Allocating resources in a data-driven college of ... - Nursing Outlook

Allocating resources in a data-driven college of nursing Gail W. Stuart, PhD, RN, FAAN Elizabeth A. Erkel, PhD, RN Lynn H. Shull, CPA, MHA

based on government stimulus incentives.6 These environmental realities challenge nursing programs as they attempt to make strategic decisions and set priorities for current activities and future growth. Like other programs, the college of nursing at the Medical University of South Carolina (MUSC) has experienced all of these competing demands. Over the past 5 years, the college raised $4 million from hospitals across the state participating in our South Carolina Nursing Collaborative partnership.7 These funds were used to hire additional faculty members and increase the number of graduate programs offered entirely online. As a result, we doubled the number of students admitted to our accelerated Bachelor of Science in Nursing (BSN) degree program and provided additional opportunities for registered nurses across the state, region, and nation to earn Master of Science in Nursing (MSN) and Doctor of Philosophy (PhD) in nursing degrees. As the only nursing program in our state that is a part of an academic health sciences center, the college of Nursing believed that it had an obligation to examine ways to offer increased educational opportunities critical in the current health care environment, such as the Doctor of Nursing Practice (DNP) degree. The challenge was that the college was operating at full capacity with no additional resources available to us. Thirty-five full-time and 100 part-time faculty members taught > 300 students enrolled in a variety programs: Accelerated BSN, RN-BSN, RN-MSN, MSN, and PhD. Within the MSN program, there were 10 specialties and 2 subspecialties. In order to implement a new educational program, faculty and organizational resources would need to be realigned. To achieve our strategic goals consistent with our faculty governance model, the leadership team agreed that all decisions would be based on empirical, quantifiable data to be evaluated by the faculty. Specifically, we wanted to assess whether our current distribution of faculty resources was appropriate and cost effective, and if we had the ability to open a DNP program with no new resources. A review of the literature revealed that this is a largely uncharted territory for most nursing programs. There are few articles focused on costing-out nursing educational programs. Those articles on the subject focus primarily

Three years ago our college of nursing faced a critical strategic planning question: How could the college initiate and offer a Doctor of Nursing Practice (DNP) degree program without additional human and financial resources? This article describes the process used to open a new educational program with no new resources by suspending educational programs that were not financially viable. While the process was difficult, shared governance and data-driven decisionmaking fostered trust and openness that allowed faculty members to make critical decisions, assuring the viability and future growth of the college. At the end of this process, faculty members were united in their decisions and actively and energetically engaged in the development of a new DNP curriculum that built upon their strengths and expertise.

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he contemporary context surrounding nursing practice and education calls for schools of nursing to increase their enrollments in programs preparing entry-level nurses, develop new programs in advanced nursing practice, increase faculty research productivity, and enhance the quality and efficacy of clinical care through scholarly practice. These demands have emerged in an environment of fiscal upheaval: State dollars supporting higher education are shrinking1; there is a growing divide between the salaries of nurse educators and nurse clinicians2,3; the cost of tuition is rising4; reimbursements for health care services are diminished in proportion to cost5; and federal research dollars are being realigned Gail W. Stuart, PhD, RN, FAAN, is Dean and Distinguished University Professor at the College of Nursing, Medical University of South Carolina, Charleston, SC. Elizabeth A. Erkel, PhD, RN, is Professor Emerita at the College of Nursing, Medical University of South Carolina, Charleston, SC. Lynn H. Shull, CPA, MHA, is Assistant Dean for Finance and Administration and Adjunct Instructor at the College of Nursing, Medical University of South Carolina, Charleston, SC. Corresponding author: Dr. Gail. W. Stuart, Medical University of South Carolina, College of Nursing, 99 Jonathan Lucas Street, Charleston, SC 29425. E-mail: [email protected] Nurs Outlook 2010;58:200-206. 0029-6554/$ - see front matter ª 2010 Mosby, Inc. All rights reserved. doi:10.1016/j.outlook.2010.05.002

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on BSN programs8,9 or nursing degree programs compared to non-nursing degree programs.10,11 Other articles addressed a faculty investment model for decision-making12; return on investment13; the direct costs of nursing education14; tracking revenue and expenses15; and comparative costs of nursing and other university-based programs.16,17 No detailed analysis was found in the literature that would aid our college in assessing the current distribution of teaching resources among our respective programs. However, decision-making based on historical allocation or ‘‘business as usual’’ was no longer an option—we needed to develop our own assessment model.

liver coursework in that program for 1 year, where 108 faculty contact hours ¼ 1 full-time equivalent (FTE) faculty. Faculty contact hours were calculated as follows: B

