2020 Strategic Plan Goal 1 Outcomes

Continue to develop, evaluate and improve programs and services that further our mission.

Virtual Quality Improvement Projects Keep DNP Students on Track During Pandemic

True to the history and pioneering origin of the University, FNU students are taught to be innovative to best serve the people in their care. The ability to assess and adapt quickly to the needs of the community are central components of an FNU education.

Since they teach these skills, it’s only fitting that FNU faculty possess them as well. Their innovative and adaptive expertise was on full display in the spring of 2020 when the COVID-19 Pandemic began its rapid spread in the United States. While many FNU students were able to continue their community-based coursework, some students entering the clinical phase experienced restrictions that took away access to their clinical sites and many faced the potential of having to take an academic hiatus.

Students in the Doctor of Nursing Practice (DNP) program must complete a quality improvement project. The DNP quality improvement project is a carefully planned and executed patient-focused initiative that requires weeks of planning and preparation. Students identify a tool kit, guideline, or algorithm that can be implemented to improve the health of a defined patient population, a commodity difficult to come by in a pandemic.

One of the few bits of good fortune during that time was that the pandemic essentially hit during the term break between courses. It wasn’t much time, but FNU’s DNP faculty were determined to find a way to allow their students to proceed without interruption. Fortunately, even before the break, DNP clinical faculty Diana Jolles, Ph.D., CNM anticipated the potential threat of the pandemic and began a brainstorming session with other faculty members, documenting the thoughts and ideas generated by the conversations.

“Dr. Jolles’ brainstorming document actually started other people thinking about what are the possibilities,” assistant professor Khara’ Jefferson, DNP, APRN, FNP-C, said.

“Even though the students worked at their clinical sites, all non-essential things were put on hold,” said assistant professor Christoper Kennedy, DNP. “Basically family practice was put on hold. Some of our students were furloughed, some were working from home, but with a different focus. They didn’t know how the pandemic was going to go.”

The solution was to create four community-based projects that could be conducted virtually.

“We leveraged our existing structure to minimize chaos and maintain the rigor to know that it would be fair,” Dr. Jolles said. “DNP Director Dr. (Jane) Houston (DNP, CNM) always said we can’t make this ‘DNPlite’. We were very committed to making sure the students had a rigorous process.”

The virtual projects the students were able to choose from included COVID-19 prevention; preventative health and wellness; end of life planning; and virtual wellness. Conducting these projects virtually, students recruited participants from the community rather than their patient base.

“The process of creating and implementing these projects embodied every aspect of the Culture of Caring, every aspect that we think about mutual support and communication,” Dr. Houston said.

Diana Jolles

Christoper Kennedy

“The students were so grateful they didn’t have to stop their programs. Because they hadn’t been part of the planning process they didn’t understand where we were even heading with this. But they made it work. That was what made it incredible. They showed true adaptability and perseverance.” -- Kimberly Couch

Sybilla Myers, DNP, APRN, FNP-C, had planned to do a quality improvement project to implement the case management system where she works as an International Health Coordinator for a Federal Organization. The arrival of COVID meant all of the organization’s volunteers were evacuated home and she wouldn’t have any new medivacs with which to implement her project.

“It would not have been possible to continue at my site,” said Myers, who chose the virtual wellness project. “My entire experience with FNU has been organized and thoughtful and I didn’t know what, but I knew something would fall into place that would allow me to continue the project. I sat back and waited and it didn’t take long for them to come up with the virtual projects. FNU stepped up to the challenge of seamlessly continuing our doctoral education despite the unexpected and sudden impact of the pandemic.”

