of qualified applicants and active student enrollments, 65 faculty exceptions were granted by the Kansas State Board of Nursing to assist nursing programs in Kansas with the nursing faculty shortage (Mosbaek, 2007). The national shortage of terminally-degreed nursing faculty prevents the future education of graduate nursing students that, in turn, adds to the already growing faculty shortage in the undergraduate nursing programs. This pipeline access issue is of grave concern to our national nursing education organizations and deans charged with leading nursing education programs in 9 their respective universities and states. This specific concern is so significant that the American Association of Colleges of Nursing (AACN) and National League for Nursing (NLN) are collaboratively recommending support for nursing education workforce development as a high level priority to address the current and impending nursing shortages at all degree levels (American Association of Colleges of Nursing [AACN], 2006a). Responding to this growing crisis, the AACN suggested support faculty and staff qualified to meet the needs of expanding nursing programs are not educated as registered nurses, thus, saving registered nurse faculty for teaching the specialized nursing knowledge in select classroom and clinical experiences (American Association of Colleges of Nursing [AACN], 2003). Overwhelming Nursing Faculty Workloads with Low Average Faculty Salaries in Comparison to Practice Peers Nursing faculty members are expected to perform as expert practitioners, educators, and scholars in the academic environment. In 2005, full-time faculty members worked an average 53 hours per week in comparison to other full-time working Americans at 43 hours per week (Kaufman, 2007; Malone, 2007a). In nursing, the average full-time faculty workload was identified at 56 hours per week by the recent NLN/Carnegie Foundation study, with 44% of faculty surveyed indicating dissatisfaction with this level of workload and at least 25% reporting likely of leaving current position with desire to reduce workload (Kaufman, 2007; Malone, 2007a; The Carnegie Foundation for the Advancement of Teaching, 2006). Adding to workload demand has been the multi-year growth in nursing student enrollment. Not only are faculty to be experts clinically and academically, their classrooms are overloaded with students as programs accept upwards of 25% more students to meet the growing societal need for additional registered nurses. The AACN most recently reported baccalaureate nursing student increases of 7.6%, 10 making 2006-2007 the sixth consecutive year of enrollment gains for baccalaureate nursing education (Fang et al., 2007a). Yet, even with these significant, multi-year enrollment gains for the profession, 38,415 qualified baccalaureate nursing students were not admitted in the 2006- 2007 academic year. This was primarily due to nursing faculty shortages and lack of classroom space (Fang et al., 2007a). These top two reasons continue the trend of 2005-2006 (American Association of Colleges of Nursing [AACN], 2006b) when a total of 42,866 qualified applicants were turned away at all levels of baccalaureate and graduate nursing education (American Association of Colleges of Nursing [AACN], 2007a). Adding to the burden of recruiting faculty, it is often difficult to retain faculty with low pay scales and heavy workloads averaging 53.3 hours per week as reported by the NLN/Carnegie National Survey (Kaufman, 2007). The primary reason for job dissatisfaction was faculty workload, as cited by 45% of respondents in the NLN/Carnegie National Survey: How Nurse Educators Spend Their Time. In addition, one in four nurse educators cited workload as a likely reason they would leave their current job (Kaufman, 2007). The workload concerns of nursing faculty are immersed throughout nursing programs. Adams (2007) reported 63% of faculty respondents in a national study of private accredited colleges and university nursing programs indicated they would not consider academic positions with greater administrative responsibility related to perceptions of heavy workload expectations. Not only is the workload difficult for nursing faculty, historically, nursing faculty salaries have been less than nursing practice salaries (Rollet & Lebo, 2008). Fortunately, there remains a small portion of nurses who felt called to be educators and have chose to work in nursing education despite its low pay. But the opportunities for graduate-prepared nurses are far greater in scope today, and therefore, strain even further the academic environments known for 11 historically low-paying faculty positions (Long, 2007). Previous benefits of faculty positions, such as prestige of academia, scholarship, work load and hours, have eroded away. Competition for clinical agency sites, research careers, and product-development companies aggressively recruit away registered nurses with graduate and terminal degrees. These more lucrative positions did not exist in the profession twenty years ago (Rollett & Lebo, 2008). Thus, recruiting and retaining nursing faculty with graduate degrees is even more challenging given the average levels of administrative (less than $60,000) and faculty salaries ($35,000-40,000 for an academic year) in the Midwest (Fang et al., 2007b). These data also are supported within Kansas by the most recent Faculty Hire and Retention Survey of the Kansas State Board of Nursing (Mosbaek, 2007) where it was reported 33% (6 of 18) of the states private and public pre- licensure registered nursing programs (98% completed survey) reported inability to retain newly- hired full-time faculty with the primary reason being low salary compounded by workload, with retirements and fiscal competition from practice environments up to $25,000 salary differentials. Nursing faculty holding graduate nursing degrees at the assistant, associate and full professoriate ranks on average earn less than practitioners at the supervisor, CNS, NP, director, or administrator levels (Stanley et al., 2007; Fang et al., 2007b; Salary.com, 2007). The gap widens in the smaller Midwest academic programs where staff RNs with associate degrees earn annual salaries equal or greater than nursing faculty or deans (Salary.com, 2007). Fang et al. (2007a & 2007b) reported the lowest full-time academic faculty salaries were $25,000 in 2006- 2007 in a BSN public institution for a master‘s degree-prepared faculty member, $33,913 for an assistant professor in a religious institution for a doctorally-prepared full-time nursing faculty member, and $47,500 for the lowest paid dean in the Midwest. 12 The 2007 NLN/Carnegie Foundation Preparation for the Professions Program data reported 53% of nursing faculty citing compensation as their primary reason for departure from academia within the coming year (Hindering Faculty Recruitment and Retention, 2007). Hiring nursing faculty is becoming increasingly difficult because of low salaries in comparison to practice environment salaries, and this is anticipated to intensify as the supply and demand gap grows (Stanley et al., 2007). Aging Nursing Faculty Workforce Today‘s 2.9 million RNs are an aging workforce with relatively few nurses educated at the master‘s and doctoral levels to lead nursing through its most disturbing workforce shortage (DHHS, 2004). In addition, our workforce is being supplied primarily by associate degree registered nursing programs in both the United States and in Kansas. Current reports from the National Advisory Council on Nursing Education and Practice recommended to the U.S. Department of Nursing that 60% of the RN workforce possess BSN degrees, with some discussion being the need for 40% of our workforce educated at the graduate level. Today, however, approximately 60% of new registered nurses are ADN graduates and 40% are new BSN graduates (Cleary, Boyer, Johnston, & Loquist, 2005). Nearly one-half of the registered nurse workforce will reach retirement age in next 10 to 15 years (Ream, 2007). Buerhaus, Staiger, and Auerbach (2000) suggested the recent increases in nursing student enrollment will not meet the growing shortage of registered nurses, as the aging workforce remains far greater than current upward enrollment trends. Nursing faculty continue to age as well. ―The mean ages of doctorally prepared nurse faculty holding the ranks of professor, associate professor, and assistant professor were 58.6, 55.8, and 51.6 years, respectively. For faculty with master‘s degrees, average ages for professors, 13 associate professors, and assistant professors were 56.5, 54.8, and 50.1 years, in that order (Fang et al., 2007b). In Kansas, the average age of registered nurse nursing faculty is 48.72 years (Mosbaek, 2007). Today, nursing faculty members desiring retirement are being denied or are encouraged to come out of retirement to educate today‘s growing student populations. Kansas private and public universities anticipate 28% of their nursing faculty to retire within the next 10 years (Mosaek, 2007). Valiga (2002) called for increased awareness of another dimension of the nursing shortage that has received ―little attention, and it‘s an impact that can have even more far- reaching consequences….the shortage of faculty to teach in schools of nursing‖ (p.1). In 2002, the NLN Nursing Faculty Census reported two-thirds of nursing faculty will retire within 20 years. The NLN‘s position statement: Mentoring of Nurse Faculty (2006) reiterated this pending crisis in nursing education and the need to design mentoring opportunities for ―early career‖ faculty using evidence-based practices for teaching and learning excellence in nursing education. The desire to address a myriad of issues facing academia is not unique to nursing, as evidenced by the American Society for Quality‘s education criteria (2008), the Academic Quality Improvement Program of the North Central Association of Colleges and Schools of the Higher Learning Commission (2007), the American Association of Colleges of Nursing improvement initiatives (American Association of Colleges of Nursing [AACN], 2006b; Long, 2004), and the NLN‘s (2003) efforts to identify and recognize excellence in nursing education. All of these initiatives support this research study. In addition, nursing education innovation through research has been supported by the National Council of State Boards of Nursing (2006), the Journal of Nursing Education, the Nursing Education Perspectives article by Diekelmann & Ironside (2002), Tanner (2003 & 2004), Diekelmann (2005), Ironside & Valiga (2006b), and 14 Ironside & Valiga (2006c). Valiga (2003) supported the pursuit of excellence in nursing education as an initiative ―to attract and retain outstanding students and faculty and prepare graduates who can provide the leadership needed to improve patient care outcomes‖ (p. 275). There remains, however, a paucity of research to foster understanding of the academic cultures that support high-performance. In spite of the literature‘s support for and contemporary initiatives for nursing education research, we have been unsuccessful in solving these complex and pervasive problems. What is missing from the conversation is a research-based discussion of the factors that constitute the culture in high-performance nursing programs where students and faculty thrive. As a dean, it is easy to quantify that which is highly esteemed in traditional-academic hierarchies: numbers of students, numbers of grants, total numbers of grant dollars, numbers of publications, educational accomplishments of faculty, etc. Conversation, however, is needed to discuss whether these criteria truly define excellence in nursing programs. A scholarly review of the literature will identify organizational culture factors that play a significant role in the creation of high- performance organizations as suggested by contemporary organizational researchers. This will be presented in Chapter 2. While it may seem apparent, the primary research question for this study remains unanswered: What important factors constitute the culture of nursing programs previously determined to be high-performing environments? Relevance of the Current Data to the Problem and This Study Failure to create academic cultures where nursing faculty thrive is a tremendous threat to the nursing profession. The growing professional nursing shortage, particularly faculty shortage, with documented workload and salary concerns, coupled with an aging workforce of highly skilled and articulate personnel present deans and policy makers with a dilemma that deserves 15 immediate scholarly attention. This seminal research will provide information on the factors that contribute and support cultures of excellence in nursing education. Details of identified factors will provide evidence-based information that could help faculty and administrators alike create healthy work environments that, in turn, may inform future faculty recruitment and retention strategies. Developing a better understanding of the cultures that support high-performance nursing programs will add new information to this important and pervasive puzzle. The use of naturalistic inquiry gave the researcher a framework to engage people, places, and things to uncover cultural pillars and/or distractors that influence these high-performing and recognized schools. Research Problem and Its Significance Therefore, the problem exists that little is known about the defining characteristics of high-performance nursing programs. No studies have been published on the NLN COE designee nursing programs‘ defining characteristics at the time this study was initiated. Thus, to develop an understanding of the factors that contribute to the development of high-performance nursing programs that promote positive work cultures for nurse educators, this study proposed to first identify what factors exist through naturalistic inquiry methods. This knowledge will be useful: (a) to initiate the conversation on cultural factors that exist in high-performance nursing programs, (b) to inform key stakeholders interested in excellence in nursing programs, and (c) for future research on excellence in nursing programs. There is a need to better understand the contexts, resources, relationships, values, norms, and partnerships that existed and supported these programs emergence as exemplars in nursing education. No studies were identified during the proposal development and review of the 16 literature review that provided insight into the contemporary context of nursing programs in the collegiate setting. Purpose of the Study The purpose of the study was to discover and define factors that exist in one high- performing nursing program. The study supports conceptual clarification of excellence in nursing education and identifies potentially new factors that create exceptional educational cultures. Nursing literature has been silent on the factors that constitute the culture of nursing programs in higher education. By obtaining knowledge regarding these high-performing nursing education programs, one might be able to improve understanding of what is needed to create higher performance in nursing programs. Research Question The primary research question for this qualitative research study was: What important factors constitute the culture of a nursing program previously determined to be a high- performing environment? Secondary Research Questions Secondary research questions were: 1. What, if any, are the human, material, or other elements/pillars that distinguish this organization? 2. What, if any, distractors challenge or impede the culture, regardless of the high- performance? 3. What, if any, are related outcomes that this high-performing organization experience (i.e., recruitment and retention, student satisfaction)? 17 Assumptions Even though the NLN COE program was designed similarly to the Magnet recognition programs, there has been no work done to determine whether or not faculty salaries, satisfaction, or retention are higher in nursing programs that have achieved this designation. Regardless, it is the only and best designation that academia uses and is justified for the purpose of this study. Based upon this assumption that these are high-performing nursing programs, the sample will consist of one nursing program from either designation that has at least one criterion that addresses faculty recruitment or retention. Definition of Terms Nursing Programs: Formal, academic, programs of nursing education in accredited institutions of higher education. These programs are accredited by the National League for Nursing Accrediting Commission (NLNAC) and/or the Commission on Collegiate Nursing Education (CCNE). Nursing programs educate nurses at the pre-licensure level to be eligible for the NCLEX-RN examination. Nursing programs in this study may educate nurses at additional levels of nursing practice; however, they must include the basic pre-licensure level for preparation to take the NCLEX-RN examination. Stakeholders: Groups of persons who might be affected by the nursing program‘s actions or success, excluding patients. Examples of key stakeholders might include deans, university administrators, nursing program workforce, university workforce, students, community partners, and/or donors. Culture: The context of the nursing program that collectively makes up the work experiences: including values, norms, workload, salaries, resources, relationships, and key 18 stakeholders, celebrations/stories, and metaphors common to the stakeholders of the nursing program or the ―way we do things around here‖ (Deal & Kennedy, 1982). High-Performance Work: (As described by Baldrige National Quality Program, 2008) The term ―high-performance work‖ refers to work processes used to systematically pursue ever-higher levels of overall organizational and individual performance, including quality, productivity, innovation rate, and cycle time performance. High-performance work results in improved service for customers and other stakeholders. High-performance work focuses on workforce engagement. It frequently includes cooperation between management and the workforce, which may involve workforce bargaining units; cooperation among work units, often involving teams; the empowerment of our people, including self-directed responsibility; and input to planning. Also, high-performance work usually seeks to align the organization‘s structure, core competencies, work, jobs, workforce development, and incentives (p. 56). Deans: Academic nursing administrative personnel who are in positions of leadership to create opportunities for change in nursing programs through internal or external influences. Policy Makers: Persons in positions of power, internal or external, who influence factors that impact organizational cultures of nursing programs. Faculty: Teachers of nursing programs at the associate, baccalaureate, master‘s, and/or PhD level of nursing education in accredited nursing programs who meet the state‘s criteria to teach nursing in the academic setting. 19 Students: Persons enrolled in courses of study in nursing programs, progressing toward degree completion, at the associate, baccalaureate, master‘s, and/or PhD level. Sustainability: The nursing program‘s ability to: (a) retain its status as an NLN COE recognition designee more than one, three-year cycle; and (b) congruence between the capabilities and capacities described in the NLN COE submission materials, report, and lived- experiences of the stakeholders. Summary Creating cultures in nursing programs where students, faculty, deans, and staff thrive is critical to the contemporary success of nursing education. Three criteria were identified that are significantly and negatively impacting the recruitment and retention of well-qualified academic nursing faculty. Several of these issues are pervasive and have been documented by nursing scholars for decades. Because of the paucity of research in understanding the norms, values and relationships that exist in high-performing academic programs, selected programs who have achieved this status will serve as potential case studies to develop an understanding of the factors that exist to create and sustain these high-performing nursing programs. This research will provide current and emerging deans, academic nursing stakeholders, and policy makers‘ research knowledge to strengthen academic nursing cultures to address the nursing faculty shortage during a time of explosive enrollment growth. 20 Chapter 2 A Review of the Research Literature A focused review of the literature was conducted to inform this dissertation research. This review of the literature is going to demonstrate that organizational-culture influences organizational effectiveness. Understanding key factors that positively influence academic cultures may result in improved faculty recruitment and retention. The NLN developed a model program calling for excellence in nursing education; however, there remains a paucity of research related to the impacts of this program. Because of this paucity three areas of related literature were reviewed to support this dissertation research proposal. First, the development and subsequent research on nursing practice‘s parallel program of excellence: the American Nurses Credentialing Center‘s Magnet Recognition Program® will be presented. This review documents 25 years of research support for improving recruitment and retention of professional registered nurses in high-performing Magnet status hospitals. Second, the initial NLN COE program foundational work and research, including the initial work leading to the development of the Excellence in Nursing Education Model (Ironside, Perkins, Shultz, Tagliareni, & Valiga, 2006) was reviewed and will be presented as foundational to this study. Third, a contemporary, multi-disciplinary scan of the research literature was conducted to demonstrate the importance of context on outcomes from three different perspectives: business, healthcare, and education. This section of the literature review supports the importance of organizational-culture in creating high-performance organizations. Throughout this review of literature, however, a gap remains. It is the lack of organizational-culture research on nursing programs, specifically high-performance nursing programs. This seminal information will provide valuable knowledge to inform deans and policy 21 makers. It will provide data for decision-making related to improving the recruitment and retention of nursing faculty during this time of documented professional registered nursing shortage, nursing faculty workload concerns and low average salary scales, and aging/retiring faculty. This review of the literature provides detailed and clear support for the proposed naturalistic research study. American Nurses Credentialing Center Magnet Hospital Outcomes Research In the parallel review of the literature of Magnet hospitals, the research results repeatedly supported excellence (as defined by Magnet status achievement) as a means for significantly improving outcomes for patients and registered nurses. The 14 forces of magnetism resulted in criteria to evaluate evidence of excellence in hospital and nursing home organizations with re- occurring themes of cultures of excellence. This was evidenced through improved recruitment and retention of registered nurses across multiple and diverse Magnet status research studies (Hinshaw, 2002; Urden & Monarch, 2002). In 1980, Kramer noted the supply of registered nurses was plenty, yet 80% of hospitals in the United States did not have adequate staffing at that time. Unable to attract and retain competent and experienced professional nurses, Kramer (1980) studied ―magnet‖ hospitals in 1981 to identify the variables in hospital organizations that were able to attract and retain competent and experienced professional nurses, unlike their peer organizations across the U. S. (McClure et al., 1983). The original study was done to discover why some organizations were ‗positive deviants‘ in that they had overcome this staffing problem. In 1981, the original research study of 16 of the original 41 hospitals was conducted. The following criteria were identified as existing in these high-performing organizations: administrative characteristics; management style-quality of leadership, organizational structure, staffing, personnel policies and programs; 22 professional practice-consultation and resources, community and the hospital, nurses as teachers, image of nursing, nurse-physician relationships; quality of care-professional model of care, quality assurance, outcomes; professional development-orientation, inservice education, continuing education, formal education, and career education (McClure et al., 1983). Also noted by Kramer were the importance of the substance and tone of the nurses‘ interviews in these hospitals as they described the elements of the environments of the Magnet hospitals (McClure et al., 1983). The original American Association of Nursing Magnet hospital designation was initiated in 1982. The Magnet program was formally initiated by the American Nurses Credentialing Center (ANCC) in 1991, with the first hospital being designated Magnet status in 1994 (Urden & Monarch, 2002). The four major areas for the standards of excellence included: management, philosophy, and practice; integration of recognized quality improvement standards; support for professional practice; and understanding and respecting cultural and ethnic diversity of patients, significant others, and healthcare providers (McClure et al., 1983). The ANCC established the Magnet program in its current format in 1993 (Cimiotti et al., 2005). As previously noted the first hospital received its designation in 1994, with long-term care facilities added in 1998, and international sites in 2000 (Morgan et al., 2006). Currently, there are fourteen recognized forces of magnetism. These include: (a) quality of nursing leadership, (b) organizational structure, (c) management style, (d) personnel policies and programs, (e) professional models of care, (f) quality of care, (g) quality improvement, (h) consultation and resources, (i) autonomy, (j) community and the hospital, (k) nurses as teachers, (l) image of nursing, (m) interdisciplinary relationships, and (n) professional development (Aucoin & Sweeney, 2006; Morgan et al., 2006; Urden & Monarch, 2002). 23 In 2003, the American Nurses Association‘s Scope and Standards for Nurse Administrators was integrated into the Magnet Status Recognition Program criteria and is retained as foundational to the Magnet Recognition Program® Model (American Nurses Credentialing Center, n.d.). Magnet status recognition exists for hospitals and nursing homes to ―achieve recognition of excellence to nursing practice resulting in positive patient outcomes‖ (Aucoin & Sweeney, 2006). Principles embodied in the Magnet journey include: working with clinically competent nurses, good nurse-physician relationships, support for education, adequate nurse staffing, concern for the patient is paramount, nurse autonomy and accountability, supportive nurse manager manager-supervisor, and control over nursing practice and environment. Much has been published on the processes of achieving Magnet hospital status in the United States (Cox, Carroll, & Sexton, 2005; Ellis & Gates, 2005). While appreciating the process by which organizations have achieved this designation of nursing excellence in hospitals and nursing homes, it is the outcomes research on Magnet facilities that informs the science of nursing practice. Consistently, publications supported the process and perceptions of improved work environments, nurse retention, and improved patient outcomes (Jones-Schenk, 2001; Mee, 2006; Schlag, Sengin, & Shendell-Falik, 1998). In 2006, Kennedy reported 194 ANCC Magnet status hospitals with an average 86% renewal rate. On December 21, 2007, the American Nurses Association press release reported 275 health-care organizations in 45 states and two other countries had achieved Magnet status (American Nurses Association [ANA], 2006; The Commission on Magnet Recognition Program®, 2007). It is the published research upon which the remainder of this section of the literature review will focus. 24 Kramer and Hafner (1989) developed the Nursing Work Index (NWI). This measurement was ―designed to quantify the values nurses associate with baseline Magnet characteristics‖. Kramer and Hafner studied nurse participants from Magnet and non-magnet hospitals to identify relationships between organizational characteristics, job satisfaction, and productivity (1989). Magnet nurses reported greater job satisfaction, the identification of additional Magnet characteristics, and the competence of autonomy (Kramer, 1990; Kramer & Schmalenberg, 1991a; Kramer & Schmalenberg, 1991b). Aiken, Smith, and Lake (1994) continued to research the relationship between outcomes and nursing practice by comparing Magnet and nonmagnet hospitals. Magnet hospitals reported lower mortality and greater patient satisfaction. Magnet attributes were assessed using the Nursing Work Index-Revised (NWI-R) and continued to be identified such as autonomy, control over practice, and positive physician-nurse relationships. The original measurement was the Nursing Work Index (Aiken & Patrician, 2000). Aiken, Havens, and Sloane (2000) conducted a descriptive study in 1998 and surveyed 1064 nurse responders (56% response rate), which included seven current ANCC Magnet hospitals and 13 original Magnet hospitals a decade apart. This survey focused upon job characteristics; job outlook; organizational attributes of the work setting; job-related feelings; and vocational exposure to blood. Results included significantly higher educational preparation in both Magnet hospital groups when compared to the national percentage of baccalaureate prepared nurses (50% vs 34%). The percentage of baccalaureate prepared nurses in the ANCC Magnet hospitals was higher than in the AAN Magnet hospitals. The ANCC Magnet hospitals nurses had significantly less nursing experience and longevity in their current practice environment. The NWI-R measurement was used in this survey. This is a 49 item 4-point Likert- 25 type scale with three sub-scales: nurse autonomy, nurse control over practice setting, and nurses‘ relations with physicians. Results of the three sub-scales were significantly higher for the ANCC Magnet hospital nurses in comparison to the AAN Magnet hospital nurses. Important characteristics supported by the data included: a powerful chief nurse executive, adequate support services, enough registered nurses to provide care, adequate time to discuss a patient‘s care, perception of being greatly appreciated, participation in policy decisions, and greater satisfaction. The original Magnet hospitals have demonstrated substantially improved patient outcomes and supported greater respect for nurses than for those in nonmagnet hospitals. Aiken et al. (2000) reported ―the ANCC‘s Magnet hospital designation process successfully identified hospitals that provided practice environments that were as good as or better than those at the original Magnet hospitals in terms of professional nursing practice and the quality of nursing care‖ (p. 32). In 2000, however, nearly 20 years later, there were only 16 ANCC Magnet hospitals. ―Our research documents that ANCC Magnet hospital designation is a valid marker of good nursing care.‖ (p. 35) and ―Consumers are seeking information about quality__and they trust nurses‘ appraisal‖ (p. 35). ―Over the last 2 decades, there has been considerable study of Magnet hospitals by those interested in understanding the relationship of nurse and patient outcomes to the workforce environment‖ (p. 35). Gleason (2000) studied 40 inpatient units with AIDS patients to examine the effects of unit characteristics on clinical integration. Unit level staffing had a significant level of clinical integration of nursing care irrespective of where the care was provided, whether it was a Magnet hospital, an organized unit, or another type unit caring for AIDS patients. McClure, Paulin, Sovie, and Wandelts (1983) conducted a qualitative survey of directors of nursing and staff nurses who represented Magnet hospitals and identified the 14 forces of 26 magnetism that are currently known today. Lake (2002) furthered this work by conducting a factor analysis, resulting in a 48-item measure, the Practice Environment Scale (PES). This scale has been used extensively in nursing research and revised as a result of ongoing data analysis. Upenieks (2002) studied 305 clinical nurses at two Magnet hospitals and two nonmagnet hospitals using a convenience sample of matching institutions. Sixteen leaders employed at these hospitals were included in the study. This research included mixed methodologies: qualitative leadership interviews and the Revised Nursing Work Index (NWI-R) for clinical nurses. The nursing leadership interviews supported previous work on Magnet characteristics, including visible nurse leaders, autonomous decision-making, support of a professional nursing climate, and adequate staffing in the workforce. Continued support for greater retention and lower turnover rates at Magnet hospitals was affirmed. Using the NWI-R, Magnet hospital mean scores were statistically significantly different on total scale scores (magnet M = 143.75; nonmagnet M = 125.33; t = 6.02; P < .001) and with all subscales where organizational structure resulted in the greatest mean difference .53 (magnet M = 2.93; nonmagnet M = 2.40; t = 9.049; P < .001). The additional five subscales statistically significant mean differences included: control, autonomy, self-governance, new programs, and physician relations. Qualitatively, the Magnet hospitals‘ nurse leader interviews supported ―clinical nurses as the most essential component of a successful professional organization‖ where nursing is recognized and highly valued. Leadership was perceived to be ―passionate about nursing, supportive, loyal, highly respected throughout the organization, inspiring, knowledgeable, consistent, fair, visible, and responsive‖ (p. 570). Additionally, adequate staffing was essential for retention, autonomy was highly valued, participatory management strategies, 27 interdisciplinary synergistic, respectful healthcare environments, and adequate monetary rewards were acknowledged as central characteristics of the Magnet hospitals. In 2003, 65 hospitals were the subject of Magnet status outcomes. Jolly & Donohue (2003) supported Magnet status‘ positive impact on recruitment and retention of registered nurses. In these hospitals, turnover rate was 2% when national average was 20%. In addition, 93% of new graduates remained employed at two years and 53% who did leave, returned within one year. Upenieks (2003) researched Magnet and nonmagnet hospitals to determine whether ―Magnet hospitals are still able to provide higher levels of job satisfaction and empowerment among clinical nurses in today‘s health care setting‖ when compared to nonmagnet hospitals (p. 84). Using the same sample noted in the previous study, Upenieks further investigated the quantitative results of the NWI-R and the revised Conditions of Work Effectiveness Questionnaire (CWEQ-II), which is a 20-item, four subscale measurement. The order of ranking the subscales between the two instruments were similar as noted above. Subscales with statistically significant differences between the magnet and nonmagnet hospitals were empowerment (magnet M = 3.55; nonmagnet M = 2.63; t = 8.559, P < .001) and power (magnet M = 3.16; nonmagnet M = 2.70; t = 6.015, P < .001). Another team of researchers used the NWI-R to further understand critical care nurses‘ perception of their work environment (Choi, Bakken, Larson, Du, & Stone, 2004). The Perceived Nursing Work Environment (PNWE) measurement was developed from the NWI-R as a result of this study. This measurement has one additional subscale: a positive scheduling climate. This was perceived as a positive factor of the work environment of hospitals. (Cimiotti et al., 2005). 