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________________________________________________________________________________________________________________ Professor Clayton Christensen and Research Associate Sarah Thorp prepared this case. HBS cases are developed solely as the basis for class discussion. Cases are not intended to serve as endorsements, sources of primary data, or illustrations of effective or ineffective management. Copyright © 2000 President and Fellows of Harvard College. To order copies or request permission to reproduce materials, call 1-800-545-7685, write Harvard Business School Publishing, Boston, MA 02163, or go to http://www.hbsp.harvard.edu. No part of this publication may be reproduced, stored in a retrieval system, used in a spreadsheet, or transmitted in any form or by any means—electronic, mechanical, photocopying, recording, or otherwise—without the permission of Harvard Business School.

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Developing Nurse Practitioners at the College of St. Catherine

I had a view that there should be a greater role for non-physician health care providers in delivering care. St. Catherine’s would be a place for me to explore the notion of creating new leaders for healthcare.

— Margaret McLaughlin, Dean of Health Care Professions, St. Catherine’s College

February 2000

It was a cold winter morning in St. Paul, Minnesota, and Margaret McLaughlin had just unpacked the last box of files in her new office at The College of St. Catherine. After a six-month transition from her former position as Associate Director of the Magee-Womens Research Institute and Professor of Obstetrics, Gynecology and Reproductive Sciences at the University of Pittsburgh College of Medicine, she was finally able to devote her full time and attention to her new charge as Dean of Health Professions. In anticipation of a meeting she was about to have with the head of the nursing department, she leafed through a pile of article clippings and pulled out a study from the most recent issue of The Journal of the American Medical Association. The headlines read:

Some Patients have Comparable Short-Term Health Outcomes When Treated By A Physician or Nurse Practitioner.1

The article provided key findings of a study that had compared outcomes for patients randomly assigned to nurse practitioners or physicians for primary care follow-up and ongoing care after visiting a hospital emergency department or urgent care center within the Columbia Presbyterian Medical Center System. The authors concluded: “Who provides primary care is an important policy question. As nurse practitioners gain in authority nationally with commercially insured and Medicare populations now accessing nurse practitioner care, additional research should include these populations.”2 The study had triggered considerable discussion and debate in the national health care community. With great excitement, McLaughlin contemplated the implications this might have for the future of their own graduate programs for nurse practitioners at St. Catherine’s.

1 Mary O. Mundinger, Dr. PH., et al., The Journal of the American Medical Association, issue 283 (January 5, 2000): 59–68.

2 Ibid.

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No sooner had McLaughlin completed the article when Alice Swan, the Chair of the nursing department, Brenda Canedy, Graduate Program Director, and Patricia Dooley Eid, a graduate nursing faculty member, entered her office. They began the meeting by updating McLaughlin on progress in the graduate nursing department. Then Swan mentioned the Mundinger article and said: “After hearing about this nurse practitioner-run clinic in New York, the faculty in our department are all wondering about creating our own clinic. Imagine, a clinic run by our own St. Catherine’s nurse practitioners and students in development!”

McLaughlin delighted in the idea. She had always thought that nurse practitioners made excellent teachers. She knew from personal experience. Two years ago, her colleague Jane Butler, a certified nurse midwife with a Master’s in Public Health who taught obgyn at Magee Women’s Hospital to University of Pittsburgh medical students, had been voted by her students as “teacher of the year.” It had been the first time at Magee that any faculty other than a trained physician had won the prestigious award. If medical students are learning effectively from nonphysician-faculty, why couldn’t nurse practitioners?

McLaughlin knew she did not have the empirical evidence to give Swan, Canedy and Dooley Eid a thoughtful response. She knew that at St. Catherine’s, students training to be health professionals were placed in local Minneapolis–St. Paul-based clinics that were run by health provider systems— HMOs, hospitals, or community-based clinics. Though most of their education had been with nurse practitioners, physicians also had played a role in their education. Further, in a physician-dominated health care community, none of these faculty or administrators had ever owned and operated their own clinic.

Eager to be supportive, McLaughlin wondered how to respond to Swan’s request. She knew such an initiative would be a tremendous opportunity for the college. “If successful, a program like this could put us on the map as innovators in this kind of training and organization. More important, it could serve as a catalyst for empowering our students.”

Health Care Reform

The 1990s brought with it a paradigm shift in the way health care services were provided in the United States. Market-driven economic policy, dramatic technology developments, changing demographics, and the knowledge explosion, were all creating a climate of continuous rapid change.3 At one time focused on illness and highly specialized treatment, the U.S. health care system was now having an increasingly greater emphasis on primary health care.4 One consequence of this was changes in those professionals who provided health care, the skills they needed, and the educational institutions that prepared them. One health professional that was impacted by this was the nurse practitioner. Cost pressures discouraged the traditional family physician from working in primary health care, and encouraged them to move into specialty areas. Nurse practitioners (NPs), who traditionally had their greatest emphasis in primary care, were now in greater demand. Representing

3 Carol A. Lindeman, PhD, RN, FAAN (Professor, Emeritus, Oregon Health Sciences University, School of Nursing, Portland, Oregon), “The Future of Nursing Education,” Journal of Nursing Education, vol. 39, no. 1 (January 2000): 5–12.

4 According to the World Health Organization, primary health care is based on five principles: community participation, equitable distribution, multi-sectorial cooperation, appropriateness, and health promotion and disease prevention. Primary Health Care emphasizes collaboration of health professionals and community members, focuses on the development of health- promoting policies, and advocates for access to care for all people. (Nursing and Health Care Perspectives, The World Health Organization, p. 116.)

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the largest group of health professionals in the United States, NPs provided a largely untapped resource to meet the primary health care needs of the nation.

Nurse Practitioners

Scope of Practice and Training

By 2000, nurse practitioners were registered nurses (RN) who had completed an accredited program of advanced nursing education. Most NPs had a Master’s Degree in nursing and were certified by a national nursing certification organization to practice as a nurse practitioner. They provided primary care services to a wide diversity of populations, often specializing in family, adult, geriatric, women’s health, school or pediatric nursing. Medical and nursing literature suggested that nurse practitioners could provide up to 80% of the primary care services traditionally provided by a primary care physician.5 (For nurse practitioner glossary, see Exhibit 1.)

As patient care became more complicated and demanding, the nursing profession demanded higher knowledge, and accordingly, higher credentials. In the 1970s, the first certificate programs were developed for nurses. Once trained in hospitals, nurses were now moved off-site to universities to develop a better understanding for a more sophisticated practice. Nurse training and preparation came to include a balance of university-based coursework in basic science and theory, and experienced-based apprenticeships (called “preceptors”) in local area clinics or hospitals.

