THE OREGON CONSORTIUM for Nursing Education

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D

EVELOPING THE

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REGON

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ONSORTIUM FOR

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URSING

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DUCATION

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ACK

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BARBARA C. GAINES, E

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D, RN

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ANGELA G. SPENCER, MBA

The Oregon Consortium for Nursing Education (OCNE) is a collaborative partnership between community colleges and a multicampus university in Oregon that developed in response to an emerging nursing shortage and changing health needs in the population. OCNE has created a redesigned curriculum with shared agreements for academic standards, admission, and seamless transition from associate to baccalaureate programs. Although the schools share pedagogical resources, curriculum, and standards, each partner school retains autonomy and accountability for its degree program. The creation and continued development of the consortium required the participation of people from multiple organizations with diverse concerns. Through a Robert Wood Johnson Foundation-funded evaluation of OCNE, this retrospective analysis was conducted to describe the process of consensus building that resulted in OCNE and to provide an explanatory framework for the benefit of others who are seeking to redesign nursing education in their communities. (Index words: Nurse education; Organizational change; Partnerships; Coalition; Collaboration) J Prof Nurs 29:197–202, 2013.© 2013 Elsevier Inc. All rights reserved.

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HE OREGON CONSORTIUM for Nursing Education (OCNE) is a partnership among eight community colleges and a multicampus, state-supported university. It was created in response to the nursing shortage and the need to more closely align nursing education with emerging health care needs of a changing population. Developed over a 6-year period of intense effort, OCNE now delivers an innovative 4-year curriculum, thefirst 3 years of which are delivered on all 13 campuses and the fourth delivered by the university either on campus or through distance technology (Tanner, Gubrud-Howe, & Shores, 2008). Integral to the establishment of OCNE was the agreement among Oregon nursing leaders that a unified solution to the shortage required a multifaceted strategy. OCNE, the educational arm of the strategy, has gained prominence as a national model to increase the number of baccalaureate graduates and optimize faculty resources (Institute of Medicine,

2010). As others consider implementing similar educa-tional consortia, OCNE has received many requests to help others better understand the collaborative processes and factors that influenced historically disparate groups to work together. This paper describes the development of OCNE through the lens of a deep or transformational change process.

This analysis was part of a larger evaluation of OCNE funded by the Robert Wood Johnson Foundation. The investigators sought to identify the driving forces that led nursing leaders to engage in planning OCNE, the processes to reach consensus in the OCNE model, the barriers to consensus building, and the ways in which these barriers were overcome. A retrospective analysis using principles from historical analysis and case study research were used to address the study aims. This mixed-method approach provided the investigators with multiple lenses to “investigate[s] a contemporary phe-nomenon within its real-life context; when the bound-aries between phenomenon and context are not clearly evident; and in which multiple sources of evidence are used” (Soy, 1997, citing Yin). Available written source materials for the investigators' use included earlier evaluation reports (Eddy, 2005; Gelmon & Norvell, 2004, 2005), project minutes, e-mail communications, key informant interviews, and the published articles from

∗Professor Emerita, Oregon Health and Science University School of Nursing, Portland, OR.

†Research Associate, Oregon Health and Science University School of Nursing, Portland, OR.

Address correspondence to Angela G. Spencer: Oregon Health and Science University, Mail Code SN-6S, 3455 SW US Veterans Hospital Road, Portland, OR 97239–2941. E-mail:spencang@ohsu.edu 8755-7223/12/$ - see front matter

Journal of Professional Nursing, Vol 29, No. 4 (July/August), 2013: pp 197–202 197

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the OCNE project (Gubrud-Howe et al., 2003; Potempa, 2002; Robb, Tanner, Gubrud Howe & Potempa, 2006; Tanner et al., 2008). The literature on transformational change was consulted during the analysis and provided a useful framework for explaining the collaborative process-es and factors that influenced historically disparate groups to work together. In the report that follows, we explore the historical context and factors that were originally contested but became the fertile ground for collaboration. The literature of organizational change describes processes that revolve around an identified, critical problem providing for a rational, planned and deliberate process of change (Kotter, 1996). The research and publications of Robert Quinn (1996; Quinn & Caza, 2004) in formulating a model of deep change have been a particularly useful lens through which to study the transformational change inherent in the formation of OCNE.