28 Kramer and Schmalenberg (2005) continued to support the eight themes associated with staff nurses perceptions‘ of giving quality care in a Magnet hospital. The themes were: (a) working with other nurses who are clinically competent, (b) good nurse-physician relationships and communication, (c) nurse autonomy and accountability, (d) supportive nurse manager/supervisor, (e) control over nursing practice and practice environment, (f) support for education, (g) adequate nurse staffing, and (h) concern for the patient is paramount (Aiken, Sloane, Lake, Sochalski, & Weber, 1999; Kramer & Schmalenberg, 2002, 2003, 2004; Upenieks, 2002, 2003; Laschinger, Almost, & Tuer-Hodes, 2003). Burke (2005) reported improved RN-MD relationship scores between 2002 and 2003 on the American Nurses Association's National Database of Nursing Quality Indicators® nurse satisfaction survey as an outcome of developing interdisciplinary collaborative models of care. Unit councils were implemented and allowed to mature resulting in ―no floating‖ programs. Departmental unplanned earned time off has steadily declined each month since implementation of the unit councils (Burke, 2005). In 2005, Cimiotti et al. studied 2,323 nurses in 110 coronary care, medical, surgical, or medical-surgical intensive care units of 68 Magnet certified, applying for Magnet certification, and nonmagnet certification hospitals throughout the United States. Each institution collected infection control data using the National Nosocomial Infections Surveillance System definitions. The surveys were completed over a six-month period in 2002 and 2003. The 42-item Likert scale, PNWE, and nine demographic items were used for data collection. The results of this research did not support the larger body of research outcomes supporting nurses‘ perceptions of satisfaction in Magnet status hospitals. Only perceptions of nursing competence were 29 significantly different in the three types of hospitals. This may be due to the study‘s inclusion of only ICU nurses or that the characteristics of Magnet hospitals have changed over time. Friese (2005) conducted a secondary data analysis on 1956 RNs in 302 oncology units in 22 hospitals, in which seven were Magnet hospitals. The Practice Environment Scale (PES) of the Nursing Work Index (NWI) was used to compare nurses in Magnet and nonmagnet status hospitals. Superior outcomes were noted when oncology nurses were compared with non- oncology nurses in Magnet facilities. Emotional exhaustion was reported as significantly lower among oncology nurses working on units in the Magnet hospitals. Friese (2005) supported the importance of practice environments (culture) to improve job satisfaction and retention. Goode et al. (2005) referred to Magnet recognition as the ―gold standard‖ to improve patient outcomes and compete for scarce RN resources by creating optimal work environment (cultures) for nurses. Their lived experiences of becoming a Magnet hospital supported previous research regarding the importance of context in creating high-performing organizations. Simply creating good structures-processes-outcomes did not create positive results unless the cultural context is a deeply woven part of the structures-processes-outcomes of the organization. Mee (2006) reported in a convenience sample of Nursing 2006 readers that RNs and LPNs working in Magnet hospitals tended to earn slightly less income. Also, key benefits were consistently higher at the Magnet facilities: pay differential for BSN, charge nurse differential, tuition reimbursement, reimbursement for continuing-education activities, conference, and travel fees, flexible scheduling, child care, and retention bonuses. ―Magnet hospitals have been well documented as providing a very positive work environment for nurses. This, along with good benefits, may offset the salary shortfall‖ (p. 51). 30 Rondeau and Wagner (2006) designed a survey that was completed by 125 directors of nursing from 300 nursing homes in western Canada with greater than 35 beds. Cronbach coefficient alphas ranged from .68 to .87 for four subscales on: Magnet strength, high involvement work practices, nurse satisfaction, resident satisfaction, and progressive decision making. Nursing homes that demonstrated strong Magnet characteristics were more likely to have higher levels of nurse and patient satisfaction. Magnet status homes were more likely to have participatory decision-making cultures and significant investment in job-related training for nursing staff. Upenieks and Abelew (2006) interviewed 12 nurse leaders and 12 registered nurses at two hospitals regarding the Magnet designation process to identify whether cultural shift within the organization occurred while seeking Magnet designation. Donabedian‘s conceptual framework (structure, processes, and outcomes) was used for this study. The purpose was to better understand the process of preparation and whether a cultural shift occurred during the process of working toward meeting Magnet status designation. There were two key qualitative questions: ―(a) What structures were implemented to achieve the 14 forces of magnetism? and (b) What processes were being implemented to achieve the 14 forces of magnetism and create a magnet culture?‖ Deductively, three structure factors were noted in these interviews: (a) a genuine loyalty toward the nursing profession, (b) adequate staffing and compensation, and (c) continuing education/clinical ladders. Five process factors were noted in the interviews: (a) shared governance, (b) collaborative teamwork (yet none of the committees had included nurses and physicians to address this cultural change), (c) evidence-based practice councils, (d) information sharing regarding Magnet status and its relationship to promoting nursing excellence, and (e) staff nurse engagement. Inductively, technology or creating efficient work 31 environments was key to ―Magnet work environment‖ structurally. Patient-centered care and mentoring of new graduates were key operational influences in striving for Magnet status cultures. Ulrich, Woods, Lavandero, Leggett, & Taylor (2007) studied nurses in intensive care environments with and without Magnet status, with and without Beacon status, an excellence designation for intensive care units (see p. 47). The results provided compelling support that the pursuit and achievement of excellence does make a difference in nurses‘ perception of the health of their work environment and perceived satisfaction with their profession and work compared with other nurses. In 2007, the ANCC‘s Magnet Recognition Program® web site, showcased benefits of Magnet recognition. These included: consistent out-performance to nonmagnet organizations, better patient outcomes, increased staff time at bedside, shorter lengths of stay, lower mortality rates, lower incidence of needlestick injuries, consistent ability to attract and retain registered nurses, lower burnout, increased job satisfaction, and higher patient satisfaction (American Nurses Credentialing Center [ANCC], 2007; Hinshaw, 2002). Transforming Nursing Education: NLN Centers of Excellence in Nursing EducationTM History and Founding Research Over the last quarter century, many individuals and organizations have repeatedly challenged nursing scholars to advance the science of nursing education toward meaningful transformation, not simply to just re-shuffle content as historically taught in nursing education (Billings & Haber, 2005; Diekelmann & Ironside, 2002; National League for Nursing [NLN], 2005b; Stevens & Valiga, 1999; Valiga, 2003). Among those who have acted upon this concern is the NLN. This has been accomplished through the development of three national-level 32 demonstration programs: Open Curriculum Project, Curriculum Revolution Project, and most recently the NLN Centers of Excellence in Nursing EducationTM Program (National League for Nursing [NLN], 1988; National League for Nursing [NLN],1989; National League for Nursing [NLN], 1990; National League for Nursing [NLN], 1991; National League for Nursing [NLN], 2006a; Notter & Robey, 1979). Designing a model similar to Magnet Hospital designation, the NLN created its newest program, NLN Centers of Excellence in Nursing EducationTM in 2003. This relatively new program is growing at a rate faster than the original ANCC Magnet Status program. There remains a paucity of research on this program‘s designees to better understand the culture of these high-performance organizations. To date there have not been any other studies published or recognition programs in the academic sector that have identified high-performing nursing program cultures. The NLN Board of Governors Nursing Education Advisory Council Executive Committee in 2001 was commissioned to develop a national program to highlight excellence in nursing education (Ironside, 2005). As a result, a qualitative study of nursing students, teachers, and clinicians across levels of nursing education explored common experiences and shared meanings of excellence. Two themes emerged: working together and learning together. Working together was further delineated as ―creating new partnerships between and among teachers and students‖ while learning together was further delineated as ―creating excellence in shaping the future of nursing education through enacting new pedagogies‖ (Ironside, 2005, p. 78). The study participants were guided to sharing experiences of excellence rather than definitions of excellence. 33 Diekelmann (2001) suggested similarly that ―concernful practices‖ occur when teachers, students, and clinicians experience learning together in partnerships. Diekelmann (2001) identified concernful practices as: (a) gathering: bringing in and calling forth; (b) creating places: keeping open a future of possibilities; (c) assembling: constructing and cultivating; (d) staying: knowing and connecting; (e) caring: engendering community; (f) interpreting: unlearning and becoming; (g) presencing: attending and being open; (h) preserving reading, writing, thinking, and dialogue; (i) questioning: meaning and making visible; and (j) inviting: waiting and letting be. Creating these new academic spaces for learning has been titled ―narrative pedagogy‖ where the classroom becomes community to reflect contemporary nursing practice for teachers and students. This community building served to diminish feelings of isolation and competition for both students and teachers (Ironside, 2005). ―Narrative pedagogy calls attention to engendering community and caring practices that address isolation and competition,‖ according to Ironside (2005, p. 82). She continued with, ―Perhaps excellence is present in schools of nursing that look for and challenge these often overlooked assumptions and commit themselves to constant improvement in learning relationships, using new pedagogies to create new ways for teachers and students to work together‖ (Ironside, 2005, p. 82). The second major theme was learning together. This theme is further delineated by describing how we learn together through our own and others‘ stories related to the content being covered in the classroom. The questioning, dialogue, and attending to others significantly shift thinking together as a community, such as in the nursing practice environment. This 34 collaborative thinking moves learning from being an isolated, competitive process toward creating communities of practice (Ironside, 2005). Ironside (2005) suggested the opportunity for developing collective wisdom of nursing education through use of the Magnet or charter school approach that rewards the ongoing pursuit of excellence through research based programs of innovation across nursing education. This approach transforms nursing education‘s history in that individual school‘s reform efforts would be celebrated with national recognition through a diverse but single program recognizing and achieving excellence in nursing education. Thus the NLN COE recognition program was formed in 2003 with approval of the NLN Board of Directors (Appendix A). The seven goals of the NLN COE program are: (a) Identify and reward those schools that excel in creating environments that enhance student learning and professional development, promote the pedagogical expertise of faculty, or advance the science of nursing education; (b) encourage faculty to continually improve their schools; (c) encourage research in nursing education; (d) facilitate discussions among faculty, students, program graduates, and employers about excellence in nursing education and how to promote it; (e) encourage the development of innovative schools that attract and retain highly qualified students and faculty; (f) facilitate positive changes that re-form nursing education based on the application of evidence gleaned from research in practice and education; and (g) influence the development of public policies that benefit nursing education, support nursing education research, and promote excellence in nursing education (NLN, 2007). 35 The NLN COEs provide public recognition for nursing programs‘ achievement of higher standards, commitment to continuous quality improvement, sustained evidence-based and substantive innovation, and ability to attract and attain higher quality students and faculty. The NLN COE designation is for a three-year period of time where the program has successfully demonstrated excellence in all nursing programs offered at the institution. This designation is awarded to schools of nursing that successfully demonstrate excellence in creating environments (cultures) that: (a) enhance student learning and professional development, (b) promote the pedagogical expertise of faculty, and/or (c) advance the science of nursing education (NLN, 2005b, p. 1). The program is designed to create recognition for nursing programs that serve as models for academic excellence (NLN, 2005b, p. 3). The program is in addition to program accreditation by the National League for Nursing Accreditation Commission (NLNAC) or Commission on Collegiate Nursing Education (CCNE). In 2004, three nursing programs received this recognition; in 2005, four nursing programs received this recognition; and in 2006, three nursing programs received this recognition. During 2007, three nursing programs received continuing NLN COE designation, as their three-year recognition was scheduled to expire, and there was one new school to achieve this designation. In 2008, two nursing programs received continuing NLN COE designation, as their three-year recognition was scheduled to expire, and four new schools achieved this designation. (Appendix B). Organizational-Culture in High-Performance Organizations Improving quality and performance in organizations has been the subject of scholarship, research, and published literature. Kramer (1974) discussed the oppressive culture of nursing practice more than 30 years ago. Most recently, Bartholomew (2006) stated, 36 ―Culture is critical in addressing nurse-to-nurse hostility in both our clinical and academic settings…interpersonal conflict has a direct negative impact on intragroup work satisfaction and will be significant as nursing addresses its impending practice and academic shortages in the next few years‖ (p. 14). Geertz (1973) studied cultures and suggested that cultures are a system of shared symbols that enable or give meaning and form to human experiences. He discussed in his work that cultures are context that can be intelligibly and thickly described. Analyses of webs of interactions are interpreted and assist humans in search of meaning, to clarify what goes on in places. Geertz (1973) suggested culture is public, patterned conduct. It is what it is and what is done. In other words, understanding culture as knowing what would make it possible to pass as a native (Geertz, 1973, p. 11). Whereas, E. H. Schein (1992a) defined culture as ―pattern of shared basic assumptions that a group learned as it solved its problems of external adaptation and integration, that has worked well enough to be considered valid and therefore taught to new members as the correct way to perceive, think, and feel in relation to those problems‖ (p. 12). Organizational-culture has been discussed in depth by Deal & Kennedy (1982), Bolman & Deal (1984, 1991, 1994, 1999, 2003, 2008 & Schein (1992a, 1992b). Bolman & Deal (2003, 2008), in Reframing Organizations, discussed culture as both a product and process that becomes accumulated wisdom renewed and re-created over time. Culture is how the methods in which old ways are learned and newcomers become teachers. Organizational cultures then, include beliefs, values, patterns, stories, celebrations, symbols, and artifacts that provide meaning for the organization and its stakeholders. 37 Bolman & Deal (2003, 2008) subsequently identified four worldviews or lenses of people within organizations. These frames or perspectives include: structural, human resource, political, and symbolic. As organizational leaders these perspectives provide references for sense-making the different worldviews of people within organizations. Bolman & Deal‘s (1991) research- supported leaders were more effective when able to engage more than one frame of reference. While their work has been completed in organizations, it is supported through the social science literature language of schemata, maps, representations, and/or paradigms. The structural frame is focused upon goals and efficiency through policies, rules, and chain of command. The human resource frame is focused upon meeting the human needs of the organization through facilitation and empowerment. The political frame is focused upon conflict and competition for scarce resources where networking, coalitions, and negotiating power bases are valued. In the symbolic frame cultural symbols provide for the shared mission and identity of the organization through commitment and charisma in which meaning is interpretive rather than objective. In 1988, Donabedian proposed a linear process to improve quality in organizations through the use of structure, process, and outcome measures. Using this framework and logic, implementation of structure characteristics/factors, such as adequate staffing, compensation, continuing education, and organizational framework would then support adequate process characteristics/factors, such as continuity of care, models of care delivery, interpersonal management. These factors in turn would subsequently increase the likelihood for good outcomes: a ―high-performing‖ culture. Donabedian‘s work was applied to hospital organizations and Magnet designation work implementation (Upenieks & Abelew, 2006) as a framework for creating culture change during Magnet hospital designation preparation. The authors, however, noted the importance of staff engagement at all levels of the organization and 38 the importance of a culture shift that was needed to transform their organization to Magnet status, beyond the linear structure, process, and outcome factors as suggested by Donabedian in 1988. Nelson et al. (2002) discussed the importance of microsystems‘ conditions to improve quality and value that are appreciated by patients and impacts that excite front-line staff who serve these patients. In this Joint Commission on Accreditation of Healthcare Organizations research, nine success characteristics were suggested from qualitative and quantitative content data analysis of 20 high-performing, diverse, healthcare organizations: (a) leadership, (b) culture, (c) organizational support, (d) patient focus, (e) staff focus, (f) interdependence of care team, (g) information and information technology, (h) process improvement, and (i) performance patterns. Two practical early steps were suggested: (a) build self-awareness by doing self-assessments within individual microsystems and (b) leaders take action to ―grow‖ microsystems‘ capacity for improvement. VanDeusen et al. (2007) suggested sustainable organizational transformation spreads over time following a longitudinal case study evaluation study of 12 health care systems using mixed-methods design. Key elements of organizational transformation to deliver high-quality patient care were identified as: (a) leadership; (b) improvement initiatives; (c) alignment from top to bottom; (d) integration across boundaries; (e) mission, vision, strategy, priorities; (f) culture, values; (g) infrastructure; and (h) organizational functions and processes. The Beacon Award for ExcellenceTM was developed in 2003 by the American Association of Critical-Care Nurses. This is an annual award supporting healthy work environments for critical care practice areas. This award includes 42 criteria in six categories: (a) innovation/excellence in recruitment and retention; (b) education, training, and mentoring; (c) 39 evidence-based practice and research; (d) patients‘ outcomes; (e) creating and promoting healing environments; and (f) leadership and organizational ethics (American Association of Critical- Care Nurses [AA-CCN], 2007). In another effort to improve quality and outcomes in organizations, the Baldrige Awards for Excellence were developed by President Ronald Reagan. The 2008 Baldrige National Quality Program Criteria include seven categories: (a) leadership; (b) strategic planning; (c) customer and market focus; (d) measurement, analysis, and knowledge management; (e) workforce focus; (f) process management; and (g) results. Each of these categories has subcategories and criteria that further explain what is expected to achieve this recognition of excellence at the national level. Between 1999 and 2006, seven academic institutions had received this excellence designation through the Baldrige Awards for Excellence initiated by the Malcolm Baldrige National Quality Improvement Act of 1987 – Public Law 100-107. The foci of these awards were improved outcomes, improved employee retention, support blameless processes for continuous quality improvement, and minimize waste (www.asq.org). The criteria also have been adapted for state and local quality award programs. Today categories exist for manufacturing, service, small business, education, health care, and nonprofit organizations. This is not, however, a nursing specific designation. Through 2006, 71 award recipients had been selected across the five categories (Baldrige National Quality Program [Baldrige], 2008; CC-M Productions, Inc., 2006). In July 1999, the Academic Quality Improvement Program (AQIP) was launched, with a grant from the Pew Charitable Trusts, to infuse ―the principles and benefits of continuous improvement into the culture of colleges and universities by providing an alternative process 40 through which an already-accredited institution can maintain its accreditation from the Higher Learning Commission‖ (The Higher Learning Commission, 2007). Underlying the principles of AQIP is a deep desire of these academic institutions to improve their performance by excelling as a high-performance organization. Based upon previous organizational research, the common principles included: focus, involvement, leadership, learning, people, collaboration, agility, foresight, information, and integrity. The nine AQIP categories include: helping students learn, accomplishing other distinctive objectives, understanding students‘ and other stakeholders‘ needs, valuing people, leading and communicating, supporting institutional operations, measuring effectiveness, planning continuous improvement, and building collaborative relationships. Within the leading and communicating category are descriptors of high-performance organizations consistent with the Baldrige descriptors. AQIP institutions seek to permeate these principles and values to improve the entire organization. Within each of the nine categories of AQIP, colleges and universities consider: the context, processes, results, and improvements on an annual basis (Academic Quality Improvement Program, 2005; Spangehl, 2000). NLN developed a Model for Excellence in Nursing Education in 2005. The eight major criteria in this model include: (a) student-centered, interactive, innovative programs & curricula; (b) recognition of expertise; (c) clear program standards and hallmarks that raise expectations; (d) well-prepared faculty; (e) qualified students; (f) well-prepared exceptional administrators; (g) evidence-based programs and teaching/evaluation methods; and (h) quality and adequate resources (NLN, 2006a). 41 Discussion Conducting a review of the literature of high-performing nursing programs presented challenges:(a) paucity of research; (b) lack of clarification between environment, context, and culture; and (c) multiple confounding factors that influence nursing programs‘ performance and what constitutes performance. Relative to this study is the emerging literature that supports the significance of culture in relation to organizational effectiveness. Magnet status hospitals were the positive deviants of the 1970s and ‘80s, as researchers attempted to understand how to improve the culture of hospital organizations when registered nurses were plentiful in supply and hospitals were unable to attract or retain this professional workforce. Subsequently, through the emergence of Magnet recognition, patient outcomes have improved, along with improved recruitment and retention of professional registered nurses and their professional relationships with physicians in hospitals. In the Magnet hospital research studies, the data supported key concepts of high-performance cultures: administrative leadership, staffing support, professional practice environment, and professional development opportunities. While the work of Geertz, Schein, Kennedy, Bolman, Deal, and Donabedian support the importance of understanding organizational-culture and factors that influence the high- performance; factors that support high-performing nursing programs are missing from this dialogue. No published research was found that studied the cultural factors associated with organizational performance in nursing programs. Multiple search terms were used to review the literature without success. Thus, there remains a paucity of research in relation to the factors that exist in these high-performing nursing programs. This research study used naturalistic inquiry case study research methodology to identify factors that constitute the culture of one high-performing nursing program. Due to the paucity of 42 research in this area, it was the intent of this study to begin to identify what factors exist, and to provide a detailed description of the identified factors. If possible, existing frameworks of high- performing organizations, such as those previously discussed in this review of the literature, will be considered for congruency with factors that emerge from the data collection and analysis. Potential information related to the successful recruitment and retention of nursing faculty may emerge to assist deans and policy-makers in solving the faculty problem in nursing programs. Summary A focused review of the literature was conducted in three related areas to this dissertation proposal:(a) nursing practice‘s parallel program of excellence: ANCC‘s Magnet Recognition Program® outcomes research, (b) the emerging work of nursing program of excellence: NLN COE program, and (c) a concept review on the influence of culture in organizational effectiveness and outcomes. In summation, the Magnet program research supported its ability to recruit and retain professional registered nurses for more than 25 years, multi-disciplinary research and frameworks support the importance of organizational-culture (context) in creating high-performance work in education, business, and health care; and nursing education has recently launched a program to support excellence in nursing programs. No studies were identified in the last 25 years that studied the contextual factors or culture of nursing programs at any level of nursing education; therefore a significant gap remains in academic nursing knowledge related to creating high-performing nursing programs. This research will do much to begin the important dialogue of factors that constitute the culture in high-performing programs. 43 Chapter 3 Case Study Research Naturalistic Inquiry Qualitative research designs are of the post-modern era (Denzin, 1989). In the naturalistic paradigm, reality is perceived as complex, constructed, and subjective interaction with the researcher and subject of inquiry. Truth is best achieved by entering into the natural environment naively (Lincoln & Guba, 1985). Entry into the natural environment provides a point for starting rather than a planned and detailed blueprint. The research design for this study was naturalistic inquiry. The emergent design of naturalistic inquiry was to select informants when little is known about the phenomena. Use of naturalistic inquiry was a particularly appropriate research design because of the paucity of research related to identifying factors that constitute the culture of high-performing nursing programs. Study Population and Case Study Selection The NLN Center of Excellence in Nursing EducationTM designees provided a rich naturalistic research setting to develop an understanding of cultures in previously identified as high-performing nursing programs. The NLN COE designees served as the population of nursing programs for this study. These COE nursing programs received national recognition at the 2004 – 2007 NLN Education Summit Conferences for excellence in one of three areas:(a) Creating Environments that Enhance Student Learning and Professional Development, (b) Creating Environments that Promote the Pedagogical Expertise of Faculty, and (c) Creating Environments that Advance the Science of Nursing Education (NLN, 2003). The potential study population included 11 U.S. nursing programs. Programs that achieved the NLN COE designation in the category Creating Environments that Advance the 44 Science of Nursing Education were excluded as this category‘s criteria does not explicitly address faculty recruitment or retention. Therefore, 10 nursing programs were potential sites. Selection criteria for the case study school included five publicly accessible factors. These factors were: nursing program degree offerings; institution and nursing program size, including numbers of faculty, nursing students, and locations; accreditation cycle and status; national examination results; potential student accessibility, evidence of filled program administrative positions, designation cycle, and any other significant status change. Web sites for the institutions, NLN, NLNAC, and CCNE and state boards of nursing were utilized to gather this data. This information was placed into a database for final selection of the case study nursing program that would most likely: (a) provide breadth and depth of access to answer the research questions, and (b) match the researcher as instrument to the case study nursing program. The selection decision was made. One NLN COE nursing program was included in this case study research using naturalistic framework as described by Anderson, Crabtree, Steele, & McDaniel (2005); Creswell (1998); Lincoln & Guba (1985); Mariano (2001); & Patton (2002). The sample selection criteria were designed to increase the likelihood of obtaining a ―thick description‖ during data collection as described by Ryle, 1949 and Geertz, 1973. The case study nursing program selected provided the opportunity to obtain a thick and rich description of a high- performing nursing program. The case study nursing program was selected for the following reasons: (a) multiple levels of nursing degrees offered, (b) traditional campus with the possibility of other locations, (c) national examination results, (d) accreditation and designation status stable through data 45 collection, (e) leadership positions filled and no faculty openings, although with an interim dean, (f) a medium sized nursing program. Data Collection To gain access, the researcher initially contacted the nursing program‘s dean. Access was granted following a brief presentation to the nursing program‘s internal decision-makers and approval of the requisite human subjects‘ requirements for the nursing program and the researcher‘s academic institutions. After receiving written consent, the immersion experience began. In this phase of the study, the researcher came to know the case study nursing program, understand the researcher as instrument, and collect data in three major areas: observations, interviews, and artifacts. Case Study School Setting The case study school was a master‘s comprehensive university with an average student to faculty ratio of 14:1. This private university provided nursing courses at one large campus, an adult education campus, and multiple off-campus locations with a pre-licensure BSN program and several MSN tracks. The student population of this institution was approximately 60% undergraduate and 40% graduate. The university was ranked in the top 25% of academic institutions of similar type and size; and very high in economic and ethnic diversity as well. More than 80% of the university faculty was prepared at the terminal degree or highest degree level for their discipline as identified on the institution‘s internet web site. The nursing faculty was prepared with diverse terminal degrees: PhD, DNS, DNP, PsyD, and EdD. Over 54% had earned terminal degrees and an additional 23% were in terminal degree programs during this study. 46 While the types of nursing degrees offered have changed over its history, the essential philosophy and mission have remained stable. The nursing program continued to innovate to meet the profession‘s emerging demands. Students are prepared for professional nursing roles in these programs: pre-licensure RN, including LPN to BSN bridge; RN-BSN; Family Nurse Practitioner [FNP] (MSN); and Clinical Nurse Leader (MSN). The pre-licensure program admits approximately 40 students every fall and spring semester. RN-BSN students and MSN students are admitted every fall and spring as well. There is no limit on the RN-BSN program enrollments as long as the student is admitted to the institution and qualified for acceptance into the program. The nursing program had more than 300 undergraduate students and over 100 master‘s students enrolled during data collection in part because pre-licensure students are admitted as freshmen into the nursing program. The nursing core begins in the third semester and is a five semester curriculum. The nursing program had three full time administrative leaders, with six additional full- time nursing faculty assuming part-time administrative leadership positions, such as to coordinate undergraduate clinical placements or graduate clinical preceptorship sites and to assist the dean with special projects and scholarship activities of the nursing faculty. During data collection there were approximately 30 full-time nursing faculty, additional adjunct clinical faculty, five nursing program administrative assistants, and work-study students also employed at this nursing program. Researcher as the Instrument In this qualitative study, the researcher was the instrument who immersed self into the natural setting for a prolonged period of time. This process included getting in, staying in, and getting out as described by Goffman in 1959. The researcher took in both that which was 47 observed and that which was not observed in creating meaning of the time, space, relationships, voice, and corporeal experiences. This immersion experience as described on page 58 was long enough to build trust within the contextual setting and maintain sensitivity yet be sensitive to issues of over rapport and premature closure as described by Lincoln and Guba (1985). In preparation for entering the field for this qualitative naturalistic study, the researcher previously completed the Health Professions Educator Certificate Program at the University of Kansas, two qualitative doctoral research courses, and conducted a qualitative research practicum evaluating two high-performing and two low performing nursing homes that resulted in a published manuscript (Forbes-Thompson, Leiker, & Bleich, 2007) and six qualitative research paper/poster presentations. Personal participation at the NLN Education Summit for five years assisted in preparing for this case study research. These educational offerings provided the researcher opportunities to interact with project management staff of the NLN COE program, gather public NLN COE documents, and listen to NLN COE nursing program presentations (Benedict et al., 2005). The public presentations of the awards, informal convention communication, and dialogue during mandatory sessions with doctoral scholar advisors provided additional information about the program‘s development, goals, categories, designees, and continuous quality improvement plans. The data collection process was conducted with an open sense of attentive awareness on the part of the researcher. During these immersion visits the researcher was attentive to observing and listening during individual and group interviews, social networking, and informal interactions. Entering the field was completed with initial observations of the nursing program‘s settings, including creating drawings, obtaining campus maps, gathering and reviewing artifacts and public documents. 