The 1970s was the era of role definition for NPs. At work, NPs focused on diagnosing patients and operated under strict protocol before administering any care. The doctor was the medication manager. In the policy arena, emphasis was on developing Scope of Practice Statements that described who NPs are and what they do. Studies were conducted to see if NPs were able to provide safe and effective care that was equal to medical doctors. Practice protocols were developed to guide the nurse practitioner and were approved by the supervising doctors. State protocols were developed to guide the nurse practitioner and were approved by the supervising doctors. State practice acts were beginning to acknowledge that NPs could diagnose and treat the common health problems in primary care.

The 1980s was the era of role differentiation. NPs were identifying how they provided unique contributions different than the doctors. On a national level, economists were predicting an oversupply of doctors so the NP’s jobs were threatened. State practice acts permitted nurses to make prescriptions and to select drugs. As a result, NPs had more autonomy in taking care of patients. For example, a nurse practitioner could prescribe antibiotics for strep throat. If serving a patient with diabetes, the nurse practitioner could prescribe the insulin and order more without consulting a doctor.

The 1990s introduced managed care and outcomes. The health care system demanded more affordable care with more cost effective workers. There was more focus on disease management, and NPs focused on prevention of illness because research showed the value of tight control to prevent complications. Nurse practitioner roles serving patients expanded and their essential competencies

5 This paragraph was taken from, “Expanding the Horizons of Healthcare: A Reference Guide,” 2nd edition, published by the Minnesota Partnerships for Training, Minneapolis, p. 1.

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evolved to include a broader range of diagnoses—some similar to those made by physicians in primary care.6 Soon enough, managed care realized that NPs could provide primary health care.

To prepare NPs for these changing responsibilities, nursing programs acclimated. They first offered diploma degrees, which were the norm in the 1990s. They were housed in hospitals and were funded similar to the Graduate Medical Education (GME). In the mid-1950s the nursing profession determined that education of nurses needed to be delivered in institutions of higher learning. While master’s education in nursing had always been located in colleges and universities, nurse practitioners were often prepared in these schools at the post-baccalaureate certificate level. In the early 1990s, the standard for nurse practitioner education was changed to master’s level. Funding for converting certificate programs to master’s programs was awarded through the Department of Health and Human Services. (Though a national accrediting body set the bar of quality for these programs and the federal government provided some sources of funding, individual states governed precisely what a nurse practitioner’s specific scope of practice could include.) Shortly thereafter, most nurse practitioners could see patients without consulting with a doctor. With changes in the healthcare infrastructure (e.g., the rise of managed care and the decrease in hospitals), the setting for work became community-based clinics. Clinics were required to demonstrate outcomes, and they generally had a specialty focus.

The Rise of Community-Based Clinics

NPs began to run their own clinics. By 1999, there were approximately 76 nurse practitioner-run clinics in the country. Since the early 1990s, the most successful clinics that served as models demonstrated the following characteristics:

1. Community Responsiveness: the models selected address a documented health need faced by vulnerable and under-served populations;

2. Innovation: creativity in program design, implementation and sustaining factors;

3. Collaboration/Integration: effectiveness in collaboration and coordination among various partners;

4. Outcomes: measurable improved access to care, health status and economic outcomes;

5. Replication/Sustainability: potential for program replication, or adaptation, and sustainability in other communities;

6. Administrative Effectiveness: quality and effectiveness in administrative systems.7

Pressures on Higher Education Institutions

Institutes of higher education reinvented themselves to accommodate the changes NPs were experiencing in their work-settings and the higher levels of knowledge and decision-making authority they now required. (See Exhibit 2.) Most experts agreed that as their role expanded, so did the number of clinical hours required to educate them. When it came to the balance of classroom

6 Katherine Crabtree, DNSc et al., “Analysis of Student Nurse Practitioner Primary Care Practice Patterns in the Northwest, Midwest, and South,” The American Journal for Nurse Practitioners, September/October 1999, p. 10. 7 Models that Work Campaign Clearinghouse, Health Resources Services Administration and the Department of Health and Human Services, http://www.bphc.hrsa.dhhs.gov/mtw/mtw.htm, phone: (800-859-2386).

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work and clinical practice, the weight began to shift more toward the clinical practicum.8 This was easier said than done, as clinical education was expensive and payers were becoming increasingly unwilling to pay for the extra costs associated with the purchase of services at teacher facilities. Some schools tried to offset these costs by creating faculty-run health clinics to bring revenue to the institution. In a report about the future of nursing education, one health care educator cautioned:

It will not be easy in the current climate for nursing to produce significant revenue through services provided by students and faculty. It will not be easy because of reimbursement issues, because these services may have a history of being provided without cost, or because other faculties are also trying to develop reimbursable services. The process of developing revenue producing services requires faculty and administrators to alter the conception of the role of faculty to include revenue generation. In addition to securing research and training grants, faculty may be expected to produce a minimum amount of tuition revenue from their teaching or clinical activities.9

Another issue was the faculty who taught the NPs. Some argued that having the students work under the supervision of a licensed nurse practitioner—not the regular physician—afforded the students the chance to “become more independent and able to function with less supervision.”10 An analysis of student nurse practitioner primary care practice patterns revealed that “nurse practitioner preceptors were significantly more likely to allow the student independence than were physician preceptors . . . (perhaps) . . . because the NP preceptors understood the wider scope of their roles.”11 (See Exhibit 3 for highlights of the scope and content of nurse practitioners’ work.)

By the late 1990s there were close to 54,000 NPs in the United States and a proliferation of nurse practitioner programs—exceeding 300 nationwide. One thousand two-hundred of these NPs were in Minnesota, most of whom were working in the Twin Cities.

Healthcare in the Twin Cities of Minneapolis and St. Paul

Healthcare Costs

Boasting one of the highest health insurance coverage rates per capita in the United States, in 1999, 95% of Minnesota residents had health insurance. In spite of this, health care delivery costs kept insurance premiums at an all time high. In the 1990s, the state legislature introduced two programs to improve the situation: 1) A health insurance program called Minnesota Cares addressed the people who needed help affording the insurance premiums, and 2) A waiver which allowed insurance companies and medical providers to merge and integrate hoping to bring about economic efficiencies. Some hospitals closed as a result, and five years later costs were still high. Janet Martins, the Vice President of Operation at a clinic in the Twin Cities, commented: “Despite its best intentions, it is clear that a shift in the Minnesota Health Care Delivery System must occur. Patient-care centers are becoming productivity-care centers.” And, while the supply side was focusing on efficiencies,

8 Katherine Crabtree, DNSc et al., “Analysis of Student Nurse Practitioner Primary Care Practice Patterns in the Northwest, Midwest, and South,” The American Journal for Nurse Practitioners, September/October 1999, p. 11.