Driving Forces for Change

In 2000, Oregon, like the rest of the country, was facing a nursing shortage predicted to worsen in the future. In addition, studies indicated that the health care needs of the public had changed along with demographic shifts. Nurses would be serving an aging and culturally diverse population, often managing multiple chronic conditions. Health care practices had also changed dramatically with shorter lengths of hospital stay, nearly 50% of nurses working in settings other than acute care, and trends toward long-term care, population-based care, chronic condition management, and health promotion (Northwest Health Foundation, & Tanner, 2001). The ability to increase enrollments and dramatically revise nursing curricula was hampered by a looming shortage of nursing faculty (Bellack & O'Neil, 2000; McBride, 1999). Nursing leaders realized that they had an obligation to find solutions to the impending crisis, and in June 2001, the Oregon Nursing Leadership Council (ONLC) released a strategic plan to address the problem. The strategic plan included a vision of a “new nurse” with competencies necessary for the health care needs of present and future Oregonians. A subsequent implementation plan advanced recommendations for transformation of nursing educa-tion, proposing a partnership among community colleges and 4-year baccalaureate programs not only as a means to conserve scarce resources in a tough fiscal environment but also as a viable way to educate the new nurse so sorely needed by changing health care system demands. Through work in jointly appointed committees, meetings among stakeholders, and acceptance of a consensus building decision model, OCNE was formed (Tanner et al., 2008). The process was not without struggle and represented a fundamental change to nurse education in Oregon.

Historical Context:

The Seeds for Collaboration

Oregon has a long, albeit inconsistently documented, history of cooperative ventures in professional education (Bloom, 1989; Joint Legislative Audit Committee, 1998). As a rural state, access to programs is important but is

balanced with a resource-conservation policy of non-duplication of effort among educational institutions. Although the nonduplication policy, which began in 1932 with the beginnings of the Oregon State System of Higher Education (Byrne, 1940), has served the state well, it has also caused various constituencies to use divide and conquer strategies in times when economic survival was seen as paramount. Nursing education has not been an exception to this rule. At least since 1976, the Oregon State System of Higher Education pursued a vision to make baccalaureate and graduate education more avail-able throughout the highly rural state (University of Oregon Health Sciences Center School of Nursing, 1997). This effort was not without its detractors; it was seen by some as a way to mandate baccalaureate entry into practice (Ruff & Anderson, 1986; C. Lindeman, personal communication, March 13, 2009) and by others as a way to“close down”the baccalaureate programs at the state colleges in areas remote from Portland.

In 1990, the passage of Measure 5, limiting property tax support of state funded education, augmented the need for new solutions to the old problems of funding nursing education. Compounding the strife were a series of national changes in how credit was awarded to graduates of associate degree nursing (ADN) programs who elected to pursue a baccalaureate degree (RN-BS). This created another serious conflict between the university and ADN communities that held conflicting perspectives on what was to be required for admission to the university RN-BS program. The university associate dean called for the formation of a task force to consider solutions. According to key informants, the broadly representative task force was a major step forward in easing the tensions between community colleges and the university, thus helping to establish an environment that would allow a movement such as OCNE to take hold andflourish. The fact that a

first significant seed had been planted and would continue to grow in the arena of the RN-BS education is not meant to imply that conflict would not exist among the nursing education programs and practice entities in Oregon between the mid 1990s and the formation of OCNE in 2002. There was a rekindling of the entry debate in 1995 and the issue of supervision of unlicensed assistive personnel in 1997. Yet even through these storms, there were the years of opportunities to come and learn together as a community of educators through the Northwest Nursing Education Summer Institutes.

Organizational Development of

OCNE

—“

The Front Story

The organizational theory literature is replete with models and processes associated with establishing alliances and partnerships between and among entities with similar or differing missions. Of significance to our story is the literature explaining how coalitions or alliances grow to become collaborative enterprises (El Ansari et al., 2001; Flowers, 1995; Gubrud-Howe et al., 2003; Himmelman, 2004; Hughes & Weiss, 2007; Kotter, 1996, 2007; Potempa, 2002; Slater, 1996). Such

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literature supports the system-level and community/ campus-level inputs and interventions that make up the planned experience or“the front story.”

Many events and rational organizational processes led to the establishment of OCNE. In January 1997, a group of academic, practice, and organizational nursing leaders in Oregon formed a coalition known as the“TriCouncil: A Coalition of Nursing Leadership Organizations” and issued a proposed set of operating guidelines. The purposes of the TriCouncil were to share information, increase shared understanding through an exchange of perspectives on controversial issues, and develop con-sensus and adopt position statements as necessary. Clearly defined as a coalition in title and purposes, the TriCouncil reinforced its status by assuring that position statements would not be published until ratified by consensus of each member organization.