48 Trust was gained as the researcher moved from being an outsider to becoming an insider. Trust began during the first immersion visit and was confirmed during the third immersion visit to the nursing program. This trust was maintained throughout the immersion experience. The interview guide provided the introductory open-ended statements to initiate the interview process (see Appendix C). These statements were explored during the formal individual and group interviews. The intent of this naturalistic inquiry was to allow the data to guide the researcher through an inductive process of sense-making. As a result the interview guide served as an opening guide for each interview and focused around the participants‘ roles and contributions within the nursing program. As the interviews were conducted previous interviews informed the next interview and follow-up interviews (See Appendix D). Spradley (1980) suggested the researcher psychologically and physically assimilate into the context, by making the familiar strange and the strange familiar. Therefore, the data collection process included a prolonged period of immersion of one nursing program with 30 days of observations, interviews, meetings, and public, events, data collection and immersion. In addition, two immersion visits of four days to the NLN were a part of this study to review the final written submission document of the case study nursing program. It was the prolonged experience where the researcher came to know the case study nursing program setting and understood the meaning of field research and bringing closure to qualitative study. The Field Experience The immersion experience began with multiple general observations; followed by specific observations in classrooms, meetings, and events; and formal interviews. While different, the four on-site visits to the nursing program were intensely immersion-oriented. The first visit was to initiate the study and observe while the second visit was to observe and attend 49 major end of academic year events and read major nursing program documents. Immersion visits three and five were extended periods of time for observations, interviews, and reviewing of artifacts. The two immersion visits to the NLN were to review the case study nursing program‘s comprehensive submission report with appendices and exhibits; and to interact with the NLN COE personnel. Informal interviews occurred throughout the immersion experience to enhance understanding of the NLN Center of Excellence program process and designation. Observations. As much as possible, participants were observed in a variety of settings: classroom; laboratories, including clinical and simulated; meetings; and gathering spaces for students and faculty, such as meeting rooms, classrooms, offices, hallways, and gathering spaces throughout the nursing program area. These observations occurred during each immersion visit. A log of the observations by immersion visit is located in Appendix E. Informal participants included persons in public-access areas of this institution; students in classrooms, break-rooms, and study areas; and other people on the campuses and on-site during observation periods. Spontaneous and naturally occurring conversations in public access areas during observations were considered potential data for purposes of this study. Members of the community were observed indirectly during the extended immersion experience on the institution‘s campus. Observation of direct patient care was not a part of this study. Culture is ―taken for granted,‖ thus the researcher‘s observations were an important component of this naturalistic inquiry study where observations of what was seen and not seen was essential to creating an understanding of the associated importance of the observed. Multi- media artifacts were provided when key events occurred and the researcher was unable to attend; 50 and when the event was of historical significance to the nursing program to provide additional observational contextual experiences. These observations allowed the researcher to come to understand the norms, values, and culture of the nursing program; or as Deal and Kennedy (1982) stated, ―the way we do things around here.‖ It was the researcher‘s intent to come to understand the shared meaning of the cultural lens of this high-performing nursing program. In other words it was to learn about the organization‘s culture through ordinary events and ―stories that convey cultural assumptions,‖ as described by Rubin and Rubin (2005, p. 29). Researcher’s Field Notes. Field notes were maintained throughout the dissertation process including: initial notes and reflexive journaling regarding the institution, nursing program, researcher‘s observations, informal interviews, high-performing organization reflections, and excellence initiatives in nursing education. The field notes were an essential part of the iterative data collection and analysis process as unanswered questions were returned to in subsequent immersion visits, the unobserved was observed, and identified data gaps were closed, for example, in an early immersion visit, a participant had used the term ―N-CLEX coach‖, yet this was not a familiar term and was not heard again until the end of the last immersion visit when students were preparing to graduate. In reviewing the field notes in preparation for leaving the field, the term was present yet unclear in understanding of its meaning. The researcher returned to the participant for clarification. Interviews. Formal and informal individual and group interviews were held with key stakeholders in the nursing program using the interview guide as a starting reference in this study. The 51 interviews were centered on understanding the cultural factors of the nursing program. The organizational-culture of the nursing program was generated by actively listening to generational and novice stories, shared metaphors, and lessons taught to new members rather than aggressive questioning of the study participants (Rubin & Rubin, 2005). This was completed by hearing stories from faculty, staff, students, and personnel closely connected to the nursing program. Interviews were continued until a ―saturation point‖ was achieved where the same stories and ideas were being repeated, as recommended by Glaser and Strauss (1967). Individuals of the community, patients, and benefactors were excluded from formal individual interviews. Sampling. Snowball technique was utilized to interview participants as relevant to the primary and secondary research questions (Patton, 2002). Individual and group interviews included: novice and seasoned nursing faculty members with classroom, laboratory, research, and/or clinical responsibilities; nursing administrative team members; nursing program support staff; nursing students at the undergraduate pre-licensure and post-licensure levels; and graduate nursing students. Each formal interview began with reviewing and signing the study‘s approved informed consent form (See Appendix F). Participants were provided a copy of the signed document. Each interview was audio-taped and professionally transcribed. Following transcription, the text was verified with the audiotape for accuracy; the interview was de-identified to remove internal personnel names, departments, and the institution‘s name. An electronic file of each interview was maintained in a password-protected database and copies of de-identified interviews and data elements were stored securely throughout data analysis. 52 Artifacts. The nursing program‘s current completed NLN COE written and submitted application, selected multimedia artifacts, and selected supplemental documentation were reviewed. The case study program‘s accreditation self-study was reviewed. Any other public documentation or reports that were available on the Internet, in common spaces, or at the college library, were accessible to gain insight into the institution and nursing program. All documents were gathered to support or refute the primary immersion experience and interview data analysis. Multimedia data sources included in the data were a review of the public web site and intranet used by students and faculty. The intranet was observed with the assistance of a nursing dean who accessed the site and demonstrated faculty resources and courses, student accesses, student groups, and student projects to the researcher. Additionally, three key nursing events were viewed via CD/DVD/VCR: (a) NLN COE celebration, (b) nursing pinning ceremony, and (c) history of the nursing program. Data Analysis Data analysis began with data collection and continued until patterns and themes emerged and created meaning for the researcher. Credibility and trustworthiness (truth value, applicability, consistency, and neutrality) were maintained through the use of: (a) member checks with participants, (b) data triangulation, (c) use of an audit trail, (d) peer debriefing, and (e) return to the data for verification. Interpretation of data continued throughout data collection until redundancy occurred (Denzin, 1989; Lincoln & Guba, 1985; Patton, 2002; Rubin & Rubin, 2005). Triangulation of data was accomplished by the use of multiple sources: settings at the nursing program, participants, and multiple forms of data. (Lincoln & Guba, 1985; Patton, 1990). 53 Reflection during observation and data collection included spaces, lighting, objects, colors, people, rhetoric, actions, behaviors, and authentic artifacts as suggested by Spradley in 1980. This reflexivity was the thoughtful conscious self-analysis of what was observed and what was not observed to answer who, what, when, where, why, and how of the data gathered for this research study as suggested by Gilligen (1993). Reflexive journaling throughout the immersion experience was maintained. Reflexive journaling and meticulous auditing in naturalistic inquiry supported dependability and confirmability as the researcher logged and examined the unfolding data throughout the research study as suggested by Lincoln & Guba in 1985. Using a reflexive process, new data were consistently reflected upon to enhance the iterative process of analysis and considered with previously collected data until data redundancy was perceived to have been achieved, including analyzing data for inconsistencies between the immersion experience and documentation from the institution and nursing program. The researcher bracketed one‘s prior knowledge of excellence and nursing education accreditation standards to minimize bias and create a situated contextual environment. This inductive approach to data collection and analysis required the process to emerge throughout the research study as temporal, spacial, corporeal, and relational dimensions were explored. The tone, intensity, and appeal of the participants‘ voices provided important information during both formal and informal interviews and observations. An inductive process of sense-making was used for interpreting the obtained data in this study. 54 Coding in Case Study Research: An Iterative Process Data were analyzed and coded using a content analysis approach with units of data being words, phrases, sentences, and passages. Data were coded in the following order: (a) interviews, (b) observations, and (c) artifacts. A very brief overview of this qualitative research study is presented in Table 3.1. This table includes a summary of the six immersion visits; 31 interviews; more than 78 hours of observations: general, event, meeting, and classroom; and more than 60 multi-media and print artifacts. Chapter 4 will present a summary of the study‘s observations, interviews and artifact data. The content analysis was conducted with a focus toward the research questions, observation of culture, and culture dialogue. While all data were about this cultural experience, the data not directly related to culture were not coded. For example, specific classroom content observation notes such as advanced knee assessment, dermatological assessment, depression, health policy, or liver transplantation course content were not coded. What was coded were faculty presence/preparation in the classroom, student behavior, and classroom teaching-learning activities. All data, however, were retained to maintain study integrity and for potential secondary data analyses. Informal conversational and observation data were coded in a similar manner as the formal interviews and observations. To assist with data analysis and the decision-making process an audit log was initiated. Coded data were analyzed using manual naturalistic inquiry processes and QRS NVivo 8 qualitative software. The researcher found the use of qualitative software to be of value in the coding retrieval process; however, manual coding methodologies were primarily used for coding and analyzing the data. 55 Table 3.1 The Case Study Summary __________________________________________________________________________ Observations Interviews Selected Artifacts __________________________________________________________________________ 20 Hours general 31 Interviews conducted NLN COE final submission document review 12.33 Hours contact 44 Participants External accreditation self- time study 2.5 Hours campus tours 26 Individual interviews; Multiple public documents and institution and program 5 Student groups communications of institution events 10.75 Hours institution 3 Academic administrators 2 Student handbooks events 5.5 Hours nursing 6 Seasoned-tenured faculty Nursing program faculty program events handbook 13.3 Hours classroom 6 Novice faculty Negotiated agreement observations document 3.25 Hours lab 6 Pre-licensure students State board of nursing observation communications 11 Hours meetings 6 LPN-BSN students 3 Annual reports 8 Undergraduate 4 RN-BSN students 3 VCR/DVD/CD nursing classroom observations program events 3 Post-licensure 7 Graduate students Undergraduate and graduate undergraduate classroom student recruitment observations documents 4 Graduate classroom 3 Internal support staff Internal working observations documents of nursing program 3 External support staff Annual accreditation report ___________________________________________________________________________ 56 Codes and categories were initially identified as data emerged. Codes and categories were added, modified, and/or deleted throughout the iterative reflexive process. A code book grid was established and organized to support the reflexive process. The coding schema emerged from the iterative process of incorporating data emerging patterns and themes. All iterations of these grids were maintained to demonstrate the reflexive processes and support the audit trail. Terms were then queried using NVivo 8. Queries were checked to determine if the data supported the occurred during this phase of the study. At least seven major iterations of the iterative reflexive data analysis process occurred prior to the final coding schema emerging. The interviews initially were coded in the order of data collection. The interview process emerged consistent with naturalistic inquiry methodology. For example, the researcher became familiar and comfortable with the emic language of the nursing program; came to know the culture that seemed to be emerging from prior observations and interviews; and became perceived as an insider versus outsider as noted during a Leadership Council meeting, ―ah, she‘s just one of us by now. Feel free to join in the discussion__or maybe you can‘t.‖ The data analysis process remained iterative throughout this qualitative study. Data analysis continued until there were no other rival explanations through peer debriefing, triangulation, and member checks to enhance credibility and transferability of the research findings. Each transcribed interview was translated to a brief synopsis, then a summary was written as a set with similar participants, and finally, all interviews were summarized as a whole. However, each interview was returned to its paper format or electronically in NVivo 8 multiple times during the study to complete this iterative process; for example to first identify the codes and categories related to the research questions, when considering emic and etic language and metaphors, to support emerging patterns and themes, and to identify and clarify study 57 terminology. Gaps and overlaps were considered after each interview and the audit log and codebook grid were revised to reflect this inductive process. Dictionary definitions were used to determine word choice accuracy as terminology was confirmed. If terminology remained unclear, professional literature was referenced until word choice clarity resonated with the data and emerging graphic representation. Definitions were verified and clarified as a result of the data analysis. These will be presented within the context of answering the primary research question. Initial metaphors were explored and multiple diagrammatic models were considered through the reflexive process. Repeated returns to the data and interview summaries continued until the written findings resonated with the researcher. Data continued to be analyzed as patterns and themes emerged from both the explicit and implicit aspects of culture included in the observations, interviews, and artifacts. The nursing program‘s norms, emic language, common and unique, but striking metaphors were organized and returned to throughout the reflexive analysis process to aid answering the research questions (Lakoff & Johnson, 1980). The faculty peer debriefer engaged in dialogue throughout the immersion experiences, listened to the interviews, and supported the data analysis process. Establishing Quality in Naturalistic Inquiry Throughout this qualitative study, the researcher was keenly aware of the importance for maintaining quality throughout a prolonged immersion experience. Each aspect of quality in naturalistic inquiry is discussed in this section. These are trustworthiness, credibility, confirmability, and dependability. Each will be discussed next in this chapter section. 58 Trustworthiness Trustworthiness began with prolonged engagement and persistent observations within the data collection process. Trustworthiness was created by maintaining a balanced, fair, and reasonable extrapolation of the research data; through vivid and thick descriptions; triangulation; member checks where findings were recognized by the participants; and peer debriefing (Denzin, 1989; Geertz, 1973; Lincoln & Guba, 1985; Patton, 2002). Congruence between the different contexts supported the trustworthiness of the research findings. Triangulation of data through use of multiple sources (settings, participants, and methods of gathering data) enhanced the trustworthiness of the research results (Denzin, 1989; Lincoln & Guba, 1985; & Patton, 1990). Credibility Credibility was enhanced through repeated immersion experiences and prolonged engagement at one nursing program. Trust was established early in the study by honoring the dean‘s requests regarding which data objects may be removed from the institution, and what was to be returned at the conclusion of each immersion visit. Trust with the prospective participants was established as often as possible prior to a request to be interviewed. This was a result of engaging in multiple observations, learning the emic language, and studying the nursing program‘s structure and curricular offerings prior to initiating formal interviews. The researcher remained mindful of the study‘s purpose and protocol; and the importance of honesty, integrity, and role throughout the data collection process. Immersion experience journals were maintained to document notes and reflections throughout the research study, a pocket calendar maintained a log of activities that were transcribed with detail into the audit trail log. Throughout the reflexive process these documents were reconsidered to support the coding process. Interviews were listened to by the researcher 59 and co-investigator; the iterative coding process was reviewed; and both were discussed on multiple occasions. Honesty, non-biased reflection, multiple data sources, and the gathering of data to redundancy supported the establishment of credibility in this qualitative research study (Coffey & Atkinson, 1996; Lincoln & Guba, 1985; Patton, 2002). The researcher was able to remain neutral throughout systematic data collection procedures as a result of rigorous training. Lincoln and Guba (1985) suggested gaining access and entry into qualitative research sites through the establishment of trust relationships. This doctoral student attended NLN Education Summit conferences as a student scholar for three years and actively participated in conference events. The researcher purposely conducted self in a professional manner at each NLN Education Summit conference for a total of five years. Informal conversations with key personnel added clarity to the study as this dissertation emerged. Prolonged engagement with persistent observations, including field notes within the situated nursing program enhanced credibility by adding scope and depth to the study. When the qualitative researcher was able to move from the front stage to the backstage, one was better able to observe and come to know the more private side of the participants as suggested by Goffman in 1959. Triangulation of data was important to establish an accurate representation of reality (Denzin, 1989; Lincoln & Guba, 1985). Denzin (1989) suggested triangulation of data, researchers, theories, and methodologies. Data were triangulated as best possible to establish an accurate representation of reality. Debriefings regarding the data obtained, member checks, and return to the literature to consider explanations of research findings occurred. Member checks 60 were conducted throughout the study as the researcher clarified and verified observations and information with participants in the nursing program. Peer debriefing throughout the immersion experience was conducted to verbally review the data collection process and remain focused upon the research questions. During data analysis regular sessions were held with the co-investigator to discuss emerging data analysis processes, verify and clarify emerging patterns and themes in the data, consider a variety of alternative possibilities, and determine next steps in this prolonged immersion process. The snowball technique was used to obtain study participants. This resulted in a variety of participants that reflected the nature of this nursing program. Participants included novice and seasoned faculty, administrators, administrative assistant personnel, program support staff, custodial staff, and students representing each level of the nursing program‘s educational offerings. Dependability and Confirmability Prolonged engagement occurred over approximately nine months from entering the field and coming to know the nursing program to completion of data collection. The initial immersion experience began in May 2008 and ended in December 2008. No pilot study occurred as the research protocol was followed. In place of a pilot study the researcher and co-investigator conducted practice interviews to prepare for data collection and analysis. An audit trail was maintained for this study from the initial development of this qualitative study to the end of data analysis. During data collection the study process was documented in a small portable calendar. The information was transferred with greater detail into 61 the formal audit document. Data management was routinely reviewed to maintain a clear and accurate audit trail. The audit trail and study data were maintained in secure locations and files throughout the study according to study protocol. Key documents were organized in secured electronic files or notebooks by topic and date. Original handwritten notes were retained for study integrity. NVivo 8 was used for retrieval of data electronically. Reflexive notes and memos of conversations with committee members, participants, and peer debriefer were included. These notes and memos included ideas, considerations, experiences, feelings and fears, and documented the emerging decision-making processes. An example of two observation and reflexive notes are located in Appendix G. The researcher served as the primary instrument throughout this study. There were no additional study personnel on-site during the immersion visits. To maintain focus and purpose, the researcher remained in contact with the co-investigator throughout the study. This supported study protocol compliance, affirmed decisions during immersion visits, and provided guidance during the study. Dependability was obtained and maintained through open communication, careful documentation, and the identification of similar findings within multiple interviews and observations. Case study research creates the opportunity to identify common defining factors using a diverse small qualitative sample size (Creswell, 1998; Stake, 1995). Confirmability was supported through the use of an explicit and detailed audit trail of all qualitative observation and interview data, including the gathering of all quantitative and/or print/media materials from the study. 62 Ethical Considerations The study was approved by the University of Kansas Human Subjects Committee and the case study nursing program‘s institution. Informed consent was obtained following the guidelines outlined by the Human Subjects Committee of the University of Kansas Medical Center. Written nursing program consent was given by the dean of the nursing program. Each participant selected for an individual interview was informed of the purpose of the study. Process consent was requested when ongoing dialogue per study protocol was initiated. Confidentiality was maintained throughout the study. In addition, confidentiality of the participants was maintained as the researcher did not identify the institution, nursing program, or the individual participants by name in the study. Anonymity was maintained by removing individual‘s names as outlined in the approved Human Subjects Protocol as a part of the transcription accuracy verification. Qualitative research brings with it a need for heightened awareness of the ethical responsibilities the researcher must maintain to protect the human rights of participants. The emerging nature of the participant relationship with the researcher in ongoing fieldwork places the participant in a position of vulnerability. Use of process consent allowed the participants the opportunity to decline further participation in the research study during a follow-up interview or when requesting a brief clarification from a previous interview. Patton (2002) stated ―interviews are interventions.‖ Thus, a good interview ―lays open thoughts, feelings, knowledge, and experience, not only to the interviewer but also to the interviewee‖ (p. 405). Patton supported interviews designed to gather information, not to change people, and that the interviewer is not a therapist. In the current study, these issues did not occur. 63 The nature of qualitative research may entice the interviewer to stray from the purpose of the interview, thus away from that in which informed consent was given. Finally, Patton‘s (2002) ethical dimensions guided the researcher‘s decision making in the field in relationship to risk assessment and data collection boundaries. Again, in the current study, these issues did not occur. Limitations Limitations of the study included: 1. The study‘s focus was on the culture that existed and not a full study of the nursing program‘s academic curriculum, documents, or quality of all the educational offerings, processes, and outcomes. 2. The study was limited to the activities and events of the nursing program at the times of on-site data collection. Summary This chapter presented the naturalistic inquiry methods utilized throughout the research study, including the study population and criteria for selecting a case study nursing program. The case study nursing program was described in the data collection section of the chapter along with a detailed description of the researcher as the instrument in this study. Next, the field experience of six immersion visits, including observations, interviews, and artifacts, were presented. Finally, the iterative process of data analysis was described including a summary of the data collected during this research study. 64 Chapter 4 Results This chapter will discuss the results of data analysis in Chapter 3 by answering the research questions. The study posed one primary research question and three secondary questions. First, the immersion visits and a brief data narrative summary will be presented. Next, the primary research question and each secondary research question will be addressed. The chapter concludes with a detailed discussion of the study‘s findings. Narrative Summary This case study immersion experience included six immersion visits. During these immersion visits observations and interviews were completed. In addition, artifacts were gathered and selected artifacts were read and reviewed within the context of the nursing program. A brief summary of the immersion visits follows. Immersion Visits Four visits were made to the case study nursing program and two to the NLN to gain access and review the complete written submission report, appendices and exhibits of the case study nursing program. This immersion experience occurred over an eight month period of time. The immersion visits are summarized in Table 4.1 The Immersion Visits Over Eight Months. Immersion Visit One: The study was initiated with institutional consent by the dean of the nursing program. This three day visit was about ―finding my way.‖ Entering the field naively provided a sense of wonderment about what would unfold in this naturalistic inquiry study. Bracketing potential bias was important as the researcher was a skilled educator. Primary activities included: meeting with nursing program administrative personnel, gathering institution 65 and nursing program artifacts, a campus tour, reviewing confidential onsite only documents, initial observations, and making preparations for future immersion visits. Table 4.1 The Immersion Visits Six Immersion Visits Number of Immersion Days ______________________________________________________________________________ 1. Finding my way at the nursing program 3 days 2. General and event observation at the nursing program 3 days 3. Knowing my way at the nursing program 12 days 4. Finding my way at the NLN 2 days 5. Being a part and leaving the field: the nursing program 12 days 6. Being a part and leaving the NLN 2 days Total Immersion Days: 34 days ______________________________________________________________________________ Immersion Visit Two: The study continued with another three day visit. The focus was becoming comfortable with ―knowing my way‖ at this institution and nursing program. Becoming more comfortable with general observations, attending commencement events, reading the onsite only confidential documents, and coming to know the institution and nursing program facilities such as locations of offices, classrooms, dining facilities, hallways, and the emic language were the outcomes of this visit. Immersion Visit Three: This extended visit of twelve days provided the opportunity to become familiar with the day-to-day routine of the nursing program. This was important as the 66 researcher worked toward ―moving inside‖ or ―becoming an insider‖. It was on Monday of the second week of this immersion visit when nursing program personnel explicitly referred to the researcher as: ―Oh, she‘s just one of us! Feel free to join in on our discussion‖ at the beginning of a planned committee meeting. This perception of being an insider was a significant development of credibility with the nursing program‘s personnel. This prolonged visit included individual planning meetings with the program‘s deans. Current academic class sessions and administrative meeting schedules were promptly provided, along with the undergraduate and the graduate curriculums. Intense general observations around the nursing program provided continuity from the previous visits. Next, classroom and meeting observations occurred and special events attended. During this immersion visit the initial administrator, faculty, and staff interviews were conducted. Active participation in meetings did not occur for two reasons: (a) being aware of the role of researcher, and (2) the researcher was an experienced dean of a nursing program with extensive knowledge in nursing education curriculum development. For example, in one meeting the members were discussing accreditation standards, their conceptual framework, and curricular alignment. Novice faculty and a less seasoned administrative leader were discussing next steps in a process and seemed a bit unclear. It would have been very easy to step into a leadership role and assist the workgroup with the task at hand. Instead, the researcher remained silent during the conversation, even when inquiry was made as to any insights from recent academic work. To actively engage in the discussion may have biased the future participants in this study. Immersion Visit Four: NLN Site Visit #1 – This visit began with planning the details for ―coming to know‖ the NLN COE context, personnel, and planning for a subsequent immersion visit to gather additional data about the NLN COE program and to finish the case study nursing 67 program‘s final written submission report review including appendices and exhibits after receiving access to the NLN COE full submission reports and following the NLN consent procedure process. Immersion Visit Five: This visit was a second extended stay of twelve days at the case study nursing program. During this immersion visit interviews were concluded with faculty and staff. Individual and small group interviews were conducted with nursing students. These student interviews were held at times and locations on campus most convenient to the participants. In addition, events and meetings were attended; general observations continued; and confirmatory observations were made. During confirmatory observations, focusing upon what had not been observed throughout the immersion visits was as important as confirming data saturation. Reflective analysis of field notes from three previous on-site immersion visits occurred. Data gaps were closed by returning to selected interview participants for follow-up or clarification of information (see Appendix D). Preparation for and ―leaving the field‖ occurred as closure was brought to this portion of data collection. Immersion Visit Six: NLN Site Visit #2 - This was a second site visit to the NLN to continue and complete data collection from the final written submission information of the case study nursing program. The focus of data collection was toward the research questions and reviewing data not obtained onsite at the nursing program. The succinct documentation of external funding; internal and interdisciplinary research; and extensive publications in one location facilitated data collection. The data at the NLN was used to support and confirm observations and data obtained through interviews and stories at the nursing program. Preparation for ―leaving the field‖ occurred as closure was brought to this portion of the study. 