9 Carol A. Lindeman, “The Future of Nursing Education,” Journal of Nursing Education, vol. 39, no. 1 (January 2000): 5–12.

10 Crabtree, p. 11.

11 Crabtree, p. 18.

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consumers were valuing personal choice over economy. To make matters worse, by the late 1990s, cuts in Medicare meant declining reimbursement by third-party providers.

Labor Shortages

The labor market was tight. Minnesota had an unemployment rate of 2%, one of the lowest in the country, putting pressure on health care delivery systems to think more carefully about how to recruit and compensate a work force. There was a shortage of nurses. The Minnesota Board of Nursing reported it would need 17.5% more nurse in 2005 than it had in 1994, and supply was not keeping up with demand. Nurses were older (average age 44) and nearer retirement age; more nurses were choosing part-time employment, and fewer people were choosing nursing as a career. Registered Nurse (RN) program enrollments were down. Leaders in every part of the health care delivery industry were looking for alternatives for efficient and effective alternatives for servicing the consumer.

An Opportunity for Nurse Practitioners

Despite the declining enrollment in RN programs, trends indicated that those who were already Registered Nurses were increasingly interested in moving to Nurse Practitioner careers.12 State regulations about the scope of a nurse practitioner’s work made the job more attractive. A Minnesota statute in 1999 authorized the nurse practitioner the following rights: “Nurse practitioner practice means, within the context of collaborative management: 1) diagnosing, directly managing, and preventing acute and chronic illness and disease; and 2) promoting wellness, including providing nonpharmacologic treatment. They can provide pharmacologic treatment with a collaborative agreement with a physician.” Prospective NPs could prepare for this practice in one of the state’s six graduate programs to train NPs.13 Together, the schools graduated 120 to 130 NPs per year. Seventy percent of the graduates worked in urban areas in primary care settings. The balance served rural communities. Half of the graduates became family NPs.

Funding for nurse practitioner training programs came from public and private sources. In 1999, federal money was available through the Department of Health and Human Services for schools which prepared a significant percentage of their graduates to practice in rural areas or for expansion of programs. Some of the universities were awarded grants to convert their nursing programs from certificate based curriculums to master’s level programs. State money supported the state university programs, but private colleges were for the most part tuition dependent. The Minnesota Education and Research Costs Trust Fund was established in 1977 by the Minnesota legislature to provide support for certain medical education and research activities in Minnesota that had historically been supported in significant part by patient care revenues. Still, some private companies and foundations were offering some financial support. Health care manufacturers and foundations at hospitals and health plans that recognized the importance of training supported the initiatives.

Changes in reimbursement from health plans were also allowing NPs to play a larger role. Put differently, as NPs took on responsibilities more similar to the physician, some insurance companies were beginning to put processes in place to allow for the reimbursement of services provided by NPs.

12 “Expanding the Horizons of Healthcare: A Reference Guide,” 2nd edition, The Minnesota Partnerships for Training, Minneapolis, p. 8.

13 The six schools included: The College of St. Catherine, College of St. Scholastica, University of Minnesota, Winona State University, Minnesota State University, Metropolitan State University. Planned Parenthood of Minnesota also had a program. All but the College of St. Catherine offered the family nurse practitioner program.

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The Medicare Act of 1998 made this possible, authorizing NPs in Minnesota to bill for their services. Medicare promised it would pay NPs 85% of the rate of a normal physician. Specifically, the Code entitled the following: “Provider reimbursement under Medicare in any location for services ‘which would be physicians’ services is furnished by a physician . . . which are performed by a nurse practitioner . . . under the supervision of a physician . . . and which the provider is legally authorized to perform by the State in which the services are performed.”14 Martins explained one opportunity the law had enabled: “At the time and still today, most insurance companies recognized ‘physician- only’ clinics and services. Still, some were warming to the idea because of the lower rates. Blue Cross Blue Shield, for example, did considerable work in the rural areas where a shortage of physicians had always opened doors for NPs to take on more responsibilities. They saw a need for it.” With this, one enterprising nurse practitioner in the Twin Cities decided to start her own clinic. In 1999, Kathleen Pasqualiani, R.N. and Certified Nurse Practitioner, launched Care Plus, the first independently owned and operated clinic in the State of Minnesota.

Care Plus

Care Plus was an adult primary care clinic located in downtown Minneapolis. Martins explained how they reached a decision about the model:

We had to make a variety of choices when thinking about our model. First was location. We knew that we wanted to be a pure primary and preventative care clinic, but we didn’t want to go head-to-head with physicians. Steering away from the suburbs, we looked at the metro area where people were under-served. At first, we found so many free clinics and community clinics that we didn’t see a clear pocket of unmet needs. At the same time, we had to consider regulatory changes explaining the scope of practice for a nurse practitioner, and about insurance company plans and how willing they would be to support us.

It would also be critical for us to have a relationship with a physician, and our medical director—though he does not provide any service at our clinic—is one. In a physician- dominated community, it’s hard to even get financing from investors and loans from banks if you are not connected to a physician. Face it, it’s a lot easier for a doctor to walk into a bank to get a loan than a nurse practitioner. Insurance companies have denied us because we didn’t have a physician on site.

We also had to think about costs and our proximity to hospitals or clinics that housed expensive medical equipment. It was better for us to partner than buy it ourselves. When thinking about financial viability, our two largest on-going operating expenses are personnel compensation and benefits, and medical technology.

Care Plus had broken ground, paving the way for other NPs in the Twin Cities to consider running their own clinic.

14 “Expanding the Horizons of Healthcare: A Reference Guide,” 2nd edition, The Minnesota Partnerships for Training, Minneapolis, p. 23.

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The College of St. Catherine

The College of St. Catherine was a Catholic college with campuses in St. Paul and Minneapolis.15 Founded in 1905 by the Sisters of St. Joseph of Carondelet,16 by 1999 the college had 4,372 students and 230 full-time faculty. The college offered bachelor’s degrees to women in liberal arts and sciences and certificate, associate and graduate degrees to men and women in health-care and human-service professions. (For list of accredited programs, see Exhibit 4.)