In May 2000, the TriCouncil (using the same operating procedures) officially changed its name to the ONLC. On July 14, 2000, the ONLC convened a summit of its member to discuss the nursing shortage and the associated issues. Through monthly meetings by fall 2000, the ONLC had designed a second summit targeted to elicit the support from nonnursing stakeholders from health care legislation and workplace arenas in the growing dilemma of predicted nursing workforce short-ages in Oregon. The ONLC succeeded to create motivation and commitment to shared action from these health care stakeholders (R.E. McCarthy, personal communication, 2001).

The intent to collaborate began with these sporadic yet sustained organizational meetings from 1997 through the better part of 2000. As the need for real personal change and organizational realignment became more apparent, a core leadership group agreed that external consultants were needed to move the group forward. R.E. McCarthy, an independent consultant in whole system improvement and strategic change with large groups, was employed beginning in the fall of 2000 and continued to work with ONLC members until June 2001. During this time, the ONLC developed a strategic plan that would direct the formalization of OCNE as an entity for nursing education in the state. McCarthy's expertise in organizational development and change would prove helpful, not only in the development of the purposes, policy, and procedural guidelines that would guide the ONLC and OCNE—the front story—but also in helping the group identify and resolve the issues that had served as barriers to their success—the“back story.”

The policies and procedures were developed to formalize and operationalize OCNE following the pre-cepts of the traditional organizational change literature previously cited. Tanner, Gubrud-Howe, and Shores (2008) described the processes that have made OCNE an organizational success. Evident in the authors' note is the importance of early, continued leadership and funding by several philanthropic foundations and gov-ernmental entities. The recognition by these groups validated not only the sense of urgency the nursing

community was experiencing around the shortage but also the direction the collaborative enterprise promised for a viable nursing education entity. OCNE was supported financially by a combination of in-kind contributions by faculty from OCNE partner schools, estimated at over $3.2 million over a 6-year period. The salary of the meeting facilitator was supported by the university for their work with the ONLC through 2002. The first grants were funded in 2003, providing for salaries of a director and administrative assistant and curriculum development consultants. Over the next 6 years, OCNE was awarded grants totaling more than $5.4 million. Nearly one half of the amount was from local and regional foundations, with another 18% from national foundations, 23% from federal sources, and the remain-der from state agencies. The success in grant writing can be attributed to two major factors: (a) the strong partnership with Northwest Health Foundation and their advocacy with other funders and (b) careful planning on the part of OCNE leadership to identify particular needs (e.g., infrastructure support, preceptor training, simulation development, clinical education redesign, curriculum development) that could be pack-aged into specific proposals for a costs of $100,000 to $800,000, within in the fundable range by many local foundations (C.A. Tanner, personal communication, November 17, 2011).

Reframing the Culture

—“

The Back Story

It is clear from the success of OCNE that members of ONLC and, later, the leaders of OCNE were serious about involving all stakeholders in solving the problems of the workforce shortages, the nursing education, and the workplace. It is also clear in the available archival materials that many barriers existed that could easily have sabotaged the venture time and time again. The organizational consultant who worked with the group stated after only two meetings that he had serious concerns about the ability of the groups to work together given the long, intense sense of unresolved issues, which he identified as “land mines” (R.E. McCarthy, personal communication, 2001; L. Wagner, personal communi-cation, 2002). One difficult exercise that in the long run helped the group reframe its thinking was asking baccalaureate educators to convincingly defend associate degree entry and associate degree educators to convinc-ingly defend baccalaureate degree entry in open debate before the larger group. The ultimate resolution of this debate became the foundation for the end of the entry into practice battle known colloquially as“My grad can beat up your grad.” Developing the trust among the group and the leadership necessary to support a trusting environment open to real change is the substance of the back story.

Much of the traditional organizational change litera-ture identifies the significant impact of culture, trust, and approaches to decision making and its relationship to leadership in building sustainable collaborative en-deavors. The literature is robust regarding building

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collaboration and cooperation within organizations across alliances such as consortia and joint ventures in the arenas of business, academia, and academic and practice partnerships in nursing (Gratton & Erickson, 2007; Jones & Brazell, 2006). Relevant nursing examples include the following: Hoffman (1998); O'Neill and Krauel (2004); Quinless, Elliot, and Saiff (1997); and Quinless and Levin (1998). Commonly missing however is the description of richness of the group interaction and the level of personal commitment that allowed such significant changes to be successfully implemented (Hughes & Weiss, 2007; McBride, Yeager, & Farley 2005; Sizemore, Robbins, Hoke, & Billings, 2007). Through the archival data available and key informant interviews that identified “land mines,”it became clear that a theoretical framework to provide a means to explore these interpersonal processes was necessary if a full picture useful to others implementing OCNE-like consortia was to be constructed. An additional search of the organizational development literature produced Quinn's work on deep change.