68 Observations Observations at the nursing program included general, meeting, classroom sessions at every level of nursing education offered, and multiple nursing related events (see Table 3.1). In summary, the initial general observations were conducted as a means to come to know the case study nursing program and setting: the institution; nursing program spaces; emic language; and nursing program structures and processes. Specific observations were focused toward the nursing program‘s day-to-day culture, and how things worked at this nursing program, including relationships, hallway conversations, and break area gatherings, before and after class/meeting/event discussions. Concluding observations were to confirm or disconfirm early study observation notes. A list of observations by immersion visit is located in Appendix E. As a result, the nursing program was noted to have many open-doors for those who enter: students, faculty, administrators, and guests. This created a welcoming environment for those who entered the nursing program space. The nursing program space was decorated with multiple artifacts that reflect the values of the nursing profession. The mission and values of the institution were explicitly identified at all public events of the institution and the core values of the institution were displayed throughout the campuses and in the workspaces of the nursing faculty, administrators, and staff. Discussion of nursing‘s values and the institution‘s core values was a typical part of the day or conversation at this nursing program, particularly when decision- making groups were gathered together, faculty were working with students or external partners, or curricular change was being considered. The nursing program personnel and those closely associated with the nursing program lived the mission and values of the institution and nursing program in their daily interactions with each other, their students, and external partners. In the classrooms, the students were 69 observed to be very respectful to their faculty, attentive in class, with textbooks and notes out ready to participate and learn. Active learning strategies and students mentoring other students during class activities was the norm. This welcoming, open-door, mentoring, and respect-oriented, ready to learn culture was also observed with the interactions between the novice and seasoned faculty members. Civility was observed and the norm at this nursing program although not a planned study observation. Interviews Forty-four participants were interviewed for this case study research. Participants included an interdisciplinary team of students, faculty, administrators, and support personnel. All personnel had significant roles with the nursing program. Interview participants included 21 personnel and 23 students. The personnel interviews included: three administrators, six seasoned faculty, six novice faculty, and six internal and external support staff. The student participant format was five individual and five group interviews. At the under-graduate pre-licensure and post-licensure level 16 students voluntarily participated while seven graduate students chose to participate in the study. All interviews occurred in a location and format most convenient for the participant. The interviews were rich with stories of what it was like to be at this nursing program. Key findings are presented. The nursing program was designed upon the mission and values of the institution and nursing‘s values. Thus, there was a very high level of respect for all human beings. The nursing administrators and faculty worked to create a culture of ―intentional caring‖ as defined by the nursing program. This intentional caring reflected the importance of dyadic relationships with the nursing students, each other and nursing as a caring profession. The curriculum was designed to have many ―extra helps‖ or wrap-around services to ensure as much as possible student 70 success in this highly-diverse student population. These programs include: mentoring groups, N- CLEX coaches, PLUS, supplemental instruction, peer-tutoring, faculty-tutoring, exam review sessions, and more. The nursing faculty, administrators, and graduate students viewed this nursing program as an opportunity for professional development and ongoing discernment of one‘s professional nursing journey. Opportunities were provided for terminal degree completion, faculty development, formal and informal mentoring, and tenure process support at this program. Each of the student participants shared their perception of being here as the ―right fit‖ for them, whether it was at the LPN-BSN or RN-BSN program level; in the pre-licensure program; or one of the MSN tracks. In some cases they purposefully sought out this program. As one graduate student participant stated: ―For me it was a necessary fit, it‘s not the closest program, but it aligns with my values and goals. I was at another program. It was good. I was doing well, but it wasn‘t right for me.‖ For the novice and seasoned faculty the passion shared about this nursing program and institution being the ―right fit‖ for them was nearly identical, whether they had been at this nursing program one or two years or more than 30 years. Most appreciated by the faculty was the camaraderie and ability to work hard together, express their own opinions openly, practice and teach in their specialty areas. In addition, novice faculty expressed appreciation for having the opportunity to seek tenure in both traditional and clinical tracks; and knowing there was a mentor/buddy to help them along the journey into academia. The faculty felt they had a great deal of autonomy and freedom to do their work. Seasoned faculty expressed satisfaction with the opportunities for growth: personal and professional during their tenure at this nursing program. 71 Selected Artifacts Nursing program‘s photos and wall hangings provided the essence of what this program was about: a deep appreciation for diversity in nursing and the professional values of nursing. This was also noted in the wall plaques honoring the legacy of nursing leaders from this nursing program. Most interesting was the manner in which the nursing program‘s history was so deeply rooted and shared in both oral tradition and historical documents of the nursing program. This was evidenced through the participants‘ interviews and stories of what it was like to be at this nursing program. Selected artifacts were used throughout the study to guide the researcher through the immersion experience and provide basic information regarding the nursing program, such as the nursing faculty listing, undergraduate and graduate master course assignment sheets, annual list of nursing faculty meetings and committee assignments. Overall, specific artifacts were consistent with the observations and interviews throughout the study. Plans of study, course listings, meeting schedules, and other similar documents were accurate. A log of artifacts and photos is located in Appendix H. The nursing program‘s final written submission report, appendices, and exhibits were reviewed at the NLN. Three key findings were noted. First, although it had been at least two years since the document was written the interview statements from students and faculty were nearly identical to those of study participants. Second, the material in the written submission report was very consistent with the researcher‘s lived immersion experiences. And third, the supplemental documentation was an excellent source of materials to validate statements from participants‘ interviews regarding their grant work, publications, and scholarly work to serve their student population. A log of documents obtained during the study is located in Appendix I. 72 Other key selected artifacts were the work agreement and tenure & promotion guidelines for the institution that clearly articulated the policies and procedures for tenure track faculty appointments. The student and faculty handbooks as well as the most recent accreditation documents, and annual nursing program reports provided documentation for data triangulation and confirmation of study data from observations and interviews. Patterns and Themes The importance of gathering and analyzing data until patterns and themes emerged in this seminal case study academic nursing program research was built upon work of noted qualitative organizational researchers. Each recognized, in their own work, the value of understanding context in creating high-performing organizations. Whether in business, health care, nursing homes, or attempting to understand how people learn, organizational culture was recognized and appreciated by Anderson et al., 2005; Bolman & Deal, 2003, 2008; Deal & Kennedy, 1982; Capra, 2002; Cilliars, 1998; Crotty, 1998; Forbes-Thompson et al., 2007; Lave & Wenger, 1991; & Skog, Negussie, & Grafstrom, 2000. The iterative data analysis and writing with its multiple iterations resulted in one metaphor, three themes, 12 patterns, and 119 codes (see Appendices J, K, and L). Subsequently, this report emerged from the iterative data analysis process and answered the primary and secondary research questions. These patterns and themes represented the culture of the case study nursing program, or the way they did things around there. At least seven different iterations of the data analysis occurred prior to reaching the final graphic representation and wording (See Appendix L). A Graphic Representation The overarching metaphor and title for the graphic representation of academic nursing 73 excellence is The Right Fit: Harmonious Alignment as shown in Figure 4.1. It is represented by three themes: (1) A Firm Foundation, (2) Nursing Program Transparency, and (3) A Vibrant Academic Nursing Community. The model‘s three themes represent 12 patterns as a synthesis of the iterative data analysis process. Each theme and the theme‘s associated patterns are identified in Table 4.2. The case study themes and patterns will be discussed in the next section of this chapter. The Primary Research Question The primary research question was: What important factors constitute the culture of a nursing program previously determined to be a high-performing environment? A detailed discussion of the study‘s findings will be used to answer this research question. The graphic representation provides a visual reference as the research question is answered. The study‘s overarching metaphor is presented to begin answering the primary research question. The Right Fit: Harmonious Alignment, was selected as the overarching metaphor that symbolized the particular way coherent connections were created at this nursing program by blending its rich heritage, contemporary values, and structures to create a coherent whole. Nursing‘s professional values as described in Nursing‘s Social Policy Statement and Code of Ethics with Interpretive Statements were aligned with the nursing program‘s values and imbedded in the observed interpersonal relationships (American Nurses Association (ANA), 2001; American Nurses Association (ANA), 2003). This metaphor was chosen as there was a consistency in the language, observations, experiences, metaphors, norms, and documents between the institutional heritage to the mission and values of the institution and the nursing program (see Appendices M, N, and O). Repeatedly, students, faculty, staff, and administrative leaders shared stories that the nursing program was for 74 them: a good fit, feeling as though one fit in, or reporting an ongoing sense of discernment of continued fit within the nursing program and institution (See Appendix P). Table 4.2 Case Study Themes and Patterns ______________________________________________________________________________ Note: Cool Colors are calming, opening, expanding. Warm Colors are intimate, cozy, advancing. A Firm Foundation is represented by stones that are depicted as a solid and stable structure. The single stone of heritage is represented as granite. This single stone bears the weathering of time. The next stones are pieced together and overlap to strengthen the structure as ______________________________________________________________________________ The Right Fit: Harmonious Alignment ______________________________________________________________________________ Theme Patterns Color A Firm Foundation Heritage Institutional/Program Mission & Values Grey Granite and Brick Stones Nursing Program Transparency Trust Respect Integrity Transparent Blues A Vibrant Academic Nursing Community Student-Centered Empowering Leadership Internal and External Partnerships Community of Learning Sound Management Processes Professional Role Socialization Diversity Advocacy Gray Red-Warm Violet-Cool Blue-Cool Green Cool Yellow-Warm Orange-Warm 75 the mission and values of the institution and nursing program. Typically, stones are very stable over time and represent weathering well with minimal change. The mission and values of the institution and nursing program were very closely aligned. Nursing program transparency is represented as a slightly notched glass balance beam atop the firm foundation. This glass is a transparent blue colored material to represent the importance of transparency in creating a calming culture of excellence. The beam glides easily to maintain balance and represent the trust, respect, and integrity evidenced in a transparent organization. At the same time, this nursing program transparency could falter if the foundational core below develops a fault line, crumbles, or breaks. And, the beam could break if trust, respect, or integrity is lost; or the third theme, ―a vibrant academic nursing community,‖ becomes out of balance. A vibrant academic nursing community is represented by a kaleidoscopic color wheel. The color wheel using the primary and secondary colors represent the color spectrum in a systematic color palate. The use of the primary and secondary colors in the kaleidoscopic wheel is representative of the unique, diverse, and closely related patterns that create synergy for a vibrant academic nursing community. These patterns are in a wheel to symbolize the importance of balance between and amongst all the parts. The use of both warm and cool color tones replicates the work of professional nursing today. For example, warm colors are described as advancing, intimate, and cozy. In contrast, the cool colors are described as calming, open, and expanding. 76 Figure 4.1 The Right Fit: Harmonious Alignment 77 The seven colors and patterns are strategically placed in the kaleidoscopic wheel. These sections are represented by a carefully chosen name that will be described in the next section of this chapter. At the core of the wheel is a gray circle which is the obtained color when the primary and secondary colors are combined together. The use of vivid colors represents the intensity of the nursing program‘s energy where nursing‘s deeply rooted values and today‘s technological advances intersect. The use of a kaleidoscopic wheel assists the visualization of the ever changing opportunities in nursing academia and that the right fit is a unique fit for the present time and changes with innovations. The Right Fit: Harmonious Alignment The overarching metaphor is The Right Fit: Harmonious Alignment. This nursing program stood the test of time by keeping that which is core and valued in nursing and education and integrating new evidence to its academic practices. As a result, faculty, interdisciplinary team members, and nursing administrators reported the team being hard working, but loving their work, and feeling like they were making a difference in the nursing profession. For the employees, it was about being employed in an academic institution where the institution‘s mission and values and the nursing program‘s mission values and work culture fit (see Appendices M, N, and O). This ―fit‖ was frequently described as being in alignment with (a) their overall personal values; (b) the strong legacy of empowering leaders; (c) opportunity to work with underrepresented or disadvantaged students; (d) the embracing mentoring and socialization opportunities in a caring environment; or (e) the ability to balance work and home life at all stages of adulthood. Or, as so many participants stated in some manner, but were unable to 78 succinctly articulate, this was a nursing program that was the right fit for them. One RN-BSN student shared this experience, I work nearby and the students are so kind and knowledgeable. The faculty; it‘s like they really want the students to be successful here, so I decided to come and check it out, and here I am. It is great. I would like to teach. They say I‘d be a good teacher. At this nursing program it was not only about ―fit‖. The administrative leaders, faculty, and students were able to learn and work together harmoniously in the classrooms, skills labs, or hallways where students studied and interacted regularly with nursing program personnel. The caring relationships were pervasive and aligned with Nursing‘s Social Policy Statement (ANA, 2003) and the program‘s philosophical model of nursing as a caring profession. The seasoned faculty spoke often of working to achieve peace, how ―they‖ come together (referring to faculty or students) on a project, and spoke of or listened to calming music or use of the campus chapel for personal life balance. Fit was observed with faculty living out the values of the nursing program, profession, and institution; the student population who chose this nursing program; and ―how the daily work was achieved‖. For the faculty it was about working together to lighten the load; and for the students it was knowing this program was right for their learning needs, nursing goals, and what they knew about how the faculty did things around there. Sample data from the coding process for ―The Right Fit‖ are located in Appendix P. Theme One: A Firm Foundation The first theme, a firm foundation, represents the solid structures upon which the nursing program is able to grow and innovate. A firm foundation is defined as a solid and stable structure that is resilient over time. Coding for a firm foundation is found in Appendix L. This foundation 79 provided the nursing program, its personnel, and students with a strong legacy of leadership and sound management processes, as well as clearly defined professional and internal values that supported the innovative nursing program and its ability to achieve a culture of excellence. Heritage The living history of the institution‘s and professional nursing‘s founders and strong leaders and its rich organizational history kept the nursing program firmly connected to its past as it prepared future nurses for society‘s needs. This is referred to as heritage. It is about the legacy of the institution and nursing program. Heritage is defined as that which is handed down by the predecessors and included its founders, key historical milestones, and legacy leaders. Coding for heritage is found in Appendix L. The heritage of the institution and nursing program was known and shared through oral history; in the official documents of the institution and nursing program; and infused throughout the year at institutional celebrations, such as at the annual staff recognition day, Founder‘s Day, and at homecoming, baccalaureate, and commencement. The nursing students and faculty also participated in elective study abroad trips where the heritage of the institution and/or nursing was explored. It was from these trips that the nursing curriculum was enriched with the institution‘s heritage. For example, in the mental health course the faculty member shared about the previous summer‘s study abroad trip and how the institution‘s founders worked closely with Florence Nightingale in caring for wounded soldiers. The nursing curriculum also encouraged study of professional nursing‘s history, founders, organizations, and values in each nursing program. Mission and Values of the Institution and Nursing Program The mission and values of the institution and nursing program were closely aligned. This part of the program‘s foundation was imbedded in the language of the institution‘s core values, 80 Nursing‘s Social Policy Statement (ANA, 2003), and Code of Ethics with Interpretive Statements for Nurses with Interpretive Statements (ANA, 2001). This was observed over time in the study participants‘ behaviors of civility during informal gatherings, in meetings, the classroom, and clinical simulation lab settings. Institutional embracing of the mission and values was evidenced at each public event, and in the events‘ documents. In this nursing program the mission of the institution was implicitly understood by the nursing program personnel, interdisciplinary team members, and students. The institution‘s mission and core values permeated the environment, informed strategic planning, annual goal development, and curricular decisions. Mission is defined as the purpose of the parent institution and nursing program. Values are defined as the principles or standards of what is judged important to the institution and nursing program. Coding for mission and values is located in Appendix L. The purposeful explicit awareness of the mission and values of the institution and nursing program maintained a solid footing upon the living heritage. Within the nursing program, each faculty and staff member posted the institution‘s core values at their offices and/or inside their offices. Most personnel were able to verbalize the core values without referencing documentation. These values were deeply ingrained into the tapestry of the daily work and relationships at this nursing program. The core values were: respect, compassion, excellence, service, hospitality, integrity, diversity, learning for life. Theme Two: Nursing Program Transparency The second theme is nursing program transparency. The term transparency was intentionally selected as information at this nursing program flowed freely amongst the personnel and students as appropriate for their position in the institution. Nursing program transparency is 81 defined as an essential element of organizational success where communication and behavior are open, coherent, and consistent with the ethical standards of the profession. Transparency seemed to be the outcome of a working and learning environment of trust, respect, and integrity. This was experienced by the researcher during the first immersion visit when confidential institutional and program documents were provided as requested in the study. The level of respect for each member of the interdisciplinary team was very high. Their individual and collective work contributions to the nursing program and level of integrity with which the work was completed supported transparency as the work of the program progressed. Coding for nursing program transparency is in Appendix L. For example, when a new degree proposal was presented before the nursing faculty, several helpful suggestions were made without any sense of defensiveness. It was a collective group effort. Later in the study, the provost met with the nursing faculty at a regular nursing meeting. In asking questions about the nursing program as a new administrative leader, there was an almost immediate transparency to the dialogue as faculty shared characteristics of the nursing programs, dreams, and desires with the provost. The faculty comments were very consistent with the researcher‘s study observations, participant interview content, and experiences at this nursing program. However, transparency can be disrupted if key stakeholders experience a break in trust, respect, or integrity from superiors, peers, subordinates, and/or students. This was not observed or reported during the study. Trust Trust was deeply imbedded in the interactions of the nursing program personnel and key stakeholders closely associated with the nursing program. Personnel perceived themselves as working, learning, and growing together as a collective whole, including their work with the 82 nursing students. Trust is defined as the firm belief in the ability of or strength of the institution or its key stakeholders. Coding for trust is located in Appendix L. There were no explicit evidences of broken trust observed, reported, or shared during the immersion experience observations or participant interviews at the nursing program. It was as if the nursing program‘s environment of trust bred greater trust. For example, the administrative leaders and seasoned faculty trusted the novice faculty at this nursing program to do their assigned work. Being assigned in team teaching work groups, having faculty mentors, and working alongside seasoned faculty, the novice faculty members were provided excellent role-modeling in a non-threatening manner and significant autonomy to do their daily work. The seasoned faculty valued the novice faculty members recent and diverse clinical or teaching experiences, while the novice faculty greatly appreciated the academic wisdom of course management, active teaching strategies, test construction and analysis, and clinical supervision of the seasoned faculty. Working together maintained a trust environment that seemed to be deeply imbedded in the culture of this nursing program. Respect Respect was foundational as to how human beings were treated in this institution and nursing program: guests, students, faculty, staff, administrators, alumni, or community members. Respect is defined as having due regard for individuals or groups without harming or interfering while admiring their abilities, qualities, or achievements. Coding for respect in located in Appendix L. The administrators spoke openly with the employees at each level of the nursing program and this was reciprocated. Respect was evident when differing opinions were expressed both in how the message was stated; received; responded to; and accepted or rejected. At the same time if there was something to be discussed that was of a confidential or sensitive nature it 83 was done in the privacy of a closed room. For example, one day a lead faculty member was concerned about an issue in the clinical setting. Very quickly the program level administrative leader and lead faculty member moved to the administrator‘s office. Later, during data collection, the researcher learned that a new and novice, adjunct clinical faculty member was in need of additional mentoring. The faculty member continued to teach for this nursing program. The nursing faculty demonstrated respect toward each other, the students, staff, and administrators. For example, during each classroom observation the teaching faculty was highly prepared with a variety of classroom activities. For the classroom, meeting, and laboratory observations only two faculty members had more than one day‘s notice for classroom observation preparation. For the faculty most observations appeared to be spontaneous, although over 90% were strategically planned by the researcher. In the classrooms faculty used a variety of active learning methodologies, students were observed helping each other solve problems, and faculty helped students answer questions with multiple problem solving strategies. The classroom environments were fast-paced, active-yet-reflective by integrating clinical experiences into the classroom discussions. The classroom environments were intense with learning, yet relaxed in atmosphere, such that the students perceived the instructor for the day as knowledgeable and themselves as respected. Students respected each other, their faculty, and the administrators. The students came to class prepared with their own notes/handouts in a printed manner of their preference. Textbooks typically were opened and used during class as students learned and worked together in class. All students were exceptionally attentive and participated actively in the classroom events. Phones did not ring; students were not texting, or distracted by other non-nursing education related devices during class. Few students used laptop computers in class. If a student would drift 84 momentarily from the discussion or class activity the faculty member quickly used an active learning strategy to subtly return the student to active classroom involvement. This was a rare occurrence. There were no reports of perceiving or feeling disrespected at this nursing program. Integrity Academically the students were expected to demonstrate academic honesty and were taught what was expected of them in their first semester of the nursing program. For example, the students were reminded to turn papers in electronically to be checked by a software program for plagiarism. Students were taught the specific meaning of plagiarism near the beginning of the nursing program at all levels. Faculty demonstrated academic honesty in their teaching. For example, the faculty participated in a test item analysis workshop and later was observed discussing the analysis and a related test-item decision with students during an informal exam review. It was also noted that exams were kept in a secured file cabinet and that faculty typically keep offices locked when not in the immediate area of their office. Integrity is defined as the personal and organizational quality of being honest and applying strong moral principles to daily interactions and decision-making. Coding for integrity is located in Appendix L. Acts of integrity and stories of integrity were shared in the interviews when participants talked about the confidential nature of the information they worked with: from knowing individual faculty salaries; having access to student GPAs and admissions records, or helping students learn what integrity means in the clinical setting during student conferences. Also, integrity was noted throughout the field notes as observations noted the overall absence of hallway and mealtime discussions regarding confidential student or faculty performance issues; program or institutional discussions; or dialogue of inter- or intra-departmental tension. At this 85 program, nursing‘s Code of Ethics with Interpretive Statements was lived out in the daily interactions amongst the nursing faculty, students, and other key stakeholders (ANA, 2001). Theme Three: A Vibrant Academic Nursing Community The third theme is a vibrant academic nursing community. At the center of this vibrant academic nursing community is the student. Around the center or core are six additional patterns: (1) empowering leadership, (2) internal & external partnerships, (3) community of learning, (4) sound management processes, (5) professional role socialization, and (6) diversity advocacy. This theme was selected as there was a synergy and sense of cohesiveness amongst the nursing faculty at this nursing program. The enthusiasm and camaraderie were infectious and energized those who interacted with the nursing administrators and faculty to a new level of learning, working, and growing as a nurse and caring human being. It was not, however, only the nursing faculty or human interactions that made a difference at this nursing program. The dynamic organizational structures and processes supported the employees‘ daily work with the nursing students. As a result, the culture was vibrant and alive with fresh new ideas to meet the nursing needs of the community. Each of these patterns will be discussed in detail in this section of the chapter. Student-Centered In this nursing program the students were perceived to be at the center of this vibrant academic nursing community. For without nursing students there is no need for the nursing program to exist. The staff, faculty, and administrators were keenly aware that each student in their program was the reason for their existence. This was presented in a very positive tone and with the intensity of a community caring for its most valued treasure. Keeping the students as the focus of the nursing program was identified through intentional orientation processes for courses 86 and programs; observed in multiple formal and informal student and faculty interactions; and with their open door practices. In this nursing program, open doors was interpreted by the students as a faculty willingness to do whatever it took help them learn nursing. This was true for the graduate students as well. Best stated by this student, ―They even have an adult orientation class and they gave you this notion that they would never just let you just go and take classes. They've been there every step of the way.‖ It was with a passion that the staff, faculty, and administrators understood their reason for existence: to serve the students. All student groups were respected and provided equal academic resources. It was a student-centered environment. Coding is located in Appendix L. For example, a group of students began regularly using a common work space in the nursing program for studying and tutoring. The dean worked to create other spaces and furniture for the nursing faculty to gather and work together. The nursing students were not restricted from learning opportunities at this case study nursing program. Each faculty and staff member understood the students they served at this institution and nursing program. The nursing student population closely aligned with the heritage, mission, and values of the institution. These students were the most diverse student group in a degree program. As one faculty member discussed in an interview, students cannot be held responsible for knowledge if they have never had the opportunity to experience or learn because of their personal background and lived experiences. At least 40% of the students were of underrepresented ethnic groups, and/or students of poverty. This nursing program, however, also served a significant number of first generation U.S citizens with non-English speaking parents 87 and international students who had recently immigrated to the United States yet might not be classified as underrepresented or minority status. The nursing faculty had designed multiple curricular interventions to assist these underrepresented, and/or underprepared students toward academic success in nursing. As another faculty member suggested, ―we are here to give the students a better chance at life, and for many of us that is what the profession of nursing did for us.‖ For the employees keeping the students at the center was very important. It gave them a deep sense of purpose for coming to work each day. This was noted in several participant interviews: staff, faculty, and administrators. Empowering Leadership The formal leadership set the tone for this dynamic community of learning. By historically selecting empowering administrative leadership this nursing program continued to develop informed leaders at all levels of the nursing program. A strong legacy of nursing leadership was a part of the oral tradition and historical documentation at this program. Current leaders concerned themselves with maintaining this legacy, seasoned faculty with passing it to novice faculty, and novice faculty with finding their way, but knew it seemed right or like a good fit. At the same time, this nursing leadership created a very welcoming atmosphere where the employees spoke frequently of feeling appreciated for their work contributions. This institution and nursing program informally referred to their management team as leaders, however in formal communication you saw them referred to as the administrative leadership. This notion of administrative leadership or administrative leaders was possibly over a century old. For the institution's founder was referred to as an administrative leader as well as all deans of the nursing program. It seems that this may be an institution that understands the difference between management and leadership and expects all managers or administrators to be 88 innovative leaders. At the same time, those connected with the nursing program provided multiple examples of developing leaders in the staff, undergraduate and graduate students, and with the novice and seasoned faculty. Seasoned faculty was annually encouraged to develop plans for ongoing growth. Each seasoned faculty member typically served in a leadership capacity to assist novice faculty development. For example, seasoned faculty served as leaders when mentoring new faculty regarding: classroom preparation, test development, clinical teaching, and/or tenure preparation. This empowerment was very freeing and afforded opportunities for growth, autonomy, and creativity early in the employees‘ work at this institution. For example, seasoned faculty actively mentored novice faculty toward achieving tenure. Tips were provided for organizing toward tenure in the first year, one to one sessions were observed as faculty members reviewed the nurse educator competencies and tenure documents, and another faculty member stated a dinner was planned to gather and meet about the tenure process. Faculty was assisted with test item analysis; novice faculty participants discussed a variety of mentoring methods to enhance their classroom teaching preparation and skill, including receiving all course materials and faculty content; and having regular team meetings. Seasoned faculty appreciated the rigor of academic leadership as several had served in formal roles during their tenure. This was stated by one participant: It‘s turned out that I have embraced this job more than I thought I was going to. That‘s been a surprise for me. The previous dean really was able to look at people with a fresh eye, and chose to embrace people in a way that they had not been embraced before, in growth experiences and leadership responsibilities. 