The school aimed to prepare students to become ethical, effective leaders in their professions, their communities and their world. The college honored a strong commitment to faith and community service and adhered to its Roman Catholic identity: “Affirming its Catholic Heritage . . . the college maintains its conviction that religious and ethical values build a framework for living, its commitment to the liberal arts as the broad base for all learning, and its pursuit of excellence for its students.” These guiding principles informed a program that enjoyed a city-wide reputation for community action. Its connection to the community was strengthened because many of the faculty, especially those who taught technical skills and professional education programs, were full-time, clinically based practitioners. Service and experiential learning strengthened the college’s educational programs. The curriculum involved real-life situations in a variety of ways, including clinical laboratory settings, internships and fieldwork assignments.

In recent years, the student body of the college had transformed, reflecting the changing demographics of the Twin Cities. An increasing number of students were on financial aid, and represented a diverse set of races, ethnic backgrounds, and cultures. In keeping with the founding purpose of the college, the student body included a number of students who were working to overcome such barriers to higher education as economic disadvantage; a physical, perceptual or other form of disability or deficits in educational background. The campus community benefited from the experience of the range of human diversity among its students and gained an appreciation for those who had a variety of abilities and backgrounds.17

In 1998, new leadership was brought to the college in hopes of strengthening the college’s programs and its reputation in the community. Said Vice President and Dean Mary Margaret Smith, “St. Catherine’s was perceived in the community as a quietly distinguished liberal arts college and yet with over 4,300 students and a variety of programs we are truly a comprehensive institution.” Under the direction of the new president, Sister Andrea Lee, the school set forth the following campus goals: “The value of the faculty and staff collaboration for the short-and long-term good of the college shall be reflected in all of the work of the campus with special emphasis on increasing: the quality of our human relationships; the language of collaboration; the community’s learning capacity; distribution of decision-making; and resource stewardship and sharing.”18 They created Centers of Excellence for women and health; women and economic justice and public policy; women and spirituality; and women and science and technology. The Centers’ organizational mechanisms were designed to strengthen interdisciplinary learning and teaching; to engage action research; to involve and respond to community partners in the work; and to engage faculty and students actively in collaborative work. They also launched a capital campaign to raise $100 million and restructured the

15 The present St. Catherine’s was the result of a merger in 1986 between a junior college in Minneapolis (St. Mary’s)and a four- year liberal arts college in St. Paul (St. Catherine’s).

16 In January, 2000, 50% of the Board of Directors were Sisters of St. Joseph.

17 Most of this paragraph was taken from the College of St. Catherine catalog, 1998–2000, p. 6.

18 These were the campus goals for 1998–1999.

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management. Three new Academic Deans were hired to oversee the college’s programs, one for Arts and Sciences, one for Professional Studies, and McLaughlin, for Health Professions.

The Health Professions Department

Smith outlined the challenges for the Health Professions Department: “One area where we had a great deal of work to do was with our programs in the health profession. Despite the fact that we have 20 health programs19 and educate a significant portion of the health professionals in the state, if you ask around no one cites it as a strength. We wanted to make it so.”

New Leadership

According to Smith, President Lee, the board, and the faculty search committee had chosen McLaughlin for the job for several reasons:

Margaret represented a different kind of experience and saw the big picture in health care, and she had some concrete suggestions for what we could do. She believed we should be asking ourselves: 1) what does the industry need in terms of professionals in healthcare, and 2) how will we prepare our students to become leaders in healthcare in the future?

We saw in her candidacy some real potential for us to do exactly the things we saw possible; not simply to get some recognition for the college, but to create for our students a real sense of opportunity and leadership; to understand their place in the healthcare system, and the leadership role they might play. This is critical because typically the positions our students take are in what might be considered pink collar aspects of the profession, populated largely by women, generally at the lower end of the hierarchy in terms of healthcare.

The Programs

The Health Professions department included 20 programs to prepare students for future careers as health care providers (see Exhibit 5 for list of programs). For generations, the programs had relied on partnerships between the university and local area hospitals and community-based clinics. This way, training in theory and basic science and structure could be taught by faculty in the college classrooms and the skills could be taught by on-site, real-life experiences under the supervision of a physician or practitioner.

The Clinics

Students from St. Catherine’s engaged over 400 clinics every year. The bulk of these were small specialty community-based clinics which served as internships for one or two students. Called “preceptorships,” many were one-time internships, where an interested student would work with the organization for a year or two at most. Other clinics were at some of the large hospitals, HMOs, or other more established health delivery systems which had offered more funding for and placement of St. Catherine’s students and graduates over the years.

19 Allied health professions is a term used to describe those who work in non-physician health professions; e.g., nurse practitioners, occupational therapists, physical therapists.

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Traditionally, the preceptors were coordinated by a college administrator or faculty member. A contract was signed, enabling a logistical and legal arrangement for the students. Then, the health care provider would provide facilities such as a laboratory, and medical equipment. St. Catherine’s faculty designed their course and communicated their goals and intentions to the hospital physicians or specialty providers. The student’s experience was largely determined by the physician.

In recent years, some new programs developed to accommodate full-time health professionals who wouldn’t need to make the commute to the college. In these “off-site” clinics, a clinic or hospital would provide the classrooms and even the marketing for the program. St. Catherine’s faculty would manage the design of the curriculum—whether it be for an associate degree, certificate or continuing education program. Robertson explained, “The faculty enjoyed these programs where they didn’t have to be responsible for administrative work, budgets or marketing materials. They could focus on their teaching.”

Pressure to Innovate

By 1999, both changes in the marketplace and pressures on higher education to raise the credentials of their graduates forced the educators to consider new kinds of preceptorships. Smith provided background on the increasing expectations of credentialing:

In the current environment, if we don’t graduate students who are professionally trained— who hold a master’s degree and if it’s required, a doctorate—then they won’t be taken seriously in the national and local conversations about care.

For example, it used to be enough to have a baccalaureate degree in occupational therapy. But now, the profession is moving in a direction that is demanding a master’s degree. For this reason, we have reconfigured our baccalaureate program to offer occupational science. Students will receive certification, the OTR (occupational therapist registered), at the master’s level. Despite long waiting lists for the program, and the fact that this was one of our bread and butter programs—we’ve done what we can to ensure that we are doing what we can for our students so that when they graduate they will be on a level playing field with their co- workers. We roll the dice. . . .

“At the same time,” Smith continued, “the managed care market is putting pressure to hire those who cost less, and have fewer credentials. But they are also asking them to provide more services.” Joan Robertson, Director of New Program Initiatives, described some specific pressures this put on the program:

We’ve had trouble accessing some internships because of the increase in programs and the decrease in health-care workers available to teach on-site. Health care providers can’t afford to take their staff away from patient care to work with trainees. Over the last few years, we’ve noticed that fewer students are going to hospitals where the physicians prescribe their experiences, and more are going to community-based clinics which are often in modest consultation with physicians.