Deep change, as defined by Quinn (1996, p. 3), “differs from incremental change in that it requires new ways of thinking and behaving…[it is] major in scope, discontinuous with the past, and generally irreversible…[it] distorts existing patterns of action and involves taking risks. Deep change means sur-rendering control,”as well as accepting that“ organi-zation and change are not complementary concepts.” Deep change is transformational change that involves a state of leadership where new patterns of behavior are uniquely matched to the context in which the players operate (Quinn & Caza, 2004). The explanatory value of a framework such as Quinn's in describing the success of the ONLC and later the OCNE program was validated by Kotter (2007), who suggested that many organizational changes fail because they do not require transformational change of their members. The leadership of ONLC and later the leadership of OCNE shared the capacity to adapt leadership to demands of the situation.

According toQuinn (1996), visionaries are internally driven. They do not view personal survival as a driving motivation. Their main objective is the realization of their vision, regardless of the price. An influential vision reflects the insight of the individual or group who has deeply contemplated the core issues. Oregon's nursing leaders could not ignore the findings of the Northwest Health Foundation study that warned of the impending shortage in nurses and nurse educators as well as the changing health care needs of Oregonians. They also believed that nurses and nurse educators should be leaders in finding solutions to these challenges. They committed to a vision, based on their understanding of the gravity of the problems they faced in nurse education, and set about initiating changes that threatened the existing paradigm but that they viewed as necessary. However, they also had to grow into their new sense of self as a group who could actually move the vision

forward in the generally territorial higher education environment. Quinn (1996; Quinn & Caza, 2004) describes this growth as“discovering the leader within.” In their work with the facilitator, the ONLC developed the communication skills necessary to build and sustain trust. They established various sets of ground rules codifying the new communication skills, “frequent, respectful, supportive communication” became the criterion by which messages were evaluated (R.E. McCarthy, personal communication, 2001), allowing the group to confront their own discomfort in addressing long-standing and divisive issues or, in Quinn's (1996, p. 189) words, to“discuss the undiscussable”and to see themselves as“walking naked into the land of uncertainty (p. 3).” Additional ground rules included honesty, recognition of the strengths of participants rather than limitations, acceptance of risk and ambiguity surround-ing the developsurround-ing collaborative process, and a shift from organizational representative to transformative leader-ship model (R.E. McCarthy, personal communication, 2001). They practiced communicating among them-selves, both in person and in writing. One example, a

flurry of e-mails titled “Living with Ambiguity” and “Living with Ambiguity II” provided members of the leadership group with support as well as strategy as they approached college administrators about the necessary and desired change in nursing education (P. Gubrud-Howe, personal communication, 2002).

Symbolic communication was also useful in the group members' growth into transformational change leaders. According toQuinn's (1996, p. 125), “to help convey a vision, a transformational leader will often engage in symbolic communication, creating vivid mental images for followers.” In the case of OCNE, leaders used clay buttons as one form of symbolism during the process. The handmade buttons were formed in a variety of shapes and represented different issues and stages of develop-ment. One was a purple heart, awarded to early leaders of the ONLC education committee for their courage in taking controversial positions that were in opposition to those held in their respective institutions and the traditional powers in university and community college systems. Another was the“hot button,” pinned to each person's shirt and used to represent issues that were highly charged. If a topic came up that elicited a strong emotional response for a member, he or she would touch his or her hot button to communicate to others that discussions on the topic required sensitivity. Other clay buttons included hearts to remind members of their core values as caring nurses and spiral-shaped buttons representing the spiraling curriculum they were creating. Another tangible illustration of the seriousness with which the members confronted their own discomfort with each other was the decision to postpone a scheduled summit meeting of all Oregon stakeholders for several months until the unified agenda could truly be agreed upon. Pledging the time required to resolve the dif-ferences was in and of itself a sign of a new accountability and cultural change for this very busy group of nursing

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leaders. In addition, the agreement to delay the already announced summit, although extremely difficult, had the desired result—a strategic vision for nursing in the state that spawned OCNE and other entities, such as the Oregon Center for Nursing, necessary to the continued progress and understanding of state needs and initiatives. Eventually, the group formed a strategic plan that became the foundation for OCNE and achieved a unified voice. Now, instead of representing their organizations (i.e., individual colleges and the university), they went back to their respective organizations to make the case for change (P. Gubrud-Howe, personal communication, 2007).