89 Novice faculty, staff, and students were also encouraged to develop their leadership skills. Potential nurse leaders: students, faculty, and future administrators were mentored toward leadership opportunities through active involvement in institution-wide committees, professional nursing organizations, and/or the development of new program proposals. This created a feeling of empowerment to engage fully in new endeavors aligned with the mission and values of the institution and nursing program. Empowering leadership is defined as a nurse leader or emerging nurse leader who possesses the skills and qualities which demonstrate determination, self-control, and good- judgment in leading and being followed by a group of people toward an emerging vision, with exemplary communication skills while valuing each member of the leader‘s sphere of influence. Coding for empowering leadership is located in Appendix L. Internal and External Partnerships Critical to the long term success of the nursing program were its internal and external partnerships. Internal and external partnerships are defined as relationships existing or occurring within the institution or coming from an external institution who share risks and profits of this nursing program. The majority of the partnerships were closely related to the mission and values of the institution and nursing program. Fitting with this several partnerships represented service to previously identified neighborhood or community agencies or groups in need of nursing care. Most often these partnerships were intentional and carefully nurtured over time to facilitate the strategic growth, workflow, and processes of the nursing program and its students. Each partnership was critical to obtaining, maintaining, and retaining critical resources for the students and nursing faculty. Multiple partnerships supported diversity and enhanced learning opportunities for students while furthering whole person development. 90 Key internal partnerships were the institutional departments that supported the nursing program staff, deans, faculty, and students. There were departments such as media relations, instructional technology services, library services, registrar services, data management services, food catering services, and the bookstore to identify a few of the departments mentioned during participant interviews. Two key internal departments that seemed more like a part of the nursing family were those assisting with the grant writing and fundraising, and the primary environmental services employee. Due to the nature of the grants and daily facilities cleaning these personnel were frequently observed interacting and available to the nursing staff and faculty. For example, personnel assisting with grant writing and institutional grant-funding budget management were most complimentary of the nursing program faculty, referring to the department as the ―crown jewel‖ of the institution. This was explained in relation to the nursing faculty‘s camaraderie amongst each other and ability to provide exemplary leadership on committees and workgroups throughout the institution, most importantly during recent institution accreditation preparation meetings. Key external partnerships were the nursing program‘s state board and accreditation agencies, as well as the organizational memberships in professional nursing education organizations. The clinical partners were well developed and nurtured by nursing faculty. Many of the faculty worked as needed (PRN) or had worked at the partnering institution. There were also key partnerships with community, regional, and federal funding agencies for both student scholarships/fellowships and program grants. These grants typically were designed to create nurse-centered clinics to serve the underserved by faculty, FNP students, and pre-licensure students. The nursing program also had some key partnerships with other academic institutions 91 in the area for articulating students into their programs and for faculty to pursue a terminal degree. Coding for partnerships is located in Appendix L. Community of Learning The community of learning was designed by empowered and engaged faculty, students, and administrative program level deans. The community of learning created new program ideas within all levels of academic programs. It was through the ongoing dialogue, positive relationships, and hard work that this community came together in three ways: (1) learn together, (2) work together, and (3) grow together. Learning and working together was similar to Ironside‘s findings in 2005. Growing together was a more intense sense of creating community from the stories shared by the seasoned faculty and staff. Each will be discussed further in this section. It was the community of learning where flexibility created a culture of ongoing curricular innovation, creativity, and early adoption of new nursing programs not available elsewhere in this nursing program‘s region. This community of learning was not only satisfied with curricular innovation and early adoption of new programs; but continuously evaluated these innovations. Formative and summative qualitative and quantitative data were used to seek a higher level of student, faculty and other key stakeholder satisfaction. To support this quest, persons in leadership positions worked to make sense of the ongoing data collection and share it with others. This supported the ongoing process of curricular innovation based upon an informed data driven decision-making process. Community of learning is defined as a high level of learning for all in the community toward the engagement and improvement of outcomes for the nursing program. The coding for community of learning is located in Appendix L. 92 The nursing program‘s curriculum was perceived as ―a work in progress‖ as there have been at least four curriculum changes over the last quarter century. The nursing faculty, leadership team, and administration view curriculum work as continually subject to evaluation and improvement. The nursing students were involved in curriculum revision through formative and summative processes. These processes informed subsequent classroom experiences as well as overall program development. For example, a novice faculty member spoke of seeking out student feedback periodically. This included during the course, through formal course evaluations, and program exit evaluations, but also, informally, after the student had progressed on to other courses. It was this feedback that was most appreciated: after students had the opportunity to reflect on the quality of teaching. The faculty also had a relentless desire to help students learn and make a difference in their lives. Following a class observation, the two faculty members teaching were leaving the room as they critiqued the course events of the day. At the core of this dialogue was their intense desire to provide the best possible course for the enrolled students. Process critique of courses was the norm. Faculty critiquing their own work after theory or simulated laboratory class was a common event in this nursing program. The conversation was always about how to improve the next class session and course offering for the students. Deliberate curricular decisions were made for this student population: small class sizes for theory and clinical rotations. Mentoring classes, PLUS, supplemental instruction, and tutoring by faculty/senior peers were specific examples of innovation and student-centered interventions. These curricular innovations were the result of ongoing faculty learning and implementation at assist student learning. Curricular decisions, however, were not always about new methodologies. At times, faculty implemented strategies from the literature such as team 93 teaching and small class sizes. For example, the typical theory class size was approximately 20- 25 undergraduate students and 7-8 students were typically reported or observed in clinical rotation photos in faculty offices. Faculty typically team taught the undergraduate pre-licensure courses and worked cooperatively in sharing the teaching load. Finally, for the seasoned faculty and staff, the opportunity to grow together was part of what fostered excellence. Growing together meant being there for each other during life‘s journey. This included: learning the academic role; moving through academic transitions such as accepting promotions, changing roles, completing/tenure applications, or walking along side one another on the next degree journey; and being there for significant family life events such as births, weddings, illnesses, or deaths of loved ones. While this was not the focus of their work it was an important part of the support voiced as to why many remained employed at this nursing program and institution. Sound Management Processes The sound management processes supported the administrative leaders, faculty, and staff in their daily work at this institution and nursing program. As a result, clear expectations were typically articulated verbally and supported in written institutional or nursing program documents, such as work agreements, orientation manuals, or admissions documentation. The sound management processes facilitated faculty and staff support; recognition of work accomplishments across the institution and nursing program; and balanced workloads. Sound management processes were essential to supporting the personnel and managing students. These processes were not top-down or rigidly enforced, rather were available to provide guidelines and assistance for those employed at this nursing program. 94 Management structures were consistent between written documents and oral conversations. The ease of access to institutional documents, consistency between written documentation and day-to-day management practices facilitated the work processes for the staff, faculty, and administrative leaders of this nursing program. Sound management processes is defined as dependable, actual application of methods and procedures for administering work or people within the institution or nursing program, without any special qualities or flair in a habitual and expected manner, yet with the ability for administrative leaders to function with creativity and flexibility. The management structures were flexible over time as seasoned personnel shared historical organizational structure changes in a consistent manner without voiced concern for the quality of the program or institution. The management structures, practices, policies, and procedures were explicitly known by the seasoned personnel and openly shared with the new employees or novice faculty. For example, novice faculty were provided information on the tenure process during their first year of employment, faculty were provided course content, student and faculty handbooks, institution orientation manuals, and a working smarter guide. Faculty mentors formal and informal willingly provided assistance and answers to departmental or institutional process issues including formal processes, such as counseling students with low mid-term or final grades, to the unwritten faculty role expectations at end of year. Novice faculty verbalized great appreciation for the openness to being accepted and guided at this department and institution. This openness and consistency supported order and positive relationships in the day-to-day work of the nursing program and institution. A part of the sound management processes included implementation of the institution‘s values in each interaction. For example: be welcoming, respect each other, work with integrity, 95 do your best, and serve others daily in a kind manner were ―just the way it was around here‖. Management level personnel were excellent role-models and supporters of these values. As a part of the heritage and management processes the institution and nursing program regularly acknowledged the contributions and accomplishments of others. Informal recognition and formal recognition occurred consistently and at appropriate times for the employees, students, and alumni. As a result, people felt genuinely valued and recognized for their professional accomplishments and employment contributions. Coding for sound management processes is located in Appendix L. Professional Role Socialization Nursing students were socialized into the community of nursing practice throughout the nursing program. This socialization began with their invitation to be involved in the campus- wide nursing community prior to entering the formal nursing coursework. Additionally, students were able to be involved in the nursing student association affiliated with the National Association of Student Nurses. Professional role socialization is defined as a journey with four interconnected components: intentional caring relationships, role-modeling, mentoring, and role formation to full participation in the profession. Together these four components created the developmental process and journey toward becoming a graduate at the BSN or MSN (FNP or CNL) level; or as a competent nursing faculty member. Coding for professional role socialization is located in Appendix L. For example, seasoned faculty and administrative leaders were exemplary role-models. Each was well-informed of the mission and values of the institution and nursing program and created very welcoming spaces with their open doors practice. Their behaviors were closely 96 observed by the novice faculty and students. Their academic skills were fine tuned and diverse so the novice faculty learned who could assist them with the multitude of faculty responsibilities, such as: test preparation, course management skills, paper/poster presentations, and clinical supervision skills. This role socialization was then replicated with their students as intentional caring relationships were formed, mentoring classes occurred, and students moved toward graduation and role development. Students were socialized into the roles of the discipline throughout the nursing program. There were multiple opportunities for the students to observe and be formed into the likeness of the profession‘s and program‘s core values: Nurses who respect human beings; serve patients and their families with compassion; and learn to do so in a safe manner while creating a trust relationship between the nurse and patient. Nursing students were offered opportunities to consider roles of advocacy, leadership, management, and advanced clinical practice through a variety of institutional and community partnership projects. This formation process was creating a connection that seemed to create a nurse acutely aware of what will be expected of them at graduation. Diversity Advocacy Diversity was not only welcomed, but intentionally sought after and in alignment with the core values of the institution. This welcoming environment supported the institutional core value of diversity and fostered respect among those who worked and attended classes at this nursing program. As both a novice faculty member and a seasoned administrative leader stated in their own ways ―we are certainly very, very diverse-- very diverse: in culture, in age, in economic background.‖ Diversity was openly discussed in the classroom, in meetings, accreditation documents, and when seeking external funding sources. Diversity was embraced in multiple ways throughout 97 the nursing program including the purposeful admission of some underrepresented and higher- risk students who meet the nursing program‘s criteria for admission into the nursing program‘s BSN clinical coursework. The nursing program was identified as the most diverse program at this institution with over 40% of the nursing students self-selecting federal ethnicity criteria for minority status. Diversity was observed at every level of academic programming and more richly than the reportable ethnicity categories. Students described themselves as being from diverse ethnicities, religions, lived experiences, and educational backgrounds. As one middle-aged, African- American, Christian, female student stated, ―My biggest thing was coming here was my age. I've never felt that I didn't fit in from the teachers to the students.‖ This student‘s closest study colleagues were representative of the diverse student population, in age, family status, religion, cultural, and educational backgrounds. For the students, diversity awareness began with coming to know one‘s personal biases. This began in the first semester of the nursing curriculum and continued throughout the nursing program. In this program diversity awareness development occurred at the program level, in course activities, and global awareness learning opportunities. Diversity is defined as ethnicity, gender, religion, lived experiences, perspectives, educational backgrounds, and ideas. Coding for diversity advocacy is located in Appendix L. For example, the students were studying healthy meal planning. Their active learning strategy was to prepare one 24-hour set of menus for a case study. Imbedded in these case studies were three major components (1) the age spectrum, (2) ethnic food choices by case study, and (3) an increasing complexity of health conditions. Each group of students worked to complete one case study and then shared the learning experience. This was facilitated in a creatively guided 98 manner by the novice course faculty to consider: age, ethnicity, and health status of the five case studies. Students and faculty shared informally and formally their study abroad experiences to Croatia, Ireland, and Turkey. Formal presentations of these experiences were shared during a global health awareness day to a standing room only crowd of nursing students and faculty. Informally, these experiences were shared when appropriate in the nursing classrooms as students and faculty were engaged in classroom discussions. Summary The important factors that constituted the culture of this case study nursing program previously determined to be a center of excellence were discussed in three sections: a firm foundation, nursing program transparency, and a vibrant academic nursing community. The intentional caring relationships of the key stakeholders at this nursing program provided a rich embracing, learning environment. These relationships were grounded in the professional values of nursing and the heritage, mission and values of the institution and nursing program where the student was perceived to be the reason for their existence. Secondary Research Questions The remaining research questions were secondary questions in this research study. Each will be answered separately in this section of the chapter. Question One The first question asked: What, if any, are the human, material, or other elements/pillars that distinguish this organization? While most of this question was answered in the primary research question, there were a few striking elements about the case study nursing program that will be discussed to answer this research question. Previously stated in question one were the 99 elements of the graphic representation: The Right Fit: Harmonious Alignment (see Table 4.2 and Figure 4.1). The culture of rich connections from the past informing actions in the present supported a vibrant student-centered academic nursing community. Stories of ongoing discernment of fit, being trusted, respected, and mentored also provided evidence of elements that distinguished this organization as a culture of excellence. On a more specific level it was the small class sizes, lower faculty to student clinical ratios, intentional caring relationships, and clear management processes that made the day to day work enjoyable. This was facilitated by a legacy of strong nursing leaders. As a result students, faculty, and staff were observed helping each other complete projects as needed, sharing resources, and faculty covering for each other to lighten their load or meet a professional or personal obligation. Seeking diversity was observed in many ways and expressed outwardly through artifacts, in the classroom, meetings, and through staff development activities. In addition, the unique elements included an intentional focus upon whole person development throughout the nursing program. The nursing students were not only taught about caring holistically for their patients and families, they were consistently challenged to consider how to integrate this new knowledge into their own lives and with their own families. For example, this was especially true when learning concepts such as wellness, nutrition, exercise, preventative measures for a variety of diseases, such as hypertension, obesity, and depression. Faculty was supported in their professional staff development, for example becoming certified nurse educators and studying the nurse educator competencies as defined by the NLN; completing advanced degrees; or studying abroad as a facilitator or co-facilitator of a study abroad team for nursing. Specific criteria and funding were available for each option. 100 An administrative leadership team had been developed and was perceived to be a positive resource to the faculty, deans, and nursing program. The seasoned faculty in a part-time administrative role was able to lighten the load of the deans serving as a clinical placement, business/financial, continuing education, post-licensure program, or health center leader. Nursing faculty salaries and workload were included in a negotiated agreement, followed, and clearly defined. Faculty salaries were reported as lower than clinical salaries. Faculty salaries were reported to be typically mid-range of AACN faculty salaries. Faculty salaries were not topics of discussion in the participants‘ interviews until the researcher posed the question. Salaries were reported to be mid-range for similar programs in the part of the United States where this program was located. Nursing faculty spoke of the option for greater salary in clinical practice; however, no one spoke of the opportunity for greater salary at another area nursing program. Faculty clearly chose the work culture and opportunity for additional clinical practice to do the work they loved in this academic environment. For the faculty interviewed, preparing the next generation of nurses and working where it was ―a good fit‖ was most important. The opportunity to engage in faculty practice was a nice additional benefit for the novice and seasoned faculty interviewed. The Boyer model of scholarship was utilized to create a new clinical track for the DNP educated nursing faculty. This was a new model for seeking tenure in the nursing program and several nursing faculty were preparing their documentation under this new model of scholarship (Boyer Commission on Educating Undergraduates, 1998; Brown et al., 1995). The nursing program grants were aligned with the nursing program‘s mission, values, needs, and areas of growth. Grants, scholarships, and funding were sought only when areas of need were clearly aligned with the future development of the nursing program. 101 The faculty and administrators were relentless in seeking excellence in their work on a daily basis. As they went about their daily work, it seemed where two or more were gathered, this group of educators were discussing and planning how to improve something: the last content taught; the clinical evaluation tool; the next program; the next simulation lab; or the next competency examination. At the same time, the faculty did this work in a spirit of joy and camaraderie. Much of this work was self-organized by work groups that chose to come together on their own. The administrative leadership team was kept informed but did not command or direct this work. The nursing faculty at each program level used a variety of active learning strategies in the classrooms. The faculty was excited to share what they were learning about teaching and how each activity seemed to work in the classroom setting. The students were engaged in the classroom settings, and demonstrated the same level of engagement as their faculty role-modeled with them. For example, their learning management system was actively used, case studies, clinical problems were presented, small group activities, short video clips, textbook podcasts, and many other strategies were observed during this study. A culture of civility was observed although not the intent of this study. Civility was noted at every level of the nursing program, in and out of the classroom, amongst the students, between students and faculty, faculty with each other, and between administrators with others in the nursing program. Because this civility was so evident at this nursing program it may be worthy of further investigation. Question Two The next secondary question asked: what, if any, distractors challenge or impede a culture, regardless of the high-performance? 102 There were no identified culture impeding challenges at this case study nursing program. A few potential challenge areas were identified by interview participants who were knowledgeable of national nursing education data. These three areas included pending faculty retirements, the subsequent need for ongoing recruitment and retention of qualified faculty, and the ability to maintain competitive nursing faculty salaries. These were not, however, dissimilar to the real challenges facing nursing programs across the United States. At this case study nursing program the deans who participated quickly identified that their nursing program had been privileged to not experience difficulty with faculty recruitment and retention. This was especially important as they had experienced some faculty retirements or loss, and significant nursing program growth over the past three years. As a result, the nursing faculty included about 50% new personnel with less than six years teaching experience at this nursing program. The nursing deans also shared a collective vision of how important it was for them to share and maintain their legacy, heritage, and values of the nursing program and institution with a novice faculty and nursing students. Awareness of the national shortage of academic nursing administrators was also shared during these dialogues. For them it was about hiring the right faculty as these individuals might become potential academic nursing administrators. Each wanted to feel assured that the intentional caring culture of excellence would be at this nursing program for the next generation of nurses. The seasoned faculty and deans valued the mentoring of novice faculty and intentionally worked at growing their own faculty through early recognition and mentoring of highly qualified nursing students. The seasoned faculty voiced as their challenge how the culture of the nursing program was carried forward to the novice faculty. For some seasoned faculty it was about having the 103 right hiring practices. For other seasoned faculty it was perceived as very important to have a strong mentoring process. Or as often was heard at this case study school, it's really about the common goal: ―We're all headed toward the same end so how can we help each other get there.‖ A final perceived challenge that also is not different than other nursing programs across the United States would be a request for additional resources. At this case study nursing program nursing faculty salaries were reported to be within the midpoint of the AACN salary surveys and this was confirmed via the confidential work agreement documents. At the time of data collection faculty had access to staff development dollars and clearly defined opportunities for travel to professional conferences for presenting posters and papers. Some faculty planned and participated in study abroad experiences with the nursing students each summer. While the nursing program, staff, faculty, and administrators had the funding to complete their daily work and annual activities, additional funding was a part of the annual goals. As many nursing programs report additional space and resources would be welcomed. The nursing program provided extensive information about internal and external partnerships and consistently reported a specific perceived need for additional resources in two primary areas: (1) funding to further serve their underprepared students of diversity, and (2) funding to serve the underserved population in their neighborhood, particularly women, children, disabled, and homeless clients. This nursing program had implemented multiple programs to support underprepared students as previously discussed. Finally, as with most other nursing programs, the growing cost of technological resources and supplies for simulation was mentioned in a couple participant interviews. A long-term goal was to have a new nursing program facility where nursing courses on the primary campus would be held in one location. A major change for the nursing program was 104 a lab addition at the adult education campus and a lab enhancement at the primary campus. Work on these projects was in process during the immersion visits. Question Three The last secondary research question was: what, if any, are related outcomes that this high-performing organization experience (i.e. recruitment and retention, student satisfaction)? This nursing program experienced several positive outcomes since the original NLN Center of ExcellenceTM designation. The pre-licensure students who completed the new five semester BSN nursing program passed the NCLEX-RN examination at a 100% pass rate. The undergraduate nursing faculty designed multiple curricular interventions including a five semester nursing core curriculum with nursing students being admitted to the nursing program as first semester freshmen. For students at this institution, automatic admission into the nursing program occurred in their second semester sophomore year, if nursing program standards were maintained in the first three semesters. In addition, multiple curricular interventions, such as formal mentoring courses, informal and formal tutoring, intentional teaching of academic success strategies, extra effort such as informal student learning sessions with nursing faculty, computer resource literacy and program access, NCLEX coaching, and supplemental learning interventions supported student success at this program. The NLN Center of ExcellenceTM designation provided increased institutional and community recognition of the nursing program. The nursing program within the second year of the Center of ExcellenceTM designation had increased undergraduate and graduate student applications for admission into the nursing programs. The nursing program has continued enrollment growth with added faculty positions. All current administrative leadership positions 105 are filled, personnel information provides evidence of minimal faculty and staff turnover, and human resource postings show no continued or long term faculty openings. The program re-applied for and received the NLN Center of ExcellenceTM designation affirming its ongoing achievement of the NLN Center of ExcellenceTM program standards. The institution continues to improve its rankings in national polls for serving students of minority and poverty status. Discussion of Results This discussion will be divided into three sections. The following topics will be discussed in relation to the case study's findings: Nursing education's ongoing crisis; transformation of nursing education; and the organizational culture of high performance organizations. Overall, the findings of this study initiate a dialogue with the research literature on identifying the factors that constitute the defining cultural characteristics in a nursing education center of excellence. Nursing Education’s Crisis The continuing national trends of aging nursing faculty, nursing faculty shortages, and lack of qualified academic nursing leaders to administer nursing programs in the United States were topics briefly discussed in participant interviews with administrative leaders and seasoned faculty. While these informed nursing academicians were well aware of the trends and national data, their nursing program seemed to possess preventative factors and did not experience difficulty with hiring qualified nursing faculty. There were no posted nursing faculty openings for the current academic years during the time of data collection. The culture of this nursing program may provide preventative factors for addressing the nursing faculty shortage: (a) sound management hiring practices, (b) culture of intentional caring, (c) mentorship toward professional role socialization for novice nursing faculty, (d) 106 aligned mission and values in a culture of transparency where trust, respect, and integrity are deeply ingrained in the daily interactions and work, and (e) opportunities for novice and seasoned nursing faculty to innovate at all levels of the curriculum. These findings will be discussed within the context research literature findings throughout the discussion of results. At this nursing program the sound management hiring processes and ability of the administrative leadership team to discern and hire faculty who were "the right fit" in this culture worked for this nursing program and is opposing contemporary nursing faculty shortage trends. Work engagement increases when personal and professional values are aligned with those of the employer. The institution and nursing program had implemented faculty hiring practices consistent with those suggested by Allan & Adelbron (2008). To support this high level of work engagement the nursing faculty workloads were honored in accordance with the faculty workload agreements. This workload agreement included very specific guidelines for course overload, new courses, development, and special project work. Consistent with research studies of other high-performing organizations, however, people employed at this nursing program chose to work here at least in part because they loved their work with the students in this nursing program at this institution. While the nursing faculty shortage continues across the United States this trend does not exist at this nursing program (AACN, 2010). The faculty and administrative leaders desired employment at this nursing program. At the case study nursing program the nursing faculty participants reported being paid less than their clinical counterparts in area acute care facilities, however, the context of their work was a key factor in remaining at this nursing program, much like RNs in Magnet designation hospitals (Mee, 2006; ). Similarly, Mee (2006) reported in a convenience sample of 107 Nursing 2006 readers that RNs and LPNs working in Magnet hospitals tended to earn slightly less income yet chose to remain employed in these high-performance organizations. The participants of this study provided information about the faculty salaries. Nursing faculty was eligible to maintain a limited practice during the academic year and to pursue any other nursing interests if not working during the summer months. As with Mee‘s (2006) findings, key benefits were appreciated by the nursing faculty participants in particular: tuition, conference/travel, staff development funds; educational pay differential (terminal degrees); opportunities for global travel with study abroad nursing students; flexible scheduling based on academic load and clinical assignments, and pleasant and positive work environment. Although some benefits were slightly different, the findings were consistent with Mee‘s research. The 2009 economic recession‘s potential impact on faculty salaries at this institution is unknown as external funding dollars and foundation accounts have declined significantly for most academic institutions as a result of the recession. At this nursing program these impacts do not seem to have influenced faculty employment status as the nursing faculty personnel remains stable, additional positions have been added, and no openings exist in leadership or faculty positions. Yet the nursing faculty crisis continues to be identified as a major wokforce issue at the present time with projections for continued growth (Allan & Aldebron, 2008; Potempa, Redman, & Landstrom, 2008; Scherzer, Stotts, & Fontaine, 2010; Toto, Bostian Peters, Blackman, & Hoch, 2009). In December 2010, the KSBN reported 43 nursing faculty hire exceptions and 52 faculty degree plans with more exceptions and degree plans to be processed for the current academic year (Moreland, 2010). At the same time, the most recent reports on the nursing shortage and nursing faculty shortage indicated the most concerning shortage is doctoral- 108 prepared nursing instructors (American Association of Colleges of Nursing, 2010a; American Association of Colleges of Nursing, 2010b, American Association of Colleges of Nursing, 2010c; KSBN, 2010). The AACN also reported that although the nursing profession employment vacancies declined as a result of the recession, the nursing faculty crisis did not demonstrate the same indicators of relief. In 2009-2010 lack of qualified faculty applicants was the primary reason for open positions at nursing programs across the United States (AACN, 2010c). At the same time data continue to suggest that openings for administrative leadership positions in nursing programs is still a nation-wide concern (AACN, 2010a). And again, this nursing program continues to keep its leadership positions filled and stable. An intentional hiring process for the dean including nursing faculty, provost, and a professional search firm seems to assist the institution in finding the type of nursing administrator needed for the nursing program at that time in its history, continued growth and development. Historically, when there has been a change in deanship, the nursing faculty has remained stable. If any of the nursing faculty workforce challenges are similar at the case study school, it would be the age of the nursing faculty. Of the novice faculty who joined the nursing program over recent years, each had at least 25 years of excellent clinical practice experience prior to being employed at this nursing program. Several had previous clinical education experience, had served as adjunct clinical faculty, or recently completed degrees including graduate level courses in preparation for the nurse educator role. The workforce while novice at teaching was not a significantly younger workforce to replace the seasoned faculty and administrators preparing for retirement over the next 10-15 years. At the case study school, nursing faculty was pursuing terminal degrees with national average salaries. This is unlike what was reported in a recent Kansas survey of nursing programs. 