Programs at St. Catherine’s needed to be designed to prepare students for more direct service. Robertson continued: “One way around this dilemma is to have health professionals at some clinics allow our students to actually perform the service.” She pointed to one example:

Last year, the master’s in physical therapy program began a partnership initiative with the Institute of Sports Medicine. This is the closest of any college affiliation with a clinic where the students and faculty are actually a part of the clinic team. It’s more than just the students doing

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the clinical rotation; they are actually a part of the clinic. The students are already physical therapists so they can function independently—as independent care providers.

In Robertson’s view, this was the best kind of preceptorship: “When all is said and done, the student who has had the experience of direct service ends up being better off—more competent and feeling more a part of the team. They are the ones who are best prepared to enter and succeed in the workforce.”

Aware of the tension between all of these competing issues and dynamic trends, Smith pointed out their dilemma as leaders of the organization:

The question becomes for us, which direction do we follow? Further, even if we see change as part of our work, there is only so much that everyone can handle at once. Our institutional resources and our human resources are stretched thin . . . everyone has a dozen plates spinning.

And, to top it all off, consider institutions of higher education. They are known for being stodgy: there are tensions and noises that can slow things down. Faculty groups ask many questions and form many committees. This raises questions with our external partners and whether we can be facile when a new idea comes forth.

The Nursing Department

The Program

The nursing program at St. Catherine’s offered both undergraduate and graduate degrees in nursing. The Minneapolis campus graduated 135 associate degree program graduates per year, and the St. Paul campus, 80 bachelor and 30 master’s degrees. Since they graduated their first diploma degree20 nurses in 1890, they had responded to trends in the marketplace: first offering an associate degree program, then a baccalaureate degree. In 1990, they created a master-level program.

The graduate programs prepared NPs. A full-time student could complete the program in four semesters and two January terms. There were four specialty areas within the master’s program: neonatal, pediatric, adult and gerontological. “We have always had the specialty options, rather than the more generalist family practitioner nurse,” Swan observed, “this way, you have more depth.”

Upon completion of the program, students took the nurse practitioner certification exam in their specialty area. Since 1992, the American Nurses Association and the National Association of Pediatric Nurse Associates and Practitioners had required that all nurses writing the pediatric, adult and gerontological nurse practitioner exams hold a master’s degree in nursing. In 2000, all nurses writing the neonatal nurse practitioner exam would be required to hold a master’ s degree in nursing (for more details on coursework and program objectives, see Exhibit 6). In 1999, legislation made it clear that NPs could only serve clients for which they were certified. In response to this, the faculty had

20 Degrees ranking from lowest to highest are: diploma degree, associate degree, bachelor’s degree, and master’s degree. Diploma programs were the norm in the mid-1990s. They were housed in hospitals and funded similar to the Graduate Medical Education (GME). In the mid-1950s the nursing profession determined that education of nurses needed to be delivered in institutions of higher learning. While master’s education in nursing had always been located in colleges and universities, nurse practitioners were often prepared in these schools at the post-baccalaureate certificate level. In the early 1990s, the standard for nurse practitioner education was changed to master’s level.

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designed three “bridge” courses to allow NPs certified in one area to take a shorter, customized course to prepare them for another specialty area.

The Vision for Nurse Practitioner Preparation

Swan, who had been designing graduate programs in nursing for the college for over 10 years, shared her thoughts about preparing nurse practitioners:

Today, we need to prepare people who are team players and who can take on the systems view. They need to be more multi-skilled with less rigid boundaries between the kinds of diagnoses and services they can provide. We need people who can think critically about what it means if someone is not on the right pathway for care; who can trouble shoot and say, “What does this mean? What can I do to get them back on the path?”

Robertson agreed with Swan’s observations, adding:

We need health professionals to be trained in a way so that when a problem arises with a patient, they aren’t thinking, “I can’t do this because I wasn’t trained; or I can’t do this because it’s not in my scope of practice.” Rather, they need to have the kind of mindset that is open enough and flexible enough that if you get into a setting and the need is for a certain kind of skill, that they are open to seeking out the right training they need. They need to be confident in their ability to master new skills.

Similar to the other health professions, the nursing department too was witnessing a change in the marketplace:

It’s been tough since managed care came to Minnesota. Some of the large systems providers where we’ve offered preceptorships will suddenly lay off employees. When we approach them with our specialty model for what we think is the proper design for clinical education, some turn it down for a cheaper model. We need to be creative about how we design programs and work with others. We also need to consider our student body. The profile is changing. There is a more multicultural mix, more need financial aid, and there are more single mothers.

A Clinic of Their Own?

In February, 2000, Swan and Dooley Eid scheduled an appointment with McLaughlin to discuss this idea. Speaking on behalf of the entire graduate school of nursing faculty, Dooley Eid explained the concept:

The idea of developing an independent nurse practitioner run clinic came to us when we were working on The Collaborative Rural Nurse Practitioner Project. This was a state-funded grant awarded to the college with five other schools to place NPs in rural areas. The groups of schools had to find NPs who were strong in their communities, and we recruited them to come to one of the schools for training and to then return to serve those communities. We began this initiative in 1993 and to date have graduated approximately 700 NPs with close to 25% of them finding employment in the rural areas of Minnesota. It was successful and now we wanted to do more.

As a faculty, we came up with this concept of developing our own clinic. We have such a rich variety of NPs and so it makes a lot of sense. We have the history and are a strong group.

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Through The Rural Collaborative we experienced what it was like to share a lot of the effort. We had to access clinical sites and deal with issues of reimbursement; dealing with the issues one faces in having to make sure that the clinics produce.

After listening, McLaughlin asked them about the goals of such a clinic. Swan replied:

The whole object of the clinic would be to provide access to care and to an under-served population and also to make it possible for NPs to bill for their own services. We would not give our time; rather, the program would support itself. Perhaps we could figure out how to partner with others to make this happen—to help us with some of the financial and administrative burden that our faculty find tiring.

McLaughlin wondered who the clinic might serve. This triggered a discussion about four possible options for clinic models.

Option A

The first option was to set up a pediatric primary clinic in a public school in the St. Paul area. The schools had a diverse student population, and in many cases had high absenteeism rates. It was common knowledge that many of the students disappeared from school because they were sick and wound up in emergency care for treatment. A school-based clinic would alleviate this problem and curb absenteeism.