“We had to do it,” Dr. Houston said of the 47 DNP students who participated in the virtual projects. “We had to allow them to continue and be successful. It helped build resiliency among both the students and the faculty that we could move forward together on this.” A DNP student last spring and now a DNP clinical faculty member at FNU, Dr. Rachel Sherman DNP, APRN, FNP-BC, Class 36, has seen both sides of the student-faculty dynamic amidst the pandemic. Sherman was working at Prince George’s Hospital Center in Prince George’s, Maryland, last spring. The hospital housed the highest number of COVID-positive patients in the state and, at the height of the pandemic, Dr. Sherman was losing five to six patients per day during her 10- to 12-hour shifts. She also has two children who were attending school from home and she organized and attended daily social justice protests in the city. Finding a way to adjust her DNP project in such a short time frame was added stress.

“I was worried because I didn’t know how I was going to get people to volunteer to talk about advanced care planning when they were already so consumed with everything else that is happening in the world,” Dr. Sherman said. “I was worried I wouldn’t have the response that I needed to have a good project. I’m watching my patients die through glass doors. I can’t hold their hands. I’m calling their family. So I’m dealing with the trauma of that and I still have to maintain a focus on my project and my kids. I thought maybe I needed to sit out for a semester, but then I got so excited to see how things were coming along and how the faculty supported me.”

Rachel Sherman

Sybilla Myers

Jane Houston

Perhaps that support from faculty was so strong because they themselves were dealing with the struggles brought on by the pandemic.

“We were going through the same experiences they were in some ways,” Dr. Kennedy said. “We were trying to grade their work or look at their assignments while we had kids online. Some of us had our clinic jobs, some had increased demands, some had decreased demands, so we were living the same things they were.”

They were living the same thing but understood that no one’s situations or experiences were exactly the same. Neither were their views or beliefs in reaction to those experiences. More than ever, learning and understanding became central to not only the student-faculty relationship but also to communities across the country.

The DNP clinical faculty remained committed to ensuring the projects were no less stringent than in non-pandemic times. They wanted the projects to have meaning, to have sustainability, and to be worth the time and effort of the students and their participants.

“They met their goal of making sure it was rigorous,” Dr. Myers said “I feel like I received the vigorous program that I signed up for. It wasn’t light. It wasn’t a shortcut.”

“These students had to gather the data, analyze it correctly, and do every single assignment that any other student going through the program was doing,” Dr. Houston said. “Without this solution, those 47 students would have had to be on a hiatus and that would have been catastrophic for many of them.”

The DNP clinical faculty were quick to credit assistant professor Dr. Nena Harris, CNM, FNP-BC, CNE, Ph.D., for reviewing the projects to ensure their rigor and structure, which was vital to the projects being approved by FNU’s Institutional Review Board.

While these projects did not persist as options for DNP students past the spring term, they proved to be highly effective and impactful in communities across the country. An unplanned benefit of the virtual structure was that, by finding project participants from the community via social media rather than within their clinics, many students

Nena Harris

Kimberly Couch

Khara’ Jefferson were able to build stronger connections within their communities and develop a greater understanding of community needs.

“They were leveraging their roles as community leaders,” Dr. Jolles said. “It just proves the point that the future is making sure our workforce looks like the communities they are serving.”

Dr. Sherman found that, in talking to community members about advanced care planning, she was able to play a much-needed role that she would never have been able to do in a clinical setting.

“I wasn’t serving in the role of clinician because these weren’t my patients, they were community members,” she said, noting that she had 85 participants in her project. “I wasn’t giving medical advice or writing prescriptions, so it was unique to step out of that role of white coat and prescription pad and be a community worker. That’s truly what community health looks like.”

To say the virtual projects went off without a hitch would be unfair. The timeline was too short, the changes too significant for it to have been a seamless solution. But to say it was anything but a remarkable achievement and resounding success would also be untrue.

“Everybody was elated when they came up with the virtual project possibilities for us,” Myers said. “This is a once in a 100-year pandemic and they gave us the opportunity to continue.”

“Some of these students have continued their projects, maybe not in the virtual reality, but they have transferred what they did in their projects to their telemedicine functions,” Dr. Couch said. “I’m really proud of them. They did a great job.”