109 Carrico, Fund, Fell, & Hornberger, (2011) discussed factors influencing nursing education in Kansas. This study replicated items of a 2005 study of Kansas nursing faculty. The authors reported an ongoing shortage of nursing faculty in Kansas, with 23% pending faculty retirements in the next nine years. All are at the PhD or MSN educational levels. No pending faculty retirements were noted for faculty with BSNs. Nursing faculty retirements were beginning with 2.3% in past two years. More startling was the reported 13.7 % faculty turnover. Nursing faculty salaries in Kansas continue to vary from $22,500 to $118,000 standardized to a 9-month pay period. Administrator salaries were standardized to a 12-month pay period and ranged from $52,000 to $128,000. Average student contact hours per week were 21.3, ranging from 11-31. Nearly 37% of the reporting schools do not have faculty incentives or financial support for faculty to return to school to advance their educational degrees. This case study demonstrates one school‘s outcomes when policy supports career advancement with multiple interventions. While Carrico et al., (2011) suggested that the nursing faculty salary gap is closing with a $8,517 gap between FNPs and 12-month nursing faculty member salary, The authors reported the MSN maximum mean at $54,407 and the PhD maximum mean at $79,076. Perron & Gerchufsky (20110 reported the average full-time NP salary at $90.770 for 2010 with physician assistants earning an average salary of $96.876. This nursing program‘s salaries were reported to be mid-range when compared to other nursing programs. Nursing administrators leveraging higher nursing faculty salaries are reported in the literature. Yucha & Witt (2009) discussed use of the nursing faculty shortage data, faculty salary data, and nursing program enrollment growth to successfully negotiate higher nursing faculty salaries. This strategy resulted in increased faculty recruitment and retention for one nursing program. This program‘s workload criteria were similar to the case study program. 110 Transforming Nursing Education Case study school was an early adopter and innovator for decades with the development of RN-BSN program, LPN to BSN program, and several of the MSN programs, including being one of the initial CNL programs in the United States. Allan & Aldebron (2008) described nursing as ―a profession that has become increasingly sophisticated, specialized and expansive in response to rapid advances in medical technology‖ (p. 286). This nursing program was consistently innovating to stay current with practice in its numerous nursing program offerings. As several seasoned faculty shared, curricular revision, continuous improvement, and trying new curricular interventions was a part of being at this nursing program. Nursing professors as the first teachers of nursing students make critical impressions upon novice learners at every level of nursing education. This was evidenced at the case study nursing program with the pre-licensure students, the RN to BSN students, and in the graduate students who participated in this research study. For the pre-licensure students they were overheard speaking about how they wanted to be just like their clinical instructors who were so kind and caring, and that they wanted to be certain to stay in touch with them after they graduated from this nursing program. In contrast the RN to BSN nursing students compared their previous nursing education experiences with what it was like to be at this nursing program. Two striking differences emerged: (a) these students shared that the faculty at this nursing program were knowledgeable, kind, and caring, and seemed to want the students to be as successful as possible at the baccalaureate level; and (b) these practicing nurses also had the privilege of observing this nursing program‘s faculty work with the pre-licensure students in the clinical setting and recent alumni. Each who had previous experience with a pre-licensure student-faculty interaction or recent alumni were very complimentary regarding the holistic patient-centered 111 caring approach and professional role socialization of nursing students at this nursing program. Stacey (2001) discusses this on two levels in complex responsive organizations: institutional memory and the importance of interpersonal relationships. The nursing faculty at this nursing program used reflective journaling with the pre- licensure nursing students in their mentoring groups and was highly protective of the privacy of the students, and their journal documents to establish group trust. This was perceived as an important and successful innovation in the nursing program from student and faculty course evaluations. Epp in 2008 reported systematic review of the literature from 1992-2006 regarding use of reflective journaling in undergraduate nursing education and noted that reflective writing improves over time and flourishes in an environment of trust (Epp, 2008). As one seasoned faculty participant shared, ―I have been on the undergraduate curriculum committee off and on my entire life here, so I have helped develop many iterations of our undergraduate curriculum. When we started the mentoring groups – was probably one that made me happiest.‖ This participant shared further the reasons for creating this curricular change: a time for caring discussions and relationship building, to role-model nursing, to create a long-term opportunity to enhance role socialization, and a safe environment to discuss the difficult issues in nursing today. The nursing faculty was ahead of the needs of nursing education and practice as they were already implementing some recommendations of Benner, Sutphen, Leonard, & Day, such as space to create meaning in learning nursing, incorporating ethics in everyday practice, and infusing caring deeply into the nursing curriculum and everyday interactions/dialogues at this nursing program (2010). This case study research supported the findings of Ironside & Valiga (2006a). Ironside, & Valiga (2006a) reported findings of the national faculty survey, stating: ―Concerns about the 112 current generation of students are frequent fodder for faculty lunch conversations and are often addressed at conferences and workshops. In general, these concerns center on the perception that today‘s students are irresponsible, uncommitted, disrespectful, and lazy.‖ The authors suggested that these common concerns merit rethinking. In this study, there was a noted lack of faculty, administrator, staff, or student complaint or discussion of other personnel. The level of personnel engagement through professional role socialization based upon the institution‘s mission and values; Nursing‘s Social Policy Statement; Code of Ethics with Interpretive Statements; and Nursing: Scope and Standards of Practice seemingly diminished this type of behavior at the case study nursing program (ANA, 2001; ANA, 2003; American Nurses Association, 2004). Ironside and Valiga (January-February, 2007) suggested the NLN hallmarks of excellence were based on an assumption that excellence is not a static. They suggested that achieving the NLN Center of ExcellenceTM designation is not a once and for all achievement, but is related to continuous improvement and that innovation should be persistently sought after and consistently evident at the same time in an academic nursing program. The findings of this part of the national survey on excellence in nursing case education noted that implementing innovative strategies tended to occur more likely in RN to BSN and graduate programs, and that possibly more could be done in basic pre-licensure programs. Valiga in 2010 continued to write on excellence in nursing education and challenged nursing faculty to consider this notion that excellence is a ―habit or way of life‖ (p. 427). She challenges teaching faculty with multiple strategies to place themselves and their teaching at a new level toward the goal of excellence and not succumb to the status quo or allow mediocrity to be awarded. At this nursing program, many of these strategies were already implemented with the nursing faculty. 113 Early adoption of creative interventions and new programs was only the surface of the innovation at this nursing program. Their programs for the underrepresented, at-risk nursing students were novel and exemplary. Each intervention was evidence-based and developed as a result of intense study of the literature and or their pilot studies and research. Seasoned faculty provided many examples of being the first in the region to implement innovations in nursing education at this nursing program. Most recently, changes to pre-licensure BSN programs was identified by the NLN as an area of nursing education in need of transformation. This program had already initiated the process. Following implementation of a major curriculum change the graduates successfully passed the NCLEX-RN examination with a 100% pass rate. The program was grounded in a legacy of strong leadership and founders who supported innovation at this nursing program. As early adopters of change this program often was quietly implementing change and producing nursing leaders before the ideas and concepts were in nursing or educational literature. It was their collective, decentralized, positive self-organizing behaviors that kept this nursing program quietly at the forefront of transformational change. This change behavior is described by Crowell (2011) in discussing organizational culture in Complexity Leadership: Nursing’s Role in Health Care Delivery. For example, recent articles identified the need for pre-licensure change, programs for students of diversity, mentorship models for novice faculty, creating cultures of safety, mentoring, creating open space, and reflective journaling. Each of these topics have already been considered, implemented, and evaluated at this nursing program (Crowell, 2011). In addition, the daily importance and imbeddedness of ethical comportment for the deans, faculty, staff, and students was a part of what made this program a culture of excellence. As described by Benner, ethics in their everyday nursing work was so much a part of their daily 114 work (Benner et al., 2010). The respect faculty, staff, and administrators held for human beings; students rising to faculty expectations; and students & faculty reaching to meet nursing program standards were just the way things were done around there. When students did not meet the academic standards they were still treated respectfully and in an ethical manner. Course, college, or career choices were explored after failing a course or the program. The nursing faculty, staff, students, and administrative leadership spoke of working, learning, and growing together at this nursing program. An environment of camaraderie and civility was observed from the first immersion visit. Ironside (2005) suggested when studying excellence in nursing education that working together and learning together creates community building and serves to diminish feelings of isolation and competition for both students and teachers. The findings of this case study supported the work of Sawatzky & Enns (2009a). This school as an early innovator has been informally mentoring and deeply caring for their novice faculty for decades. Mentoring was deeply rooted in the tradition of this nursing program. Sawatzky & Enns (2009a) supported ―A caring mentoring environment is an important and timely strategy to ensure that the integrity of nursing education is sustained in the years to come‖ (p. 149). Boyd & Lawley (2009) and Smith Glasgow, Weinstock, Lachman,, Dunphy Suplee, & Dreher, (2009) also reported positive impacts as a result of mentoring or formal coaching programs for new faculty or academic nursing administrators. For both, these types of programs seemed important to the retention of nursing faculty human capital. Sawatzky & Enns (2009a) supported the relevance and timeliness of mentorship of novice nursing educators. ―There is a dearth of publications specifically related to the mentoring of nurses as educators. Moreover, although caring theory is central to most nursing curricula__ it 115 is generally not reflected in the mentorship programs of novice educators‖ (p. 146). Sawatzky & Enns in 2009 supported academic administrators and seasoned faculty accepting responsibility for mentorship of students and faculty as a means for moving a nursing school toward excellence. This case study provided one nursing program‘s approach to managing nursing faculty workload, with a history of low-turnover, and teaching faculty with master‘s degrees and/or progress toward terminal degrees or having earned terminal degrees. This case study nursing program‘s culture seemed to encourage nursing faculty to return to school. The novice faculty was successful at earning terminal degrees while remaining employed full-time. There seemed to be an overall sense of respecting workload and life balance for these faculty members to succeed in their new roles and in terminal degree programs. These practices were consistent with Swearingen & Hayes (2009) recommendation that careful attention be paid to effective management of faculty workload in this era of nursing faculty shortage. The case study‘s findings were similar to work by Schumacher, Risco, & Conway in 2008. The Schumacher Model proposes a model for novice and seasoned faculty to work together in a mentoring relationship. Trust and respect are key constructs of this model as faculty work together to minimize real or perceived barriers toward ―the ultimate goal of fostering nursing scholarship, excellence, and faculty recruitment and development.‖ (p. 571). Novice faculty and seasoned faculty came together to share their professional talents and gifts. Key topics of the Schumacher Model are: vision, trust, respect, commitment, scholarship, excellence, faculty role orientation, development, socialization, service, and future leader development. This model promotes both one-on-one mentorship relationships and mentoring of new faculty by the entire faculty workgroup (Schumacher et al., 2008). Underlying this model are major tenets of 116 nursing: caring, competence, respect, and excellence. Similarly, Altuntas & Baykal (2010) identified when nurses trust their managers, organizational trust is higher and the nurses‘ demonstrated more frequent organizational citizenship behaviors, such as conscientiousness, courtesy, and altruism. Organizational Culture in High-Performance Organizations This study‘s results were similar and supported common descriptors of high-performance organizations as previously identified in the research literature and program standards documents of programs such as the ANCC Magnet Status Recognition® program, AACN Beacon Award for ExcellenceTM, Baldrige Awards for Excellence in Education (2011-2012), and the Higher Learning Commission‘s AQIP criteria of a high-performance academic institution. Since this nursing program had received the NLN Center of ExcellenceTM designation it was not unexpected that similar findings may have been a result of this study. But beyond these commonly identified criteria this nursing program‘s culture of excellence uncovered important additional findings: (a) the importance of mission and values guiding everyday interactions and outcomes; (b) an intentional caring culture cultivates human growth, learning, and civility; (c) the importance of keeping the heritage alive with stories and events encouraged a drive toward excellence; and (d) creating camaraderie to work, learn, and grow together was described as being a community with a soul. It seemed when these factors were present the ability to recruit and retain qualified students and faculty were not issues for this nursing program. This academic nursing program was strengthened by a culture where students, faculty, and staff come together as a nursing community of learning. As noted in the literature multiple studies identified the importance of culture as a characteristic of successful, high-performing organizations (Nelson et al., 2002; VanDuesen et al., 2007; AA-CCN, 2007; ANCC, 2007). In 117 this study, the nursing administrators, faculty, staff, and students came together in their daily work and learning as a community to help each other on their journey: toward a nursing degree, an accreditation report, a new grant proposal or management, a new course or innovative idea, toward achieving tenure or promotion. Withholding of information, lack of follow-through, or setting one up for failure was not a part of this nursing program‘s day to day business. Sawatzky & Enns (2009a) reported five key findings that are very similar to the findings of this case study. The only major finding of difference was the case study nursing program‘s ability to recruit, hire, and retain qualified faculty and administrators whereas Sawatzky & Enns reported different findings. Sawatzky & Enns (2009a) findings included: (1) ―fitting in‖ was important; (2) trustworthiness and respect were key; (3) administrative support was key infrastructure; (4) access to support services were important resources however tended to be underutilized; (4) faculty shortage due to aging professoriate; (5) faculty salary gaps are growing at an unprecedented rate and making recruitment and retention of nursing faculty more difficult. These participants were able to articulate the difference between the case study program‘s graduates and graduates of other nursing programs in the area. They were described as being kind, caring, knowledgeable, and hard-working registered nurses. These nurses tended to do the extra something for the patient and/or their family that made the difference in the perceived quality of care or patient outcomes. For the graduate student participants most had identified a nursing professor they wanted to be just like: either an FNP or educator. For some it was to be like an alumnus practicing in nursing administration near the institution. At this case study nursing program the sound management processes enabled the nursing administrators, faculty, and staff to engage in their day to day work with ease. Support to make informed decisions in alignment with the institution and departmental policies and procedures 118 moved nursing program work forward with ease. Active clinical practice was supported within the policies and procedures for faculty active practitioner roles maintaining licensure in this nursing program‘s state. This management support is congruent with the identified major areas for standards of excellence by McClure et al. in 1983, particularly: (1) management, philosophy, and practice; and (2) support for professional practice. Data from this case study research in an academic nursing environment were thick and rich with examples of the ―deeply woven cultural context‖ and its influence on the day to day interactions and decisions of this nursing program. Goode et al. (2005) referred to Magnet recognition as the ―gold standard‖ by creating optimal work environment for nurses. Simply creating good structures-processes-outcomes did not create positive results unless the cultural context is a deeply woven part of the structures-processes-outcomes of the organization. This case study‘s findings were similar to Aiken, Havens, & Sloane 1998 study (2000) and Upenieks work (2002) which identified: exemplary administrative leadership, adequate staffing, time to discuss situations, perception of being appreciated or highly valued, autonomy, engaged participation, and respectful work environments as characteristics of organizations creating and sustaining environments of excellence. As Hinshaw (2002) and Urden & Monarch (2002) reported cultures of excellence resulted in evidenced improvement of recruitment and retention of nurses across diverse studies. These findings are consistent with the data and participant interviews of this case study. Or as stated by several faculty participants in a variety of ways: ―It must be a good interview process who they select here,‖ ―It is about a good fit-for me and the nursing program‖, ―Oh, no one really ever leaves here,‖ and ―They usually retire or die. Oh a few have left, but very few and I‘ve been here a long time!‖ This nursing center of excellence had no current faculty openings 119 and the researcher had not observed any open posted positions over a period of two years. Consistent with the ANCC‘s (2007) reported benefits and outcomes for patients and RNs in Magnet facilities, this nursing program also reported a perception of better student satisfaction and outcomes, increased faculty time with the students, consistent ability to attract and retain nursing faculty and students, and increased faculty satisfaction. These perceived and factual outcomes were in existence before the NLN designation. The intentional caring relationships and extra faculty effort were significant cultural characteristics influencing these positive outcomes. Sawatzky, Enns, Ashcroft, Davis, & Harder (2009b) also noted the importance of caring in nursing curricula and nursing program relationships. In 2003, McManis & Monsalve Associates in partnership with the American Organization of Nurse Executives suggested six critical success factors including leadership development and effectiveness, empowered collaborative decision-making, work design and service delivery innovation, values driven organizational culture, recognition and reward systems, and professional growth and accountability when striving for excellence. Most notably the ―values driven organizational culture‖ and recognition and reward systems were identified more explicitly in McManis & Monsalve Associates (2003) work. This institution and nursing program was clearly a values driven organizational culture and aligned their recognition and reward systems with the mission, values, and heritage of the institution and nursing program. These alignments provided special meaning and memories when staff, faculty, and students were recognized for special achievements and for extra-work efforts. Congruent with contemporary literature on creating cultures of trust as discussed by Covey (2006), Shockley-Zalabak; Morreale, & Hackman (2010), and Singahl (2006) in their recent work on the topic, these forms of recognition supported their trust environment. A culture 120 of trust at this nursing program, however, was so deeply ingrained that participants did not discuss the lack of trust or feeling mistrusted. The trust, respect, and integrity observed at this nursing program were consistent with the literature on high-performance organizations, particularly the work of Shockley-Zalabak et al. (2010) who reviewed over 3500 published articles on trust and compiled their meta-synthesis into strategies for building high-trust organizations. Their work was also complementary to the contemporary study of dyadic relationships and organizations as complex adaptive systems (Stacey, Griffin, & Shaw, 2000; Stacey, 2001). Complex adaptive systems of the human nature are founded in rich dyadic relationships. These dynamic relationships create multiple intersecting connections both internally and externally in the professional work of nursing and outside to other professional disciplines. In complex adaptive systems, the leadership sets the communication tone of the organization and works to eliminate silos within the organizational chart and work. In complex adaptive organizations, order and disorder will exist; however, order is greater and disorder is quickly embraced to create new and higher order for the relationship, work group, or organization. This dynamic property promotes emergence of innovations and supports positive deviance when embraced by the leadership (Zimmerman, Lindberg, & Plsek, 2001; Lindberg, Nash, & Lindberg, 2008; Sternin, 2002). While excellence informed all major decisions it was also about the seemingly small things, like morning greetings, inviting the researcher to join in on a formal mentoring session with a novice faculty member, helping each other cover clinical days or classes, voluntarily coming together to work on the dean‘s five priorities for improvements during the academic year, or meeting with a worried student that really made excellence come alive for this nursing 121 program. Collectively, it was the consistency of excellence in the small acts rather than a focus on a few big changes that supported the students, faculty, staff, and administrators toward a culture of excellence and adaptation. As a result, greater than expected outcomes occur when small, but significant changes are embraced by all. This nursing program seemed to have the qualities of a complex adaptive system with ability to be an early adopter of change and innovation. The nursing faculty self- organize to create new nursing education interventions for their students with a synergy that is noticeable to those who intersect with this work group. Their outcomes with a very diverse nursing student population, faculty recruitment and retention, and percent of nursing faculty with or seeking terminal degrees are all greater than anticipated outcomes for this nursing program‘s administrative leaders. Summary The defining cultural factors at this nursing program were identified by answering a primary research question and three secondary questions. The primary research question was answered with a graphic representation as a result of the iterative coding process. This nursing program was a welcoming place with intentional caring relationships grounded in the mission and values of the institution and nursing program. The students were at the center of the nursing program. The chief administrators of this nursing program historically provided a long, legacy of valued nursing leadership. Each provided the type of management style and vision for the nursing program that was needed at the time of their administration. These various leaders achieved different goals yet typically led in alignment with the mission and values of the institution. Those who served shorter terms or in interim roles were valued for their leadership 122 with no striking differences between those who served significantly longer terms. The institution‘s focus on administrative leadership as a part of its legacy created a foundation for excellence. For example, the strong focus upon nurses‘ socialization came from a dean who served over 20 years ago, while a recently hired dean was perceived by several faculty as one who ―shook us up,‖ creating the dynamic leadership team of nine people, facilitated the clinical tenure track, and re-ignited faculty scholarly publications and presentations in areas of expertise. This dean was fondly known as the dean with ―an article in her pocket‖ because she was very adept at empowering faculty and creating freedom to develop whatever was in the best interest for their nursing students. For one faculty member attempting to describe excellence at this nursing program, as many, struggled with this question. Often for them it was just the way we do it. After a period of reflection, this reflection captures what it was like to be a part of this nursing program: When I worked at another academic health center, it was a wonderful institution that is very elite. We did cutting edge stuff there. It is very hierarchical. They paid you well, it was wonderful work, I loved the staff I worked with, and I liked my boss. When I compare the two places, now that I am out of there, it‘s like that place doesn‘t have a soul, and this place does. People here really do care. Now, individually, people there care a lot, too, but collectively, it is different. It is just a feeling you get of the culture, somehow. It‘s just different. ―Just different‖, however, was not only what made this nursing program excellent. It was the whole, not the parts, and it was the small things that people did for and with each other. It was about the program‘s foundation, heritage, mission and values; the nursing program‘s 123 transparency; the vibrant academic nursing community; and being a good fit for those who intersected with this nursing program and its people or as stated by an external participant, ―the nursing program is definitely the crown jewel of the institution‖. The program held many of the traditionally documented and acceptable standards of excellence in academia: (1) highly qualified faculty, (2) adequate resources, (3) scholarly research and publications with evidence of research trajectories in seasoned faculty, (4) contemporary clinical practitioners, (5) external funding resources, (6) exemplary leaders, and (7) excellent NCLEX-RN and certification pass rates. In the end, however, it was the ―intentional relationships‖ that made this program different in its daily interactions among its students, staff, faculty, partners, and administrators. 124 CHAPTER 5 Summary, Recommendations, and Conclusion This chapter provides a summary of this qualitative study, including recommendations from this study: implications for future research and for nursing programs; suggestions for solving the nursing faculty shortage and creating academic leadership development opportunities; and suggestions for local, regional, and national nursing faculty policy development. The chapter ends with concluding statements. Summary The purpose of this study was to identify the important factors that constitute the culture of a nursing program previously designated as a center of excellence. The case study nursing program‘s naturalistic environment provided a rich field of study where culture was explored through general, classroom, and meeting observations; nursing and public events; participant interviews; and selected artifact reviews. This nursing program was an exemplar of academic nursing excellence. The nursing program‘s personnel was highly relational with the nursing students and other key stakeholders through a model of holistic intentional caring for humans. This was deeply rooted in the history of the nursing program: its mission, values, and leadership. At the same time the program embraced contemporary pedagogical and technological change constantly innovating to meet the demands and changes in academia and professional nursing practice. The study provided answers to the research primary research question and secondary questions. The primary research question supported development of an initial graphic representation of the defining cultural characteristics at one case study nursing program. The Right Fit: Harmonious Alignment and three themes: (1) A firm foundation, (2) Nursing program 125 transparency, and (3) A vibrant academic nursing were supported by 12 patterns and discussed in detail in Chapter 4. The most significant finding of the study was the importance of creating intentional caring relationships aligned with the mission and values of the institution and nursing program. These interactions created an environment of caring and resulted in designing intentional interventions to support student and faculty success, such as formal and informal mentoring programs to bring students, staff, and novice faculty into full role participation. The development of these values-based relationships also seemed to diminish any evidence of competiveness within this vibrant academic nursing community. The result was a culture of intentional caring where trust, respect, integrity, and civility were the norm. Intentional caring was experienced at every level of this nursing program‘s structures, offerings, and by this researcher in the typical day to day interactions. It was really just the way ―they did things around there.‖ The result seemed to be evidenced in the exemplar graduates who fully embodied what it was to be a professional nurse academically, physically, emotionally, socially, and spiritually. Overall, key findings from this study were: A firm foundation based upon the mission and values of the institution and nursing profession and program provided the opportunity to create and maintain a culture of excellence. A culture of trust, respect, and integrity amongst the students, faculty, staff, and deans supported intentional caring relationships. Creating a vibrant community of learning required the co-existence of multiple intersecting cultural factors at this nursing program. Keeping the student as the focus 126 of the nursing program‘s work it was the six components of the vibrant academic nursing community supported this dynamic nursing program. Novice faculty hired to teach at this institution were successfully mentored into academic roles. The environment of civility, professional role modeling, and committed ―investment‖ by the nursing faculty and administrators resulted in increased recruitment and retention of diverse socioeconomically and disadvantaged nursing students. These minority or under-represented students were successful in achieving academic degrees in nursing; passing licensing and certification examinations; and advancing into leadership and management positions within the profession. Professional role socialization was an outcome of the mentoring classes, ongoing faculty development, and the caring environment where the nursing personnel and students learn, work, and grow together. This culture created a different type of nursing graduate who embodied the basic and enduring tenets of professional nursing practice. This was described as being caring, kind, knowledgeable, and whole-person oriented. Clearly defined hiring, admissions, and retention processes supported discernment of fit for faculty, staff, and students at this nursing program. This included faculty and staff alignment of individualized curricular and program workload assignments; discernment of student academic nursing interest, abilities, and need for academic support; and implementation of ethical retention practices within the nursing program. Each of these processes was in alignment with the institution‘s mission and values. 