Swan liked this idea. She explained:

This plan fits with the college’s mission and would be terrific for the school system in St. Paul. It would be easy for us to do because school-based clinics are not new to the school system—I can think of a few already that serve them. In addition, we might be able to find a partner in Health Partners,21 who are right across the street. This would also ensure good physician support. Fifty percent of the students are HMO Medicaid covered and Health Partners would probably be delighted if we took responsibility for caring for the children. Further, we could get grant money from foundations easily because of the cause—school children in need.

Dooley Eid added: “This model would also be great for us because of the educational component. Working alongside local area schoolchildren would force our faculty and students to become culturally competent care providers.” She then outlined the possible challenges of implementation:

This could be tough because the school district we would want to serve is a bit north of St. Paul and may cross over district lines. We’ve also heard that Health Partners might be starting a family practice unit in this area, and we would not want to create any conflict with them. Another problem is that using grant money to get ourselves going might not be the best idea— you never know how long it will serve you.

Option B

The next idea was to partner with a Catholic Charity in the city. One of these was St. Mary’s clinic—a place for people to come who have nowhere else to go. It was run by the Sisters of St. Joseph

21 Health Partners is health delivery system which was already an active partner of the St. Catherine’s.

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of Carondelet. There was no doubt there was a need for this, and the Sisters were already connected to the college, so it would be a logical move.

Still, there were concerns. All three agreed with Swan that there were problems with the model. The clinic was based on a physician-run model. They agreed it might be better to go to an area where they could have the best chance of creating success for NPs. Dooley Eid added, “If we did this one, we would most likely have to provide our services on a volunteer basis.” This raised an important issue for the college. McLaughlin elaborated: “This idea of charging fees for services may not rest well with the central tendency in this college, which is to give because giving is a valued thing to do and so doing pro-bono work is what is valued. Do we really want to move away from that if we begin a clinic where we charged for our services?”

Option C

Dolly Eid had been investigating other nurse practitioner models outside of Minnesota. One was CAPNA (Columbia Advanced Practice Nurse Associates) which had a clinic positioned near Central Park in New York City. It was the site of the recent Mundinger study. Dooley Eid had visited with Karen Piacentini, who had been recruited from Prudential Insurance Company by Mundinger to oversee CAPNA. The six NPs who staffed the clinic had joint clinical and academic appointments and had been handpicked for this model in the national eye. She explained what she knew about it:

This clinic provides primary preventative care for business women in Manhattan. The group received start-up funds from Columbia Presbyterian Hospital. They provide a continuum of care. NPs can admit patients to Columbia Presbyterian Hospital where the physician can take over care. Then, the nurse practitioner can do all of the work around the patient’s discharge.

The group has a great financial person on site and the NPs have autonomy to structure the clinic as they wish. It is a research model, so their practice is designed to research all of the questions about themselves and what is working and what is not.

For us, the problems with the approach is that the model isn’t interdisciplinary in the way that St. Catherine’s would probably want ours to be. They don’t allow students into the model. And, it is an independent model. You could argue that Columbia would help them out if they had problems, but they haven’t organized themselves in a way that formally links them to partners and collaborators.

Option D

The last model was a clinic similar to one offered at Georgetown University in Washington, D.C. This was a primary clinic that was launched with grant money from national foundations. It was a collaborative model in which patients could go to the clinic for one-stop shopping. One site—an old school redesigned and turned into a primary care clinic—housed everything from after school programs for children to prenatal care offered by nursing midwives. They bill for all of the services— educational and healthcare related.

Swan explained why they liked this one:

Health care practitioners in Minnesota are beginning to explore alternative health care delivery systems in the community that match the lifestyles of the population, and this particular model would fit well with it. Further, in this kind of clinic you are meeting a broad

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set of education needs: it serves a broader lifespan—not just children, but adults—and it provides a good place for everyone to learn. It could also be multidisciplinary. With this, we might be able to include some of our other health professionals at St. Kate’s, such as our occupational therapists.

Food for Thought

After discussing these ideas, McLaughlin suggested that they spend some more time thinking about exactly how this would work and what questions would need to be answered before moving forward. She remembered the conversation she had with Brainerd, who had helped her develop a list of criteria by which she would evaluate the four options:

1. They would need to determine how to organize the clinic in a way that it had links with a medical group, particularly for patients who were not well enough or who needed hospitalization.

2. There would be opportunities for financial support. Would it be better to fund the operation through fees and reimbursement, or through tuition and grants?

3. Liability issues were a concern. Would it be easier to deal with these as a small independent group, or with links to a larger organization that already had systems in place?

4. There were logistical challenges in terms of location and proximity to resources. They would need to consider the administrative structure, partnerships, and how much it would all cost.

On top of this list, McLaughlin considered her own set of criteria as Dean of Health Professions:

1. This needed to make sense for The College of St. Catherine. And if it did, the nursing department needed to have a broad enough vision for what it could become. It should be different from other clinics in Minnesota and the rest of the world.

2. It ought to have an optimal vision of reward for the college’s generous and enthusiastic faculty.

McLaughlin could not wait to find some answers.

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Exhibit 1 A Snapshot of Nurse Practitioners in Minnesota

Nurse Practitioner (NP)

Education

The standard for nurse practitioner education is at the graduate level; however the few certificate programs remaining are with Planned Parenthood. Nurse practitioners hold a Master’s Degree from a graduate nursing program offering preparation as a nurse practitioner. Programs are accredited by the National League for Nursing and follow standards and guidelines developed by the National Organization of Nurse Practitioner Faculty.

Licensing/Registration

Must be licensed as a Registered Nurse by the Minnesota Board of Nursing. Licensing requirements include graduating from an approved nursing program and passing the NCLEX exam. Nurse practitioners do not have another license as a nurse practitioner.

Certification

There are four national nursing credentialing organizations which certify nurse practitioners through an examination. Applicants must be registered nurses and have graduated from an accredited nurse practitioner program. One of the credentialing organizations requires that the NP have a Master’s Degree in nursing (American Nurses Credentialing Center). Practice and continuing education hours are required to maintain certification.

Scope of Practice

Nurse practitioners provide common primary care services to a wide diversity of populations. They may have a general focus on the family or specialize in the care of children, women, or elders; some may specialize in mental health. As independent practitioners, NPs may establish their own practices or work as collaborative partners with physicians and other health care team members. Common service delivery locations include clinics, nursing homes, hospitals, and schools. NPs perform physical examinations, conduct holistic and comprehensive health assessments, diagnose and treat common acute illnesses and injuries, provide immunizations, manage a variety of common chronic health problems, order and interpret x-rays and other diagnostic tests, and counsel patients on disease prevention and health promotion. Nurse practitioners work in collaboration with all members of the health care team, which involves consultation and referral when a problem is beyond their scope of practice and their individual expertise.