In Quinn's (1996) transformational paradigm, the organization is viewed as a moral system, with values and principles that transcend the political interests of any particular coalition. As nursing leaders came together to reform nurse education, they viewed their work as a “moral obligation”with the health of Oregonians at stake. They acknowledged the significant contribution of community college education to the workforce of registered nurses and resulted in a curriculum with the associate of applied science degree as an exit option. As the consortium matured, members developed a set of primary guiding principles: inclusiveness, beneficence, collegiality, courage/perseverance, healthy conflict and shared leadership for transformation (OCNE, 2010). The core values are still a source of power in OCNE and serve as a touchstone for members as they move forward strengthening the work of the consortium.

Deep change also involves strategic complexity. In addition to continued work on their home campuses, the developers of OCNE were working to address multiple issues in the state's nurse education system simulta-neously. They had no examples from other states that had successfully undertaken a similar task so they had to create the solutions themselves. They addressed multiple aspects of nurse education, including curriculum, academic standards, admission, progression, co-admis-sion into community colleges and the university, student records, prerequisite requirements, and financial aid. Because of their intimate knowledge of the systems in which they operated, combined with the changes in their personal beliefs about best practices in nursing education, they were able to offer solutions over time that overcame barriers and allowed the new system to emerge, illustrating Quinn's elements of “getting lost with confidence”and“moving forward.”

“Getting lost with confidence”is best illustrated by the movement within the group from a position of“my grad can beat up your grad”to the overt position that level of entry into practice was not the salient issue for nursing education in Oregon (Eddy, 2005; P. Gubrud-Howe, personal communication, 2002; R.E. McCarthy, personal communication, 2001).“Moving forward”was evident in the formation of OCNE, after 2 years of discussion, with leaders from all participating schools signing the document that created OCNE in 2002 and recognition of the consortium by the Oregon State Board of Nursing. Consequent to the signing of the document, the

significance of forward movement was evident as increasing numbers of faculty from each campus got involved in curriculum development, thereby spreading leadership beyond the initial, formative group andfinally by the launch of the new curriculum and continuing addition of other consortium partners.

The deep and lengthy process facilitating this signif-icant change among the Oregon nursing community is reflected by the works of Quinn. He wrote that people who successfully make deep changes are able to get lost with confidence because they“begin to see deep change as developmental process that can be understood.”Quinn goes on to describe their experiences as learners who relate to“learning that helps us forget what we know and discover what we need.” The faith this transformation engenders allows them to “know how to get lost with confidence”and become“master change agents”as they “learn their way into the new and emerging world” (Quinn, 1996, p. 12).

These are the most significant outcomes for others replicating the OCNE experience. It is clear that in addition to financial and in-kind resources to support meetings and curriculum development, participants must be willing to personally change. Participants must commit to staying the course as they confront barriers andfind common ground on which to stand. A clear vision, that all participants can endorse, is key to building and sustaining an educational consortium such as OCNE. Establishing rules for communication, soliciting outside expertise to facilitate meetings, and a willingness to consider each others' perspectives are also important. OCNE developed within the context of the Oregon higher education system and was undoubtedly influenced by this environment and the personalities involved. As others seek to create educational consortia in their own regions or states, they must honor their unique circumstances and identify the salient issues for themselves.

Today, OCNE functions as a true collaboration with relationships to a larger coalition (ONLC). OCNE has accomplished what no single school could have done alone. It has increased access to baccalaureate nursing education in a rural state and produced a curriculum with knowledge and skills necessary for competent nursing practice in the 21st century. In addition, equally as important, the creation of the OCNE culture embedded in members a unified respectful attitude about what is important for nursing education now and in the future. As one participant said, “we no longer know, and it is not important, what school any of us is from.”Quinn's (1996)summary of the change experience resonates well with the OCNE experience and is included here as a guide for others:

This team is not perfect by any means, but it continues to grow. It continues to confront new issues and is adapting on all fronts. I doubt if anyone at our first meeting could have imagined the present level of behavior. To reach this current level, team members had to work hard and make some tough decisions. They all had to pay a price, a

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price that most management groups are not willing to pay. Deep change at the collective level requires deep change at the personal level. Organizational change cannot occur unless we accept the pain of personal change. These people did, and they grew into something more than they had been. (p. 193).

Acknowledgments

We gratefully acknowledge past and current members of the OCNE Coordinating Council and the Research and Evaluation Committee for their contributions to the study design and implementation. The development of OCNE was supported by grants from the US Department of Health and Humans Service, the Health Resources and Services Administration, Northwest Health Foundation, William Randolph Hearst Foundation, Kaiser Northwest, Meyer Memorial Trust, James and Marion Miller Foundation, and The Ford Family Foundation. The study reported here was supported by a grant from the Robert Wood Johnson Foundation.

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