127 Excellence is not obtained or static; it is a level of achievement consistently desired: to continuously improve upon the current state of excellence. This study suggests that culture is deeply imbedded and difficult to describe by those who go about their daily work in the same place over time. In the staff, faculty, and dean participant interviews the study‘s definition of culture was the most difficult question to answer. It seemed the researcher pressed participants to describe the way in which they came to know how to do things at this nursing program. As a dean stated one day, ―I can't imagine what you're seeing or what you see through your eyes; it's just the way we do things‖. It was only through reflection and being given space to think about the posed question that faculty, staff, deans, and students were able to share experiences and stories from which the treasured values, norms, and relationships came to life. It was difficult with one naturalistic inquiry study to determine what came first or which findings were most influential in creating the observed culture. Or, is it the whole that fosters achievement and perpetual striving for academic nursing excellence? Overall, the findings of this research were consistent and complementary with current literature regarding the transformation of nursing education and high-performing organizations. Parallel to the development of the initial 14 forces of magnetism this study serve as the initial defining characteristics of excellence in nursing education with the opportunity for additional research studies. This nursing program is not experiencing the nursing faculty recruitment and retention problems or leadership gaps as identified in the AACN faculty shortage literature. One might suggest that this values-driven culture of intentional caring is a protective factor at this nursing program. 128 There was a high level of consistency with the major components of the NLN Model of Excellence. Three observations were made for further consideration and dialogue. First, the importance of mission and values emerged as significant to creating a culture of excellence. While the case study nursing program wrote extensively about this in its NLN Center of ExcellenceTM document, it does not seem explicit in the NLN Model of Excellence at this time and may warrant further investigation. Second, the importance of nursing program transparency emerged as foundational in creating a vibrant academic community of learning. The importance of this theme and the patterns of trust, respect, and integrity are also areas that may be of interest for further investigation within the NLN Model of Excellence. And finally, the NLN Center of Excellence documents use the language highly qualified students and qualified students. The outcomes of this nursing program suggest further investigation into these terms, their definitions, and nursing programs‘ criteria for student admission be explored. As the nursing profession continues its quest in the profession to mirror the demographics of our communities it is important for student admission criteria to be based upon factors of student success. This case study program‘s success may add data to contemporary admission evidence of best practices. Given the nature of this study, the results have been interpreted in the context of the case study nursing program and institution. The idea of being the right fit may work across nursing program contexts, if the fit is right. Therefore, this is not an open ended implication as a single case study and warrants further investigation. Recommendations from This Study This study provides recommendations in three major areas of nursing: future research studies, implications for nursing programs, and policy development to address the nursing 129 education crisis. In the area of nursing program education, implications are suggested for the program administration/development, faculty recruitment/retention, and leadership development. Implications for Future Research Conduct a follow-up study of the NLN Center of Excellence written submission reports data to further develop the graphic representation. Conduct a secondary analysis through lens of complexity theory with a focus on the non- linear relationships and outcomes of this nursing program. Replicate this study to further enhance the graphic representation‘s development at other NLN COE schools. Investigate further the RN-BSN students‘ voiced perceptions of respectful, caring student- professor interactions at this nursing program. Conduct a comparative interview analysis between the novice and seasoned faculty to further develop the concepts of ―fit‖ and professional role socialization. Conduct a meta-synthesis of major findings/criteria from programs/models of excellence. Implications for Nursing Programs Keep alive the heritage of the institution and nursing program. Balance contemporary innovations with the constancy of rich historical perspectives. Align the mission and values of the institution and nursing program to create a fit for key stakeholders. Foster trust, respect, integrity, and nursing program transparency. Keep the focus on the student. Base curricular innovations and revisions on the mission and values, global society, nursing profession, and what is right for the nursing program and the community it serves. 130 Purposefully integrate nursing‘s Code of Ethics and Social Policy Statement in providing intentional care in a high-tech health care environment into academic curricula. Create and sustain a community of learning with ongoing curricular innovation and continuous quality improvement. Maintain and implement contemporary sound management processes which are readily available and known to the personnel who use the information. Foster, maintain, and strengthen internal and external partnerships. Advocate for diversity of experiences, perspectives, and ideas, in addition to gender, race, cultures, and ethnicities. Solving the Nursing Faculty Shortage Grow one‘s own faculty internally from exemplar students interested in the professoriate or from recruiting alumni who have achieved faculty role preparation or a terminal degree. Provide opportunities to explicitly discuss the institution and nursing program‘s expectations of the professoriate. Create an alignment of mission, values, curriculum, and faculty to achieve the ―right fit‖ for the institution and nursing program. Develop multiple opportunities for professional role socialization through intentional relationships, role-modeling, and mentoring. Creating Academic Leadership Development Opportunities Select the ―right‖ administrative leader for the ―right‖ time in the organization‘s history. Create multiple and ongoing opportunities for leadership development at all levels in the nursing program and support leadership development opportunities within the institution. 131 Recognize achievements with a wide variety of meaningful formal and informal approaches which are aligned with the institution and nursing program‘s mission and values. Developing Local, Regional, and National Nursing Faculty Policies Foster fair and equitable faculty workloads. Support local, regional, and national leadership development at all levels of nursing programs. Recognize and value terminal degree achievement in the nursing professoriate. Introduce the Boyer model of scholarship (embracing PhD and DNP). Conduct research to support or refute the outcomes of this emerging model for tenure. Explore more deeply the definition and outcomes of the NLN‘s Goal 5 ―well-qualified students‖ and the effectiveness of interventions designed to support ―at-risk‖ students in competitive academic environments. Conclusions This research informs current and future deans, faculty, and policy makers regarding the important factors that constituted the culture of a high-performing academic nursing program currently designated as an NLN Center of Excellence in Nursing EducationTM. Identification of such factors provides information for other institutions seeking excellence in nursing education. Articulating the human, material or other elements/pillars that distinguished this organization initiates a scholarly dialogue of the key cultural elements for achieving cultures of excellence in academic nursing programs. The factors that emerged from the data in this program provide information to further study the ongoing nursing faculty shortage. Articulation of this exemplary nursing program‘s culture and early outcomes provide a foundation for future nursing education 132 research. The information obtained in this case study lends support to previous literature and research on the importance of culture or ―the way they did things around there‖ for academic nursing programs to consider the implications of their day to day interactions with students, peers, staff, and administrative leaders. This nursing program‘s final written submission report, appendices, exhibits, and this study resonated with the NLN‘s eight major criteria in the Model for Excellence in Nursing Education (a) student-centered, interactive, innovative programs & curricula, (b) recognition of expertise, (c) clear program standards and hallmarks that raise expectations, (d) well-prepared faculty, (e) qualified students, (f) well-prepared exceptional administrators, (g) evidence-based programs and teaching/evaluation methods, and (h) quality and adequate resources (NLN, 2006a). One criterion or title had been modified since the beginning of the NLN Centers of ExcellenceTM program was initiated: well-qualified students to qualified students. As previously stated this research suggests potential value in further investigating the NLN‘s and the profession‘s definitions of ―qualified nursing students‖. This nursing program‘s diverse student population, multiple academic interventions, and successful NCLEX-RN pass rates suggest several important considerations for future nursing education research and discussion. This nursing program was committed to serving underrepresented students of diversity. These students demonstrated the capacity for achieving success in the profession of nursing. Creating a culture of intentional caring where the nursing faculty was committed to putting in the extra effort needed to ensure student success creates the opportunity for rich dialogue and further investigation in nursing academia. 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For this program, "school" includes any designation for the nursing unit in the institution (i.e., College of Nursing, School of Nursing, Department of Nursing, Division of Nursing, etc.); "program" refers to the particular type of nursing program (i.e., practical nurse, associate degree, diploma, baccalaureate, master's, or doctoral), offered by the "school." GOALS Recognition by the National League for Nursing as a Center of Excellence in Nursing Education is designed to distinguish those schools that: demonstrate sustained, evidence-based, and substantive innovation in the selected area; conduct ongoing research to document the effectiveness of such innovation; set high standards for themselves; and are committed to continuous quality improvement. Such recognition indicates a commitment by the school as a whole to pursue and sustain excellence in student learning and professional development, development of faculty expertise in pedagogy, or advancing the science of nursing education. The designation of a school as an NLN Center of Excellence in Nursing Education is a voluntary process that involves preparation of material by the school itself and peer review. Recognizing the uniqueness of each school relative to its mission, the Centers of Excellence Program sets high standards and serves to truly distinguish and publicly recognize those schools that excel in a particular area. The goals of the program, therefore, are as follows: 1. Identify and reward those schools that excel in creating environments that enhance student learning and professional development, promote the pedagogical expertise of faculty, or advance the science of nursing education. 2. Encourage faculty to continually improve their schools. 3. Encourage research in nursing education. 4. Facilitate discussions among faculty, students, program graduates, and employers about excellence in nursing education and how to promote it. 5. Encourage the development of innovative schools that attract and retain highly qualified students and faculty. 6. Facilitate positive changes that re-form nursing education based on the application of evidence gleaned from research in practice and education. 7. Influence the development of public policies that benefit nursing education, support nursing education research, and promote excellence in nursing education. 156 ELIGIBILITY All schools of nursing that are accredited by a national nursing body (i.e., NLNAC or CCNE) are eligible to apply for recognition as an NLN Center of Excellence in Nursing Education. Since designation as a Center of Excellence is awarded to the school of nursing as a whole, schools with more than one program must show evidence of excellence in all programs. All criteria delineated in the application must be fully and clearly addressed with evidence provided as appropriate. CRITERIA A school will be selected for designation as an NLN Center of Excellence in a) Creating Environments that Enhance Student Learning and Professional Development, b) Creating Environments that Promote the Pedagogical Expertise of Faculty, or c) Creating Environments that Advance the Science of Nursing Education, based on the extent to which the evidence provided in the application indicates excellence and innovation in the selected area as specified by the criteria delineated below. These criteria were developed based on insights gained from a search of the literature and research related to the educational process. Creating Environments that Enhance Student Learning and Professional Development Research in nursing and higher education supports the need to engage students in the educational endeavor (Bean, 1996; Boyer Commission, 2000; Bransford, Brown, & Cocking, 2000; Dahlberg, Ekebergh, & Ironside, 2003; Diekelmann, 2001; Sinnott, 2003). This can occur through flexible curricula, innovative teaching strategies, and collaborative efforts between and among faculty and students in which mutual respect, empowerment, and trust are evident (Chickering & Gamson, 1991; Diekelmann, 1995, 2001; Diekelmann, Ironside & Harlow, 2003; Gordon, 2002; Ironside, 2001; Swenson & Sims, 2003). Schools will be recognized as NLN Centers of Excellence in Nursing Education based on the extent to which they demonstrate sustained efforts to enhance student learning and professional development that serve to truly distinguish them from other schools. The criteria used to define excellence in this category are as follows: Faculty are committed to a collective vision and implementation of a comprehensive plan that develops students' values and socializes them to new roles, professional involvement, commitment to lifelong learning, and creativity. Pedagogical research is used to develop innovative program designs that prepare graduates to engage in high-quality, evidence-based practice. Curricula are flexible and dynamic in order to (a) remain current and relevant and (b) empower students to pursue individual interests as they learn the practice of nursing. 157 Faculty, students, and clinical partners collaborate to ensure innovative, individualized, and evidence-based nursing education. The active engagement of students and faculty in their communities serves to enhance student learning and professional development, as well as advance the profession. Faculty are encouraged and supported to develop new pedagogies that create and sustain dynamic learning environments. Creating Environments that Promote the Pedagogical Expertise of Faculty Research supports the need for the continuous development of faculty related to the full scope of their academic role including their ability to envision, design, implement, and evaluate environments that enhance student learning and professional development (Gaff, Pruit-Logan, Sims, & Denecke, 2003; Gaff, Pruitt-Logan, & Weibl, 2000; Pruitt-Logan, Gaff, & Jentoft, 2002). Such goals also are supported in the National League for Nursing's position statements on The Preparation of Nurse Educators (2002b) and Lifelong Learning for Nursing Faculty (2001), as well as in the faculty competencies that have been developed by the NLN (Halstead, 2007; NLN, 2005b). Schools will be recognized as NLN Centers of Excellence in Nursing Education based on the extent to which they demonstrate sustained efforts to promote the pedagogical expertise of faculty that serve to truly distinguish them from other schools. The criteria used to define excellence in this category are as follows: All faculty are committed to a collective vision that promotes excellence in teaching, student advisement, and curriculum development. Faculty interactions with students and professional colleagues a) are characterized by mutual respect, empowerment, collaboration, and trust; b) promote innovation; and c) contribute to the creation of a preferred future for nursing education in their own school or for the profession. All faculty consistently develop their pedagogical expertise using the provided resources and support, to design and implement educational experiences that enhance student learning and professional development. There is a clear plan to evaluate and continually refine the faculty development program so that it is effective in helping faculty achieve their collective vision for growth as pedagogical experts and prepare graduates who are excited about learning and able to function effectively in practice. Insights gained from regular self, peer, student, and administrative evaluations are used to formulate and pursue personal goals and objectives related to excellence, innovation, and continued growth in the faculty role. Creating Environments that Advance the Science of Nursing Education In order to sustain excellence in nursing education, increasing attention has been focused on developing the science of nursing education (Diekelmann & Ironside, 158 2002; Ironside, 2003; National League for Nursing, 2002a; Stevens & Valiga, 1999). To this end, innovation in nursing education must be research based (Stevens, 1999). Recommendations from scholars such as these served as the basis for the criteria in this category. Schools will be recognized as NLN Centers of Excellence in Nursing Education based on the extent to which they demonstrate sustained efforts to advance the science of nursing education that serves to truly distinguish them from other schools. The criteria used to define excellence in this category are as follows: Faculty activities reflect a commitment to a collective vision that supports the utilization and conduct of pedagogical research that advances the science of nursing education. Faculty regularly undertake pedagogical projects or programs of research that advance excellence in nursing education. Faculty use research findings as the basis for curriculum design and for developing instructional strategies and evaluation methods that enhance student learning and professional development. Faculty advance the science of nursing education through ongoing research or other scholarly endeavors. Faculty contributions to the science of nursing education reflect dissemination through publications, particularly in peer-reviewed journals, or presentations in local, regional, and national forums. Faculty engage students in developing the science of nursing education by involving them in pedagogical projects and evidence-based nursing education. PROCEDURE Schools seeking designation as an NLN Center of Excellence must submit a preliminary application, accompanied by the initial fee, by October 15. This application will provide demographic information about the school, indicate the specific category for which the designation of excellence is being sought, and summarize activities related to each criterion. A consultant, selected by the NLN, will visit each school that has submitted a preliminary application to guide faculty and students in highlighting their strengths and emphasizing their uniqueness. Consultants also provide answers to questions related to the Centers of Excellence Program or preparation of the final application. All expenses related to this visit are the responsibility of the school. The consultant will write a summary of the visit and submit it to the school. The final application must document how all components of each criterion in the selected category is fulfilled by all programs offered by the school. This application must describe relevant activities and initiatives that serve to create an environment where excellence is pervasive. Since the supportive evidence is intended to showcase the school's excellence in the selected category, the material 159 submitted will be unique to each school. This final application, postmarked on or before May 31, must be accompanied by the remaining application fee. The Centers of Excellence Review Panel will examine all application materials and make recommendations to the NLN Board of Governors about Center of Excellence designations. All applicant schools will be notified of the outcome of the review and approval process. Those schools selected as an NLN Center of Excellence in Nursing Education will be granted that designation for the next three academic years and may use the designation and special logo in their promotional material. Schools not selected as Centers of Excellence may re-apply in subsequent years. Schools selected as NLN Centers of Excellence will be expected to participate in interviews about achievements related to each criterion, the impact the Center of Excellence designation had on student and faculty recruitment and retention, contributions to nursing science, and other relevant outcomes. Schools that wish to continue this distinction for an additional three years will receive specific instructions about fees and the application process. There is no limit to the number of times a school may submit an application for continuing designation as an NLN Center of Excellence in Nursing Education, and schools may hold designation in more than one category simultaneously. Throughout the three years they carry designation as Center or Excellence, schools will be expected to be available to other schools seeking to improve their programs. In addition, before their three-year designation expires, these schools are required to submit (a) an abstract for presentation at an NLN Education Summit, and (b) a manuscript for review and possible publication in the NLN's journal, Nursing Education Perspectives. Both of these submissions must describe the school's activities related to the Centers of Excellence designation (National League for Nursing [NLN], 2007). 160 Appendix B Centers of Excellence in Nursing EducationTM Designees by Category and Recognition Year(s) Creating Environments that Enhance Student Learning and Professional Development Community College of Philadelphia Department of Nursing 2004, 2007, and 2010-2015 University of South Dakota 2004, 2007, and 2010-2015 Villanova University 2004 and 2007 Excelsior College 2005 and 2008 Samford University 2005 University of Oklahoma 2006 and 2009 St. Xavier University School of Nursing 2007 and 2010 East New Jersey University - Trinitas 2008 Regis College - 2008 East Carolina University - 2008 Duesquesne University – 2008 Christ Hospital School of Nursing - 2009 UPMC Shadyside School of Nursing -2009 The Johns Hopkins University School of Nursing - 2010 Hunter Bellevue School of Nursing -2010 Creating Environments that Promote the Pedagogical Expertise of Faculty University of Louisiana – Lafayette 2005 The University of North Carolina – Greensboro 2005 and 2008 Indiana University- 2006 and 2009 Brookdale Community College – 2009 Creating Environments that Advance the Science of Nursing Education Blessing-Rieman College of Nursing 2006 Villanova University -2010 161 Appendix C Participant Interview Guide Interview #: Date: Participant Identifier: Orient self to participant and document in field notes the following information: A. Conversational interviewing style Presence Listen Sensitive B. Close Observation Space Time Body Relationships 1. General demographic information (as appropriate for the specific participant) Participant‘s Role with the Nursing program: Type of Education Pursuing: AD BSN RN-BSN MSN ARNP PhD DNS Other Highest earned degree: AD BSN RN-BSN MSN PhD DNS Other Number of years in school: Would you mind telling me how old you are? How long have you been a nursing student/faculty member/support person? How did you decide to become a nurse/support person? What brought you to this nursing program? Gender: Any other information you want to share with me? 2. The Interview: a. An Ordinary Day: The work of a nursing _________ is important and will continue to grow in importance as the nursing shortage increases in the near future. I would like for you to help me understand your work. What is it like as a nursing ________________ at this school (college/university)? For example, you might begin by telling me about what a typical day is like for you when you are in school. I realize that many days may not be typical, but let‘s begin with a ―typical day‖. How many of you (this type of position) are here at this school of nursing? How does your typical day match your job description? 162 b. 1. I Felt Really Good About My Work When: When was there a time that you felt really good about the work you do as a nursing ___________ in this school (college/university)? I‘d like for you to recall and share as many details as possible about what this experience was and what it was like for you personally. b. 2 What makes this a good place for ______to be? c. A More Difficult Time at Work Occurred When: Now let‘s turn to a more difficult time, when your work was particularly hard. As nurses we sometimes have difficult times, but it helps us to know and understand our work and dilemmas better. Can you recall a time when you (as a group of___________) were having a difficult time and how you worked through the situation? d. The Students in this Nursing Program: How are you involved with the other students at this school? Are there particular things you do for and/or with each other as group? What are the special traditions and stories of the ________ nursing students? What makes it special to be a student in the ______program at this university? Let‘s talk about this for a while. f. Creating Excellence in Nursing Education Nursing education is attempting to change the ways in which we work and teach students about our profession. Tell me about excellence in nursing education at _____. What does this mean to you and your colleagues as ________? (Think back to a time in this organization when you felt most effective and engaged in your career. Describe for me the experience. How you felt, what made this situation possible.) g. One way to develop an understanding of excellence is to listen to the richness of stories others have to share about their experiences in high-performing academic programs. Do you have a special story that would help me understand what it is like to be a _____________ at ____________________? j. For the Deans and Nursing Faculty: k. Do you have any special artifacts, relationships, or traditions you believe I should see or know about to help me understand what it is like to be a part of the ____________________ school of nursing? l. Is there anything else you would like to share with me that might be helpful information for my study? Thank you for your participation. 163 Appendix D Follow-up Interview Suggested Probes The last time we visited, you mentioned OR discussed ____________. Is my interpretation/perception an accurate description? Obtain more specific information as needed related to: Depth Clarification: contrasts, comparisons, evidence, contradictions Detail Pursue themes Draw out more information Bring attention to Examples Eliminate gaps in information Explore undefined terms 164 Appendix E List of Observations by Immersion Visit Immersion Visit Type Observation Specific Observation IV1 General Arrival on Campus IV1 General Skills Lab Area IV1 General Observations First Immersion Visit IV1 Tour Campus Tour IV2 General Within Nursing Program IV2 Public Event Commencement Liturgy IV2 Public Event Special Event Undergraduate Commencement IV2 Public Event Special Event Graduate Commencement IV3 Classroom #1 Nursing and The Arts Elective IV3 Classroom #2 PLUS IV3 Classroom #3 Concepts of Professional Nursing Soph II IV3 Classroom #4 Holistic Health Assessment RN BSN IV3 Classroom #5 Health Policy and Systems Finance Graduate IV3 Classroom #6 Bridge Course LPN RN IV3 Classroom #7 Health Policy RN BSN IV3 Classroom #8 Pharmacology Jr I IV3 Classroom #9 Community Health Sr I IV3 Classroom #10 Advanced Therapeutics Sr II IV3 Classroom #11 Nursing Philosophy, Ethics, Theory Graduate IV3 Classroom #12 Health Promotion Jr I IV3 Classroom #13 Psychiatric Mental Health Nursing Jr II IV3 General Computer Lab IV3 General Within Nursing Program Week #1 IV3 General Within Nursing Program Week #2 IV3 General Simulation Lab Area IV3 Lab Medication Administration Skills Assessment 1 Jr I IV3 Lab Medication Administration Skills Assessment 2 Jr I IV3 Meeting FACT Meeting IV3 Meeting Graduate Curriculum Committee IV3 Meeting Evaluation and Research Committee IV3 Meeting Leadership Council IV3 Meeting Student Nurses Association Board IV3 Public Event Community Presentation - Guest Speaker 165 IV3 Special Event Guest Speaker - Hosted by Nursing Program IV3 Tour Satellite Campus Tour IV5 General Within Nursing Program #1 Week #1 IV5 General Within Nursing Program #2 Week #1 IV5 General Lunch with Seasoned Faculty Member IV5 General Within Nursing Program Week #2 IV5 General People IV5 General Space IV5 Lab Clinical Simulation Sr II IV5 Meeting Undergraduate Curriculum Committee IV5 Public Event SNA Blood Pressure Checks IV5 Public Event Homecoming 5K Run/Walk and Outdoor Fair IV5 Special Event Local STTI Chapter Induction Ceremony IV5 Special Event Alumni Recognition Ceremony and Reception 166 Appendix F Consent Form Cultural Characteristics of a Nursing Education Center of Excellence: A Naturalistic Inquiry Case Study Informed Consent Introduction As a student, faculty member, staff member or administrator of a nursing program you are being invited to participate in a research study aimed at better understanding the defining characteristics of a nursing education center of excellence. This study is being conducted through the University of Kansas Medical Center with Leonie Pallikkathayil, D.N.S. as the primary investigator and doctoral student Tona Leiker, M.N., A.R.N.P.