Prescriptive Privileges

NPs have had legislative authority since 1990 to prescribe drugs including controlled substances and therapeutic devices. To be eligible for prescriptive authority, the NP must be certified by a national nursing certification organization recognized by the Board of Nursing. In addition, the NP must have a signed written agreement between a physician and the NP. The written agreement defines the prescribing responsibilities of the NP and the categories of drugs the NP can prescribe. The agreement is based on standards established by the MN Nurses Association and the MN Medical Assn.

Source: “Expanding the Horizons of Health Care, A Reference Guide,” 2nd edition, The Minnesota Partnerships for Training, University of Minnesota, Minneapolis, pp. 36 and 37.

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Exhibit 2 Predicted Changes for Nursing Education between 1999 and 2025

McBride’s Prediction

McBridea predicts major paradigm shifts in health care delivery and academia. Based on these shifts, she predicts the following ten changes in nursing education between now and 2025:

1. Schools will focus on the concept of lifelong learning, not just on academic degrees, with alumni becoming as important as students in degree-granting programs.

2. Career counseling will become increasingly important with emphasis on having a “full” career, assuming positions beyond the discipline specific, and nursing as good baccalaureate preparation for all aspects of the health care industry.

3. Centers of excellence will take shape, and with them a growth in postdoctoral training and in scholarship congruent with the institutional mission.

4. Consortium education will grow; programs and schools will join forces across state and national boundaries to offer collectively the full range of academic opportunities.

5. Schools/programs will increasingly operate in terms of the principles of responsibility- centered management, with a corresponding emphasis on bench-marking, economic modeling, overhead management, and entrepreneurial activities.

6. “Best practices” in health education will be established and nurses will take the lead in designing life style-change programs and a broad array of learning products.

7. There will be renewed interest in recruiting young adults into nursing, particularly in supporting research career trajectories straight from baccalaureate education through to postdoctoral.

8. Faculty roles will continue to evolve, with increasing emphasis on the concept of “faculty mix.”

9. The role of the dean will become substantially external, with emphasis on forgoing community/business partnerships and fund raising.

10. Links between nursing education and nursing service will continue to grow.

McBride also believes nurse educators will have to resolve “entry into practice” and the relationships among baccalaureate, masters, and doctoral education.

Source: Carol A. Lindeman, “The Future of Nursing Education,” Journal of Nursing Education, vol. 39, no. 1 (January 2000): 8–9.

aA.B. McBride, “Breakthroughs in Nursing Education: Looking Back, Looking Forward,” Nursing Outlook, 47 (3), 1999, pp. 114–119.

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Exhibit 3 Analysis of Student Nurse Practitioner Primary Care Practice Patterns in the Northwest, Midwest, and South

Overview This analysis was conducted to examine the adequacy of clinical preparation of nurse practitioner students for their complex roles as primary care providers. The content and scope of practice patterns of NP students from four universities with well-established NP programs were examined. Data were collected using a standardized form for 8,027 patient encounters reported by 30 adult NP and 42 family NP students in primary care settings during one year of the program. Similarities were numerous across NP specialties and educational programs despite geographical, regulatory, and curricular differences.

Exhibit 3A The 20 Most Common Reasons for Visits to Physicians Offices

Note Acute problems were the most frequent (52%) reason for a visit, followed by chronic problems (27%). Health promotion and health maintenance visits accounted for 22% of the total visits.

Rank Reason for Visit 1. General medical examination 2. Acute upper respiratory infection

3. Hypertension

4. Prenatal care 5. Acute otitis media

6. Acute lower respiratory tract infection

7. Acute sprains and strains 8. Depression and anxiety

9. Diabetes mellitus

10. Lacerations and contusions 11. Malignant neoplasms

12. Degenerative joint disease

13. Acute sinusitis 14. Fractures and dislocations

15. Chronic rhinitis

16. Ishemic heart disease 17. Acne and disease of sweat glands

18. Low back pain

19. Dermatitis and eczema 20. Urinary tract infections

Source: Adapted from Katherine Crabtree, “Analysis of Student Nurse Practitioner Primary Care Practice Patterns in the Northwest, Midwest, and South,” The American Journal for Nurse Practitioners, September/October 1999, p. 11.

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Exhibit 3B Nursing Diagnoses and Interventions Made by Students

Note The most frequent nursing interventions (horizontal axis) reported were teaching, monitoring and surveillance, counseling, health promotion, and advice concerning over-the-counter (OTC) medication. The nursing diagnoses reported most frequently are in descending order (vertical axis). The diagnoses complemented the top five medical diagnoses made by NP students, which the study found to be, in descending order of frequency: hypertension, pregnant woman, diabetes, sinusitis, and upper respiratory infection.

Teaching Monitoring/ Surveillance Counseling

Health Promotion Prescription OTC Med

Nursing Diagnoses n (%) n (%) n (%) n (%) n (%) n (%)

Health Maintenance 256 (18.7) 133 (9.7) 35 (9.7) 158 (11.5) 30 (2.2) 2 (.2)

Altered Health Maintenance

208

(33.9) 119

(19.4) 83

(13.6) 78

(12.7)

53

(8.6) 19

(3.2)

Health Seeking 574 (47.8) 164 (13.6) 149 (13.3) 200 (16.6) 51 (4.1) 5 (.4)

Health Management Deficit

70

(48.3) 20

(13.8) 20

(13.2) 12

(8.3)

9

(6.3) 0

Knowledge Deficit 661 (73.5) 10 (1.1) 157 (18) 19 (2.1) 13 (1.4) 2 (.2)

Pain 202 (31.2) 136 (21.0) 82 (12.9) 20 (3.1) 123 (19.0) 48 (6.8)

Impaired Tissue Integrity

0

0

0

0

0

0

Potential for Infection 95 (31.1) 49 (16.1) 60 (19.8) 28 (9.2) 50 (16.4) 9 (3.0)

Totals 2066 631 586 515 329 85

Source: Adapted from Katherine Crabtree, “Analysis of Student Nurse Practitioner Primary Care Practice Patterns in the Northwest, Midwest, and South,” The American Journal for Nurse Practitioners, September/October 1999, p. 17.

“n” = number and % = percent.

Exhibit 3C Differences in Students Level of Responsibility and Preceptor Type

Note Nurse practitioner preceptors fostered independent decision-making more than physicians did.