Innovative FNU Faculty Adjust to Students’ Needs During Crisis

By Dr. Joan Slager, CNM, DNP, FACNM, FAAN Dean of Nursing

Just as FNU teaches our students to understand and address the needs of the communities they serve, our faculty and staff are keenly aware of the needs of our student community. Those needs are ever-changing, never more so than during the pandemic. I am incredibly proud of how our faculty and staff acted with tremendous efficiency, professionalism, and care to ensure the best possible outcomes for our students.

As the wave of COVID-19 grew and spread, FNU began receiving notices from many of our clinical partners that they were either limiting or eliminating clinical rotations for students. By April 24, 140 clinical organizations had suspended all student rotations and 13 clinical organizations had implemented restrictions but had not suspended all student rotations. Thus, 289 students had rotations impacted by COVID-19 restrictions or cancellations between March and July.

Some of our students were about to travel to spring clinical bounds and begin the last leg of their FNU journey. Some students were abruptly without clinical sites in the middle of their clinical experience, and some could see the finish line, but no longer had the opportunity to complete their final clinical hours. In the DNP program, carefully planned quality improvement projects imploded as patient visits decreased or priorities shifted in the sites.

Faced with these urgent issues, the FNU team rapidly went into problem-solving mode. As President Stone reminded us, with our expanding use of technology to develop and refine a quality education program for students all over the country, while maintaining a sense of community, we have prepared for this for years.

Within a few short weeks, the following programming and policies had been developed:

• Regional Clinical Faculty and didactic faculty developed simulated and web-based activities that can be counted as clinical hours, thus allowing progress in clinical courses.

Students who have met a minimum of 500 face-to-face clinical hours can use these experiences to complete their required clinical hours and graduate.

• Policies allowing telehealth visits in the family nurse practitioner, women’s health nurse practitioner, and midwifery programs were approved.

• The number of telehealth hours permissible in the psychiatric-mental health nurse practitioner program was increased.

• Virtual clinical bounds were developed for all programs.

Students joined faculty via telecommunication sessions and practice skills in preparation for clinical.

• The DNP faculty developed four virtual quality improvement projects (see story on page 8) allowing students to continue progress toward their Doctor of

Nursing Practice degree.

• For students unable to engage in either clinical or didactic work, academic hiatuses were approved and are not counted against the number of allowable hiatuses in a year.

The efficient and well-planned development and implementation of these measures were vital to our students, many of whom would have had to go on hiatus or even drop out if these options were not available to them.

As the year continued to be challenged by the pandemic, the adjustments that were developed to enable students

to continue to progress in their clinical education provided some valuable insight and lessons for the faculty and students. The faculty discovered that some of the skills taught during on-campus clinical sessions could be improved using the technology employed during the virtual clinical bounds. For example, demonstrating suturing techniques on a large display screen was more beneficial than when a single instructor circulated around a room of students practicing this skill. The simulated clinical scenarios that were taught in a virtual environment demonstrated the value of incorporating simulations into the clinical bound courses and the mega course to enhance students’ exposure to infrequent clinical presentations or to facilitate evaluation or remediation.

In all tracks, the initial clinical courses (712) were converted to a virtual format taught by a combination of didactic and clinical faculty. Students practiced foundational clinical skills such as history taking, critical thinking, and clinical reasoning guided by expert faculty. The feedback from students and their preceptors revealed that students demonstrated more confidence and were better prepared for clinical experiences after completion of the virtual 712 courses. As clinical sites began reopening to students the tangible evidence that some clinical preparation beyond the one-week intensive clinical bound week was beneficial led to the development of a hybrid approach to the clinical courses. Currently, all students receive from 30-60 hours of virtual clinical instruction led by faculty in a simulated environment and the remainder of the hours are fulfilled in the clinical sites.

Prior to the pandemic, the psychiatric mental health nurse practitioner (PMHNP) students spent about 10% of their clinical time providing care via telehealth. Although discussions about including telehealth in the other program tracks had occurred, no provisions for this had been developed. Many clinical practices rapidly converted to providing some visits via telehealth which accelerated the development of policies and procedures that allowed students in all tracks to participate in telehealth visits with their preceptors. In the PMHNP program, the utilization of telehealth increased to 70%.