-C.N.S. as the co-investigator. Approximately 50 participants will be invited to participate in this study. The number of participants enrolled will depend on the amount of data obtained throughout the study. You do not have to participate in this research study. It is important that before you make a decision to participate, you read the rest of this form. You should ask as many questions as needed to understand what will happen to you if you participate in this study. Background Over the last quarter century, many individuals and organizations have repeatedly challenged nursing scholars to improve nursing education. Among those who have acted upon this concern is the National League for Nursing through the development of the Centers of Excellence in Nursing EducationTM Program. Factors influencing the most recent initiative include the current and future nursing workforce shortages, faculty turnover related to the aging nurse educator workforce, low faculty salaries in comparison to our practice peers, and the low percentage of nursing scholars with terminal degrees. At the same time, institutions of higher education are responding to political pressures to expand nursing program enrollments, improve graduation rates, and produce high-performing graduates. Purpose The purpose of this study is to improve understanding of the defining characteristics which exist in nursing programs recognized for excellence. Procedure Your participation in this study will involve being interviewed by the investigator at a scheduled time and place that is convenient to you. The interview will last about one hour, however, you may stop participation at any time. Some interviews may be individual and some interviews may be with groups of students, faculty, and/or other interested stakeholders of the nursing program. The interview will allow you as much opportunity as possible to share your thoughts about experiences in this nursing program. You may request to have a copy of the interview questions 167 in advance. You may be asked for, or may request another interview at some time after the first interview. In follow-up interviews, you will have the opportunity to discuss any further thoughts that you wish to add to your initial interview. You may also provide an update about your view of the nursing program. The researchers may ask questions to be certain that we understand the information that you have chosen to share about your views and experiences. These scheduled interviews will be tape-recorded. A transcriptionist will type out a written transcription of the audio-taped interviews. Your name and the name of the setting will not be used to identify these written transcripts. Transcripts will be identified by a code letter and number and known only to the research team. Participating in the study means that the researchers will want to know how you are getting along after the scheduled interview takes place. If you agree, she will greet and visit with you informally in the nursing program‘s settings. These informal encounters and conversations will not be tape-recorded. However, the investigator may take notes to help remember information shared. You understand that some questions may be answered by information in publicly written records, such as accreditation documentation, NLN Center of Excellence designation report and supporting documents, the University‘s web site, annual reports, or meeting minutes. Also, during the study you may be observed in everyday activities of the nursing program. You may be invited to share literature or events about the nursing program that will help the researchers understand the culture of this nursing program. You may also be asked to participate in a small session with other students, faculty, and/or stakeholders who are also participating in this research. You may be asked to participate in email or telephone conversations to verify and clarify research data obtained during the investigator‘s visits to the nursing program. A report of the study‘s key findings will be provided to the Dean, School of Nursing upon completion of this research study. Duration The research study is scheduled to last over several months. Initially, the researcher will be at the nursing program to gather general field information, set up interviews, and make observations in public areas. Subsequent visits will be for conducting additional observations, research interviews, and focus groups. Final contacts may be brief follow-up contacts, if needed, by email or telephone. The initial interview will last approximately one hour. Follow-up interviews may last 30 minutes to one hour in person or by telephone. E-mail follow-up will be used if in person or telephone contact is not an option or for very brief follow-up of less than 3 questions. Description of Events As a research participant, you will be asked to speak one or two times with the investigator, and possibly provide verification and clarification of research data and results by email or telephone. You may also note the investigator spending time in open areas of the nursing program, which 168 include laboratory settings, clinical practice environments, classroom sessions, break rooms, hallways and offices. Risks and Benefits There is a risk of a possible breach of confidentiality, however, information shared will not be individually identifiable. Protocols are in place to protect individual confidentiality. You may feel distress as a result of thinking about and responding to the investigators questions. There may be other risks that have not yet been identified and unexpected side effects that have not been previously observed may occur. You may feel uncomfortable during the interview. You may take a break, skip a question or quit participating in this study at any time. You are unlikely to personally benefit from this study. However, we hope to better understand academic nursing programs and help other interested persons and groups by defining cultural characteristics of a nursing education center of excellence. Alternatives The alternative to participating in this study is to not participate. Cost and Payments to Participants There is no cost/payment to me to participate in this study nor is there any payment. I may be offered food or snacks depending upon the agreed upon times to visit with the investigator. Confidentiality I understand the investigator will keep secret all research related records and information from this study; however, any records from this study may be inspected by a sponsor should funding be obtained for this study, a regulatory agency, and/or the University. I understand the investigator will not reveal my identity if the results of the study is published or presented. Institutional Disclaimer Statement If you think you have been harmed as a result of participating in research by Kansas University Medical Center (KUMC), you should contact the Director, Human Research Protection Program, Mail Stop #1032, University of Kansas Medical Center, 3901 Rainbow Blvd., Kansas City, KS 66160. Under certain conditions, Kansas state law may provide compensation to persons who are injured in research at KUMC. Voluntary Participation and Termination of Participation in Research Study Your participation in this study is voluntary and that the choice not to participate or quit at any time can be made without penalty. I understand that by not participating or quitting without any impact on your status as an employee or student of the University. Questions and Contact 169 You have read the information in this form. Before you sign the consent, the investigator should answer all your questions. If you have any more questions, suggestions, concerns or complaints after signing this form, you may contact Leonie Pallikkathayil, DNS, RN at (913) 588-3351 or Tona L. Leiker, MN, ARNP-CNS at 316-253-8735. If you have any questions about your rights as a research subject, or if you want to talk with someone who is not involved in the study, you may call the Human Subjects Committee at (913) 588-1240. You may also write the Human Subjects Committee at Mail Stop #1032, University of Kansas Medical Center, 3901 Rainbow Blvd., Kansas City, KS 66160. Consent The investigator provided information about how you will participate in this study and how long it will take. It is voluntary and there are no known risks or benefits. You agree to take part in this study as a research participant. You are aware that you may quit at any time or refuse to answer any questions that are uncomfortable for you. In the event that you decide to quit, the information you have already provided will be kept in a confidential manner. You understand that you will receive a copy of this form to keep for my records. ____________________________________ Type/Print Subject's Name ____________________________________ ______ _________________ Signature of Subject Time Date ____________________________________ Type/Print Name of Witness ____________________________________ __________________ Signature of Witness Date ____________________________________ Type/Print Name of Person Obtaining Consent ____________________________________ __________________ Signature of Person Obtaining Consent Date 170 Appendix G Sample Researcher Observations with Reflexive Notes Immersion Visit One As it is early in the morning, I realize this is the door/area that faculty use to enter the building in the morning. While the students are waiting to enter the skills Lab for their final skills check-off as first semester clinical students. Three faculty members stopped by and in particular, engage in conversation with the female Hispanic student who on each occasion shares that she is a new mother, and her baby arrived early, about a week ago, and was in the NICU for a short period of time, but was now home and doing well. Each faculty member was female and Caucasian and wanted to make certain the student was doing ok. All seemed to know that she should not have delivered this baby prior to the end of the semester. Between the faculty dialogues with the students they continued to study for their final skills check-off. One student was text-messaging on her cell phone…The students continue to gather as it was time for the next e xam sessions. Dialogue amongst the students begins regarding types of procedures, skills, dressing changes, medication administrations, insulin dosing, gloving, heparin dosing, etc. This included had to do in their skills check offs. It quickly became clear that comprehensive preparation was required. Quickly the students awaiting the exams returned to general review and clarifying areas of uncertainty, such as, ―May we use calculators?‖ ―Oh, I forgot my calculator!‖ ―You can use mine, if we need one.‖ The students then moved on to discussing exam preparation. One asked the others waiting if they had all eaten before coming this morning [Is this a part of the program? Teaching test taking strategies?] At that point, I noted the students awaiting their turn, pulling out what they called their review guides and becoming much more focused and intent on reviewing in the last few minutes before entering the exam setting. The tension seems to rise a bit, but overall the students are relatively calm considering the experience they are about to undergo. At this time another faculty member (female, Caucasian) comes into the building and asks the students: ―How are you doing?‖ There was general light dialogue and the Asian student states, ―At least we have a second chance on Friday.‖ One of the students waiting crosses her arms and legs and intently states: ―Ok, I know this!‖ while studying intently papers in her hands. The students then discuss the method for preparing an injection and when to put air into the syringe and vial. The conversation changes as a student comments: ―She is like a saint. She is my clinical instructor. I want to be just like her when I am a nurse. I can see myself coming back to visit her when I have graduated and am working. I want to stay in touch with her when I graduate.‖ At 9:30 am a student was in the lab crying quietly. Did she fail the check off? Or was something else going on? It takes little time for a faculty member to stop by and visit and I over hear quietly something about car issues. The faculty member stays with the student visiting quietly in the computer lab for a few more minutes [I don‘t really know who the faculty are, so it was difficult to describe who was doing what yet. I have so much work to do to come to know the nursing program and its ways.] 9:40 am another faculty member came in and students were still waiting for their exams, book bags still being left in the hallway. Three students were working together on the computer. One left when they took a phone call on a cell phone. The faculty member spoke briefly with the 171 students providing quick reassure of their ability to do well this morning. [It seems the faculty was acutely aware that this was a big event for this level of students today.] A faculty member doing the exams was checking on the students and how they are doing in between each of the competency exam sessions. I stay for a while longer. The rhythm of the morning seems set, students enter, take their competency exam and leave. Students are arriving about 20-30 minutes ahead of schedule and are leaving almost immediately after they have finished their obligation. Book bags and purses lay in the hallway as students take no textbooks or personal items with them into the skills lab area except their pencils. No one seems concerned about the security of their personal belongings. Immersion Visit Five What was interesting was I have never heard student‘s complaining about the work, on breaks between classes, before classes, or after classes. They seem to take it all as a part of ―becoming a nurse‖. Faculty members are not talked about in public forums or during break in general. At the same time, students are not talked about in public forums. There was a level of respect or a culture of expected behavior that I cannot seem to get to. It seems to be so deep that it was as if it doesn‘t cross the students or faculty members‘ minds to discuss….it was so deeply ingrained in the fiber of the organization. Students are respected, staff are respected, faculty are respected, administration is respected [Does this come from the founders? And/or, is it the strong women of the nursing program?] When disagreements exist, the disagreement is discussed, not the personalities. Boundaries are clearly defined when decisions need to be made, yet, decisions and boundaries are not held over people as the way to do the day to day work. Faculty was engaged in helping students learn, whether in the classroom, in small group sessions formally or informally, or individually. It seemed this way for me as well. As a doctoral student, I became a student of ―theirs‖ and it was important for them that I succeed in my work. At first this seemed like gracious hospitality, and it was, but it was deeper in the core of the institution…it was about bei ng true to the mission of the institution and its core values, which I heard on several occasions: baccalaureate liturgy, undergraduate commencement, graduate commencement, on the flags flying on campus, from the dean, in the interviews. The core values: respect, compassion, excellence, service, hospitality, integrity, diversity, learning for life. 172 Appendix H List of Artifacts and Photos Item Type Date Item Description Certificate 2003 CCNE Accreditation Certificate Certificate 2007 NLN COE Designation Certificate 2008 AACN Membership Certificate 2008 NLN Membership Drawing Moon and Stars Plaque 1987 Distinguished Nursing Alumni Award - For contributions to the nursing profession Plaque 1996 Outstanding Undergraduate and Graduate Student Award Plaque - For Commitment to nursing, academic excellence, community service, and patient advocacy Plaque 2006 Outstanding Graduate Student - In memory of Dr. A P Died Fall, 2005 Plaque 2006 Outstanding Undergraduate Student - In memory of Dr. A P Died Fall, 2005 Plaque L C H C Dedication Plaque Memorial Plaque - Former Dean Died March 7, 1986 Donated by Graduating Class 1986 Poster "I want to be treated like a human being" Rosa Parks An African-American Civil Rights Activist Poster ANA Poster of Diverse Nurses and Roles Poster Do Justice Poster Florence Nightingale - Fame, Power, Influence Poster Florence Nightingale – Museum Poster I'm a Nurse: Johnson and Johnson Posters Poster Mary Eliza Mahoney - 1879, First Black Nurse Poster Mr. A R Photo - Donor, Benefactor Poster Native American Nursing - Three posters/prints Poster Nursing: A Career Not Treasured in Years But in Moments Poster Nursing: Dedicated to Caring Poster Nursing: The Finest Art Poster School of Nursing Mission Statement Quilt Quilt of Nursing Quotes by Nurse Theorists/Alumni 173 Appendix I List of Documents Document Title About the University: From Web site: Fast Facts Academic Calendar: Fall 2008 Accreditation Report 2002 Application for Graduate Nursing Programs Packet Application for Post-Licensure Baccalaureate Nursing Packet - School for Continuing and Professional Studies Application for Pre-Licensure Undergraduate Admission Campus Map Campus Ministry Brochure Center for International Education Study Abroad Handbook Commencement Program Undergraduate and Graduate Curricular Sheet: Bachelor of Science in Nursing for the Registered Nurse RN-BSN Curricular Sheet: Master of Science in Nursing Clinical Nurse Leader Curricular Sheet: Master of Science in Nursing Family Nurse Practitioner Curricular Sheet: Master of Science in Nursing Special Entry Option Curricular Sheet: Nursing (Pre-licensure) Curricular Sheet: Nursing (School for Continuing and Professional Studies) Curricular Sheet: Nursing LPN-BSN Option Faculty List with Committee Meetings Flyer: Global Health Awareness Day Graduate Admissions Test Information: GRE Graduate Programs Brochure Graduate Studies Recommendation Forms (2) Graduate Tuition and Financial Aid Information Brochure Graduate Tuition Schedule 2008-2009 Institution: At a Glance Lifelong Learners Scholarship Application Liturgy Mass Program Marketing Brochure: Center for Religion and Public Discourse: Center Your Self Marketing Brochure: CINE Marketing Brochure: Health Center Marketing Brochure: SON Seeking Faculty Postcard 174 Marketing Brochure: SON Graduate Programs Marketing Brochure: SON Nursing Education in the 21st Century: Implications of an Aging Population Summer Institute Marketing Brochure: Volunteer Corps - Transforming… Lives Perspectives The World --Celebrating 30 Years Working for Social Justice Marketing Brochures: IIEPassport Focus…Turkey, Ireland, Croatia Marketing Postcard: Achieve your potential NLN Center of Excellence Postcard Position Openings: Dean Announcement Postage Paid Return Envelope Provost Announcement of Dean Opening Scholarship and Professional Development PPT School of Nursing Annual Report 2004-2005 School of Nursing Annual Report 2005-2006 School of Nursing Annual Report 2006-2007 SON Baccalaureate Program Student Handbook 2007-2008 SON Graduate Program Student Handbook 2007-2008 Strategic Plan Student Excellence Essay Paper Student Records Technology Software List Undergraduate and Graduate Degree Programs Internal Information Documentation University Annual Report 2007 University Annual Report 2008 Video: COE Celebration Video: Nursing Pinning Ceremony Work Agreement Document: Faculty Working Smart: Faculty Resources Notebook 175 Appendix J Iterative Data Analysis Process – Mid-Point The Right Fit: Harmonious Alignment Maintaining a Culture of Excellence Fit Harmonious Alignment Right Fit Love my work Dream job Feels right A feeling 1) A Firm Foundation Legacy History Heritage Legacy Parent Institution's Mission and Values Mission Values Nursing Program's Mission and Values Values-driven Mission Values 2) Organizational Trust Respect Trust Integrity 3) A Healthy Academic Nursing Community Student-Centered About the students Formal orientation processes Strong student-faculty relationships Love the students Extra helps for at-risk students Work Engagement Workload Love their jobs Openings Balance Embrace personnel development Salaries Faculty Preparation Engaged employees Rank Tenure Ongoing Curricular Innovation Curriculum Revisions Innovation Aligned to institution Formative Theory Aligned to nursing program Summative Labs Aligned to profession Course Level Research-Based Faculty Level Curricular Rigor Program Level Data Informed Change Strong Nursing Leadership Strong Leaders Leadership Development Supportive Legacies of Leadership Tenured faculty held previous leadership roles Welcoming Hired internal and Right leader 176 external leaders Internal and External Partnerships Internal Resources External Resources Personnel Agencies Sharing Departments Linked to Community Partnerships Tuition People Work together Supplies Funding Technology Grants Professional Role Socialization Socialization Mentoring Role-modeling within curriculum within curriculum professional nursing within procedures formal scholarship of teaching Professional Influence informal service Faculty Role Modeling faculty respect students administrators Solid Management Practices Clear Boundaries Hierarchy acknowledged NOT: Job Descriptions Steady processes/procedures Top-down Order and disorder Authoritarian Strategic Planning Caring Relationships Open Communication Support Caring Mutually respectful relationships Spiritual Soul Relationship-Oriented Like a family Professional Informed Empowerment Creativity Collaboration Position Knowledge Electives Camaraderie/ Cohesive Empowered Computer Simulation Cooperation Passion Learning Community Learning Centered Formal Leadership Development Students Informal Sabbaticals Faculty Resources Profession Awareness Staff Technology Whole Person Ongoing faculty development Continuous Quality Improvement Data Driven Decisions Solid Sound CQI Day Surveys Course Evals 177 Quality Focus Groups Exit Evals Nursing Worldview Awareness Annual Goals Exit Interviews Diversity Embraced Appreciation of Diversity Welcoming Embraced Human Beings Faculty models Nursing Profession Learning Experiences Program Models Tenure and Promotion Recognize Achievement Recognition Acknowledgement Appreciative 178 Appendix K Iterative Process – Initial Linear Coding Culture of Excellence (Outcomes: Faculty and Student: Recruitment, Retention, Empowerment) FIT Concepts Concepts Concepts Structure Process Context Mission/ Vision Worldview of the Community of Nursing Practice Mission (Institutional and Nursing)- Outward Worldview Learning Centered Teaching Students Appreciation of Diversity Values- Diversity Faculty Caring (Embraced, Love, Like a family) Heritage- Legacy Learning Student Collaboration Faculty Comraderie (Cohesive, Espirit de corp) Hierarchy Engagement (Structure) President Orientation Integrity Provost (change/values /innovation) formal Passion Dean informal Professional Associate/ Assistant Deans (maintenance) Respect Faculty Role- modeling Mentoring Students Soul of Nursing Students Faculty Trust Staff NOT: Socialization Human to Human Top-down Profession (Outward view) Authoritarian Leadership 179 IS: Welcoming/ Open-Door/ Clear Boundaries Leadership Curriculum Innovative Curricular Plans Research Theory Rigor Strategic Planning Labs: Simulation/ Human Data Small Class Size Quality Data Driven Faculty Empowerment Art/Science/ Profession Partnerships Agencies Mentoring Classes Funding, Accrediting, Clinical PLUS People Supplemental Instruction Internal, External Tutoring Employee Workload Administrators Salaries/ Benefits/ Development Faculty Openings Staff Education/ Expertise Rank Tenure Resources System, People, Financial Tuition Grants Internal/ External 180 Appendix L Iterative Data Analysis Process Outcome  The Right Fit: Harmonious Alignment  Curricular alignment with the parent institution, nursing program, community partners, and nursing profession  Faculty and students feel they fit here  Faculty and students work toward personal health and wellness  Ongoing discernment of fit with mission: parent institution and nursing program  Students matched with clinical agencies and vice versa  Seek funding that supports the nursing program  Hiring practices seek the right personnel  Nursing program fits personal values of faculty  Ongoing faculty and student discernment of fit  I love my work  A Firm Foundation  Heritage Institutional history is known and shared There is a legacy of strong leaders for several generations at multiple levels of the organization Founder's history is known and shared History is in official documents History is shared in nursing program materials  Institution and Nursing Program Mission & Values Mission and values are in official documents of the parent institution and nursing program Mission and values are verbally integrated in public events of the institution Are displayed prominently in the nursing program Discussed in meetings, the classroom, between and among intra- and interdisciplinary teams, and students  Nursing Program Transparency  Trust Seasoned faculty trust novice faculty Students trust clinical faculty Students trust faculty mentors staff 181  Respect Students respect faculty, administrators, and each other Personnel respect each other Faculty and students demonstrate respect and integrity by being prepared for class  Integrity Integrity is demonstrated amongst team members and students Academic integrity is the norm Academic dishonesty openly discussed with students Integrity was evidenced and highly valued amongst all personnel  A Vibrant Academic Nursing Community  Student-Centered It's about the students Faculty members want to help the students' learn Orientation processes were designed for programs/courses: commonality was noted Intentional student-faculty relationships Administrators, faculty, and staff love working with the students Extra helps are designed for at-risk students Open-door policy amongst faculty and administrators with students  Empowering Leadership History of strong administrative leaders Develop internal leaders in the program and institution (such as committee chairs, program level leaders, etc) Leaders support each other and emerging student leaders Legacies of leaders‘ work ethic and accomplishments are shared in stories Tenured faculty held leadership roles and were comfortable returning to faculty positions A welcoming environment existed for students, faculty, and guests Right leader for that time of service: internal or external hire Faculty were encouraged to be creative in developing courses and course materials Nursing faculty and other teams often self-organize to get the work done Faculty has a passion for what they do— Passion for preparing the next generation nurses Appreciate others in their day to day work  Internal and External Partnerships Many internal and external resources are available and used with relative ease 182 Internal and external resources are maintained by people working together toward a common goal The nursing program is linked to the greater community through faculty, graduates, students, and other professional relationships Support personnel is provided to ease the work of the faculty Technology enhanced learning/communication hardware and software is used Clinical agencies are critical to effective learning-centered processes Tuition is a major source of funding External funding helps meet student and community needs served by the nursing program  Community of Learning Learning is embraced by all in the nursing program Staff wants to do whatever helps the faculty and administrators do their jobs well Faculty engage in scholarly work: research, new courses, or course improvements Personnel embrace ongoing professional development and certifications Whole person development is valued (embraced—encouraged) Ongoing faculty development is provided Four or five undergraduate curriculum revisions have occurred in the last 30 years Curricular innovation is strategically planned at undergraduate and graduate levels Curricular changes are informed by institution, nursing program, nursing profession, and community data Internally generated research and published research inform curricular change Administrators and faculty desire a solid nursing program Administrators and faculty want to make solid, data informed decisions Quality of the nursing program and graduates is highly valued Student, faculty, community partners, and alumni data inform curricular change Local and global nursing issues inform nursing program decisions  Sound Management Processes Clear boundaries are known by nursing program personnel and encouraged The hierarchy of the parent institution is acknowledged However, it did not seem to be a top-down, authoritarian institution or program Job descriptions are written, known, and available Faculty and staff know their positions, boundaries, and do their work Decisions were based upon steady processes and procedures Order and disorder co-exist with disorder being used to create new order Annual administrative and faculty goals align with the nursing program‘s strategic plan Regular program reports to administration Workload is clearly articulated 183 There are no faculty or staff openings in the nursing program Faculty is qualified for employment Employees work to do their best each day Work-life balance is encouraged and shared with novice faculty Administrators want faculty to have resources needed to do excellent work with the students Faculty are granted sabbaticals Faculty retires or passes away unexpectedly; few leave Formal recognition programs are based on the heritage, mission and values of the parent institution and nursing program Acknowledge achievements by parent institution and the nursing program  Professional Role Socialization Open communication with and between students, faculty, staff, and administration Caring was purposeful and intentional within the nursing curriculum: core to the profession The nursing program was described as having a soul or being spiritual or a calming place to be Students and faculty were encouraged to develop professional relationships Mutually respectful relationships were observed Relationships between faculty and between students were described as being like a family Nursing faculty provides exemplary role-modeling for the nursing students Seasoned faculty role-model scholarship of teaching to novice faculty through team teaching Faculty and students engage in service learning projects locally and globally Mentoring occurs formally and informally for students and faculty For students formal mentoring occurs as a course Mentoring future leaders is provided through program opportunities and organizations For faculty formal mentors are assigned to new faculty Informal mentoring is ongoing, as: Faculty mentor students Students mentor students Seasoned faculty mentor novice faculty –regarding roles as educator, parent institution‘s tenure process, committee leadership, work-life balance, classroom management Seasoned faculty mentor seasoned faculty Administrators mentor students, leaders, faculty, and staff Socialization into the nursing profession occurs: Across the nursing curriculum In the classroom and clinical experience From positive behaviors of program graduates 184  Diversity Advocacy Appreciation of diversity broadly understood Nursing program welcomes diversity of experience, perspectives, and ideas Diversity openly discussed Uniquely designed learning experiences created for student and community needs Clinical and traditional tenure tracks exist Local and global worldview of nursing Purposeful selection of underprivileged students 185 Appendix M Case Study Nursing Program Norms Management Processes Curricular Processes Resources Environment Hiring processes Written position descriptions Summative and formative evaluations Workload for administrative leaders, faculty, and staff Overall administrative processes Syllabi expectations Clinical evaluation tools Summative and formative evaluations Student admission and progression processes Consistent grading scale in nursing Consistent faculty expectations across all programs: In classroom preparation, test development, test analysis Clear processes for curricular changes Atmosphere of continuous improvement, querying curricular processes to be the best possible Student handbooks updated annually Faculty resource guide-Working Smarter Promotion and tenure guidelines- institutional Hardworking, with clear faculty expectations: values-driven, helpful, caring, supportive Espirit de corps Camaraderie Working together Support institutional, nursing program, and nursing profession citizenship Quiet excellence ―Unwritten rules‖ of faculty engagement Welcoming, honest, assertive 186 Appendix N Case Study Nursing Program Metaphors Overarching Orientation Leadership Faculty Orientation Relationship Orientation Nursing Program Orientation Curricular Design The right fit Strong women or strong leaders Compassionate and caring We‘re here for the students! Intentional caring Values-driven Make solid decisions or work solidly We're all in the same boat Student-centered We‘re encouraged here. Open-doors Knowledgeable At the end of the day, we're all going for the same goal Seasoned faculty Be aware of our own biases A better chance at life Supportive Open and welcoming Novice faculty Whole person development Empowerment Like a family Deep roots Build upon the previous Feeds my soul Work together or come together Grow our own Extra-helps 187 Appendix O Individual and Institutional Metaphors Individual Metaphors Institutional Metaphors No one has to be alone. Success with Purpose Always with a buddy. There‘s virtue in hard work. Achieving peace. Administrative leaders Little life preservers around for everyone. The crown jewel of the institution! 188 Appendix P Sample Coding of Data Analysis Supporting: ―The Right Fit‖ Code: Fit Role Quote Seasoned Faculty -1 It has been a wonderful place to work. It really fit with my personal values, and, I guess, maybe, that's just because I am a graduate of this program, but I truly believed in the mission of the organization, and I think, as an institution, it fulfills those. Seasoned Faculty -1 You know, most faculty who come here – and maybe it's just our hiring practices, I don't know – but they seem to really fit fairly well into the institution‘s way. Curricular fit with the parent institution, nursing program, community partners, and nursing profession Seasoned Faculty -2 I've been through about four or five curriculum revisions, and that's when it's really fun. A lot of work, but it's a lot of fun, which you can dream a little, and think about what would…how would it look different, and what could we do differently to make it fit in with what's going on nowadays? Faculty and students work toward health and fitness Seasoned Faculty -3 Administrative Leader My sense is the university would say, "Go for it!" for anything that we feel would be a fit for the school of nursing. They aren't necessarily going to have the kinds of resources to support us, you know, so we have to look hard at the grant proposal and figure out if it is something that we can pretty much do on our own, you know, within the school of nursing that we have the resources to support. 189 Ongoing discernment of fit with mission: parent institution and nursing program Seasoned Faculty -3 Administrative Leader I think there was a time in the school of nursing where you would look at a grant proposal and say, "What could we do to fit this proposal?" And now, more and more, we are looking at, "What are we doing?" and so, we select a grant that fits what we are doing, anyway, you know? Because, it just doesn't work well the other way, to try to scramble to design something that is going to fit the grant. Fitting students into clinical agencies Seasoned Faculty -Dean 3 I think that the faculty who stay here a long time – and not necessarily for their whole career, but who, you know, stay here for a good number of years – they do so because they feel they fit, you know? Funding that fits the nursing program Seasoned Faculty - Dean 2 So, I got a Bachelor's degree next, and then I thought, "Well, __ I won't be able to teach anywhere," which is what, I think__, and I don't know, it just seemed like a good fit for me. And so, he (spouse) encouraged me__ and I got a master‘s degree (in nursing), and I went on and got a doctorate in Education Curriculum. Hiring practices fit the heritage Seasoned Faculty -Grad This past semester, in the Health Policy class that you observed, we had some wonderful guest speakers available, and I will always use those. I will use them if they would fit in, and usually, you can make them fit in most contexts. Ongoing faculty discernment of fit Seasoned Faculty- Administrative Leadership that I made the leap, because it also fit with my family at that point, and I went full time. Professional role fit FACT Mtg- Provost The University is actively working with a search firm as they believe that search firms help them find the right candidate who will stay longer than a few years and with getting the right fit. Recruiting for student/faculty/and administrative right picks General Obs Notes IV4 the senior faculty say, they come from being right picks or fit…that these people are aligned with the work of the School, that it is an easy fit. 190 Student discernment of fit Grad Students 3 And I was progressing – that wasn't a problem, and in fact, when I was telling them I was leaving, they were like: "Oh, you were doing fine!" you know? "Why would you want to leave?" But it's just like I had other things going on, and I truly just did not feel like I belonged. And so, I was looking for…I mean, a conscious effort for something different when I was starting my search to go back to grad school. And not to say it's not a good program – I'm sure it is. But for me, it wasn't good. And so, I had to find something else, a good fit for me. Students try to make education fit into busy lives MBA-MSN Student And saying, "I know this is new," and "I know you can do it," you know? "You just have to really be prepared to devote the time," because it was a challenge trying to fit, you know, work, family, school, you know? A student‘s fit with the holistic caring framework MBA-MSN Student I think, even in this selection, I need that part of it, for me, as a student nurse and as an adult – that faith based is very important. How can you be a nurse and not have that spiritual side? Not religious side, but that spiritual side of it – not be a part of your curriculum? It‘s a necessary fit for me. Fit of the academic faculty role in this nursing program Novice Faculty – MS I had been teaching adjunct for many years for one school and then this university. It seemed like the perfect fit, and I was glad that they should offer me the position of that nature. Adding a new MSN degree discussion Ldshp Council They talked about this in relation to the state‘s Nurse Practice Act and the requirement of an MSN to be able to teach, and the importance of preparing additional nursing faculty, and that indeed does fit the mission and vision of the School of Nursing. 191 Hiring practices for fit with curricular and nursing program needs Novice Faculty - OB They did pass the Clinical tenure track, the year after I got here, and I think when the Dean – the Dean hired me and two other people in midyear like that, and then the fall she hired seven new faculty, and I think, when I was hired, she was working…they were working o n getting that Clinical tenure track to go forward, and I think she hired people that were going to fit into that. The right fit with values: feels right Novice Faculty - MS when I interviewed with her the second time, I said, "You know, when you just feel like it's right?" You know, your gut says this is the right thing to do. That fit was there, so, that was just…I think we've, kind of, shared the same values… Decisions fit with program and institution mission Dean 1 I constituted an advisory board for the health center, and finding some ways: "How can we do a better outreach?" (As you know, we are a community and an academic health center – a very unusual model.) But it has really served the community, and how can we do that in a partnership and in a better way? And, our MD on the advisory said, "Okay, this is the mission of the Health Center. Always bringing us back – does this fit? Are we within the parameters of what we are meant to do?" And I love that they always bring us back to ―Is this our mission‖ Fit as being a part of feeling of being accepted Sr. II 4 students My biggest thing was coming in to here at my age with a bunch of young students. I've never felt that I didn't fit. I didn‘t feel that I didn‘t fit in from the teachers to the students. I didn't feel ostracized, or anything. I felt accepted.