Preceptor Type

Exam by Student; Decisions by

Preceptor

Exam by Student; Decisions Jointly

with Preceptor

Exam and Decisions by

Student, Preceptor Validates

Exam and Decision by Student

Independently Nurse Practitioner 6.9% 23.6% 54.4% 15.0%

n = 324 Physician 9.0% 44.9% 42.7% 3.4%

n = 178

X2=38.08; p<.001

Source: Adapted from Katherine Crabtree, “Analysis of Student Nurse Practitioner Primary Care Practice Patterns in the Northwest, Midwest, and South,” The American Journal for Nurse Practitioners, September/October 1999, p. 18.

“n” = number.

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Exhibit 4 Accredited Programs at St. Catherine’s

History and Accreditation

The College of St. Catherine-Minneapolis offers health-care and human-service career opportunities through associate degree and certificate programs. Founded in 1964 as St. Mary’s Junior College, the institution merged in 1986 with the College of St. Catherine, a four-year liberal arts college located in St. Paul. As a result, the College of St. Catherine-Minneapolis is in the process of expanding its educational mission and continues to offer innovative, high-quality educational programs responding to the ever-changing needs and technological advancements in health-care and human-services careers.

Accreditation and Approval

• The College of St. Catherine is accredited institutionally by the North Central Association of Colleges and Secondary Schools.

• The Nursing program is accredited by the National League for Nursing Accreditation Commission.

• The Occupational Therapy Assistant program is accredited by the Accreditation Council for Occupational Therapy Education (American Occupational Therapy Association).

• The Phlebotomy program is approved by the National Accrediting Agency for Clinical Laboratory Sciences, the Commission for the Accreditation of Allied Health Education Programs and the American Medical Association.

• The Respiratory Care program is accredited by the Committee on Accreditation for Respiratory Care, Commission for the Accreditation of Allied Health Education Programs, American Medical Accreditation and American Medical Association.

• The Health Information Management program is accredited by the Commission for the Accreditation of Allied Health Education Programs in cooperation with the Council on Education of the American Health Information Management Association.

• The Physical Therapist Assistant program is accredited by the Commission on Accreditation in Physical Therapy Education (American Physical Therapy Association).

• The Radiography program is accredited by the Joint Review Committee on Education in Radiology Technology.

• The Sonography program is accredited by the Joint Review Committee on Education in Diagnostic Medical Sonography and the Commission on Accreditation of Allied Health Education Programs.

• The Chemical Dependency Family Treatment Counselor program is accredited by the Institute for Chemical Dependency Professionals of Minnesota.

• The Center for Contemporary Montessori Programs is affiliated at all levels with the American Montessori Society.

Source: St. Catherine’s College.

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Exhibit 5 Programs in the Health Profession Department

College Program

Chemical Dependency Family Treatment Coding Specialist Exercise and Sport Science Health & Wellness/Holistic Therapies Health Care Interpreter Health Information Management Medical Records/Health Information Specialist Medical Transcription Nursing Program (AAS) Nursing Program (BSN) Nursing Program (MANU) Occupational Therapy Assistant Occupational Therapy Masters in Occupational Therapy Phlebotomy Physical Therapist Assistant Physical Therapist (MPT) Radiography Respiratory Care Sonography

Source: St. Catherine’s College.

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Exhibit 6 St. Catherine’s College Masters of Arts in Nursing: Program Overview

Course Work

The 40-credit Master of Arts in Nursing program consists of core content in critical decision making, ethical leadership, cultural diversity, health promotion and maintenance, nursing theory, nursing research, administrative problem solving and health policy, and practice-specific content in the chosen area of nurse practitioner specialization: neonatal, pediatric, adult or gerontological nursing.

A full-time student can complete the program in four semesters and one January term. Priority is given to applicants who wish to pursue full-time study. Upon completion of the program, you will be eligible to write the nurse practitioner certification examination in your specialty area. Since 1992, the American Nurses Association and the National Association of Pediatric Nurse Associates and Practitioners have required that all nurses writing the pediatric, adult and gerontological nurse practitioner exams hold a master’s degree in nursing. In 2000, all nurses writing the neonatal nurse practitioner exam will be required to hold a master’s degree in nursing.

Advanced Practice

The Master of Arts in Nursing program builds upon the existing skills and experience of the professional nurse, providing preparation for advanced practice in the health-care system. Nurse practitioners implement the nursing process through expanded assessment, planning, intervention and evaluation modes and incorporate a holistic approach toward the care of clients. Advanced practice is based upon an extended knowledge base, advanced decision-making skills, research experience, a conceptualization of advanced nursing practice and a well-developed ethical framework. The program addresses each of these areas.

Clinicals

Students complete more than 600 hours of an advanced clinical practice experience. Clinical coordinators work together with students to secure preceptors prior to clinical course work. The option coordinator approves all clinical placements for students with that option. Faculty supervise clinical placements by making visits to each site and arranging conferences with students and their preceptors. The nursing faculty is committed to providing health care to underserved populations, including consumers in rural areas. Students who wish to pursue clinical experiences in these areas are supported in their efforts.

Prior to the beginning of clinical course work, students must verify that they have an active Minnesota nursing license and malpractice insurance.

Thesis

The program includes a thesis requirement. The student will complete a thesis based upon a research project focusing on an advanced practice clinical issue, defend the thesis and then make a public presentation of the research findings.

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Schedule

Courses in the Master of Arts in Nursing program are offered in a semester format. Fall semester begins in September and winter semester in February. Classes are block scheduled weekly or biweekly in late afternoon/early evening time frames on Wednesdays and Thursdays. Clinical experiences are arranged to meet student and preceptor schedules. In the second year, there is an intensive clinical experience during the month of January.

Degree

Through the Master of Arts in Nursing program, you can earn a master of arts degree with a major field in nursing in one of four areas of specialization: neonatal, pediatric, adult or gerontological nurse practitioner.

Program Objectives

After completing the course work in the Master of Arts in Nursing program, you should be able to:

1. Synthesize knowledge from nursing theory, nursing research, primary care and health policy in advanced nursing practice;

2. Demonstrate ethical decision making and professional accountability in the advanced practice nurse role;

3. Utilize nursing research to promote care of clients in advanced nursing practice;

4. Incorporate components of leadership theories to promote quality health care in advanced nursing practice;

5. Contribute to the development of advanced nursing practice as a collaborative member of the primary health-care team;

6. Use written and verbal communication to present substantive strategies to support advanced nursing practice;

7. Provide primary health-care services using a holistic approach;

8. Demonstrate advanced nursing practice that integrates theoretical knowledge from nursing and other disciplines;

9. Manage clients with acute, chronic and/or complex alterations in health using the advanced practice role set; and

10. Demonstrate caring in the delivery of comprehensive primary health-care service to individuals, families and aggregates.

Source: St. Catherine’s College.

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