While telehealth as a care delivery modality preceded the pandemic, its utilization has expanded exponentially, especially in rural communities. Recognizing the need to prepare our graduates to deliver care via telehealth, software was purchased which will facilitate the incorporation of simulations into our programs across the curriculum as well as enable us to teach students how to provide healthcare via telehealth.

While many universities struggled with the challenges associated with the COVID-19 Pandemic, FNU seized the opportunity to adapt, learn and improve our programs. These examples of flexibility, creativity, and resilience are part of our heritage.

Virtual Frontier and Virtual DNP Bound - Student Responses

(Does not include the on campus Bounds that occurred in Winter 2020)

Indicate your level of connection to the following during orientation:

80%

60%

40% 66.40%

30.58%

20%

0% 3.02% 0%

Presenters

Very connected Connected

58.97%

32.54%

7.69%

0.79%

Students

Somewhat connected Not connected at all Virtual Frontier and Virtual DNP Bound - Student Responses

(Does not include the on campus Bounds that occurred in Winter 2020)

Do you feel like connectivity would have been greater during an on campus orientation?

36.08% 46.08%

15.29%

Definitely Probably Probably not 2.55%

Definitely not

FNU Delays Straight-Through BSN-DNP Implementation

By Dr. Joan Slager, CNM, DNP, FACNM, FAAN Dean of Nursing

In January of 2020, the FNU community and the Board of Directors approved a 3 year (2020-2122) Strategic Plan. Goal 1 of the Strategic Plan is: Continue to develop, evaluate, and improve programs and services that further our mission.

Objective # 1 of Goal 1 was: Develop a plan for pathways to the Doctor of Nursing Practice (DNP) degree for potential implementation for 2022. This goal was developed in response to the 2018 National Organization for Nurse Practitioner Faculties (NONPF) commitment to “move all entry-level nurse practitioner (NP) education to the DNP degree by 2025. A workgroup was formed to begin to explore our current and future pathways toward obtaining a DNP.

Frontier has offered a Post Masters DNP since 2008 for applicants who completed their Master’s Degree at FNU or another organization. In 2017, FNU began offering the Companion DNP which allowed FNU graduates who began their programs of study after January of 2014 to proceed directly into the DNP having completed the first 9 credits of the DNP degree in their Master’s curriculum at Frontier. If the DNP were to become the entry-level degree for nurse practitioners, FNU would need to offer a BSN to DNP program, particularly for students in one of our 3 NP tracks Family Nurse Practitioner, Women’s Health Nurse Practitioner, and Psychiatric Mental Health Nurse Practitioner).

In 2020 a preliminary program of study was developed for all programs with projected implementation in January of 2022. This included a BSN to DNP with an optional MSN stop out for students in the nurse-midwifery program since the level of support for the DNP as an entry-level degree was not as robust as for nurse practitioners. During the January 2021 strategic planning sessions, Objective 1 of Goal 1 for 2021 was: Implement BSN-DNP programs of study for 2022. An initial meeting of FNU faculty and staff representatives met to begin to plan for the implementation of the straight-through BSN-DNP. During that meeting questions and concerns from the group were raised that caused university leadership to reconsider the wisdom and feasibility of moving toward developing the BSN-DNP.

Of primary concern was imposing a longer and more costly program of study on our students. Secondly, NONPF was the only national organization to fully advocate for the DNP as an entry-level degree for NPs. Accreditation bodies, national certification organizations, and the state boards of nursing have made no move toward making the DNP a requirement for national certification or state licensure. Additionally, most employers were not requesting that clinicians have a DNP to practice. Finally, FNU provides graduates from our MSN or Post Graduate Certificate (PGC) programs with an opportunity to complete a DNP degree at FNU. For these reasons, FNU decided to delay the plan for implementation of the straight-through BSN-DNP and continue to offer an MSN for all tracks and maintain the Companion DNP program as an option for graduates.