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REQUIRED DATA ELEMENTS To assess if any of our college educational programs were too costly to sustain, and if their required resources could be used more productively in a DNP program, we analyzed faculty costs for delivering each educational program offered by the college in relation to the revenue it generated. Faculty costs included salary and benefits for regular and modified (clinical or adjunct) faculty members, employed either full-time or part-time. Administrative and academic support services were excluded from the analysis. Thus costs in this analysis are not reflective of total program costs, only faculty costs. The analysis needed to compare costs and revenues across programs, and consider the complexity and variability of faculty workloads and salaries, plans of study and credits per course, numbers and proportions of students enrolled full-time and part-time in different programs, and percentages of tuition dollars returned to the college by type of student. Thus it was necessary to standardize the measurement of faculty resources required to deliver a program of study, the cost per faculty, and the cost per student. It should be noted that, at the Medical University of South Carolina College of Nursing, all programs are offered in year-round plans of study. The 12-month academic year begins with fall semester and has 3 semesters: Fall and spring semesters are each 16 weeks in length, while summer semester is 15 weeks long. Faculty members may teach across undergraduate and graduate programs in their areas of expertise. Faculty members comprise a faculty of the whole without graduate or undergraduate designation. The percent effort allocated to teaching, practice, and research in an individual faculty member’s workload is determined according to the faculty member’s abilities and interests and ever-dynamic college priorities. Aggregate analysis of required faculty resources for delivery of educational programs and specialties is not affected by individual differences in teaching effort among faculty members. For the purposes of our analysis, we assumed that: Faculty resources per program can be measured by the number of faculty contact hours required to de-

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1 semester hour of lecture ¼ 3 faculty contact hours (1 hour direct contact and 2 hours indirect contact for preparation/grading) 1 semester hour of seminar ¼ 2 faculty contact hours (1 hour direct contact and 1 hour indirect contact for preparation/grading) 1 semester hour of direct clinical supervision ¼ 5 faculty contact hours (3 hours direct contact and 2 hours indirect contact for preparation/grading; maximum 4 hours indirect contact per day of direct clinical supervision) 1 graduate student in practicum supervised indirectly ¼ 2 faculty contact hours (nurse-administrator, nurse-educator, nurse-midwifery, and nursepractitioner students)

Student enrollment can be measured by the number of FTE students in a program, where 1 FTE ¼ enrollment in 12 semester hours of coursework. (To avoid over-estimating the number of graduate students compared to undergraduate students, the FTE was standardized at 12 semester hours for all students.) Faculty-to-student ratio per program or specialty ¼ # FTE faculty / # FTE students for 1 year Salary plus benefits for one FTE faculty ¼ $110 000. This salary figure consists of an average faculty salary of $88 000, with a fringe benefits cost of $22 000. Revenues per program comprise tuition and fees generated by that program for 1 year

STEPS IN THE ANALYSIS Data were collected for the 12-month 2006-07 academic year, using the actual student enrollment data and faculty resources used per program of study. To arrive at comparative data, calculations involved determining the following: 1. Mean # students by program/specialty (to eliminate duplicate counting of students) a. Add the number of students enrolled in the particular program/specialty during fall, spring, and summer semesters b. Divide the sum by 3 2. Mean # FTE students by program/specialty a. Add the number of semester hours that students enrolled in the particular program/specialty had taken during fall, spring, and summer semesters b. Divide the sum by 3 ¼ mean semester hours c. Divide the mean semester hours by 12 (12 semester hours ¼ 1 FTE) 3. Required faculty resources by program/specialty (excludes unpaid preceptors with modified faculty appointments) J

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student, and student-generated revenue (tuition and fees) for each program and specialty. Table 2 displays the total cost and per-student cost of faculty resources that are required for teaching the courses in specific plans of study by program and specialty for 1 year. We found that the higher the faculty-to-student ratio, the higher the cost per student, regardless of total faculty cost for a program or specialty. For example, the perstudent cost of faculty resources for the NNP specialty was nearly 4 times that for the FNP specialty ($34 242/$9 062 ¼ 3.79). The results for the cost-revenue comparison for all programs and the MSN specialties are displayed in Table 3. It should be noted that the rate of tuition return to the college is higher for MSN students (29%) and advanced practice specialties (38%) than undergraduate students (22%), while it is highest for PhD students (89%). The number of students was highest in the baccalaureate program. However, its low rate of tuition return produced a comparatively large deficit between faculty cost and student revenue. (This deficit was previously funded by hospitals in the South Carolina Nursing Collaborative.) Among the 3 specialties with high faculty cost (>$200 000), the FNP specialty with a high student enrollment was able to support its faculty costs with tuition and fees while the NNP and nurse midwifery specialties with low student enrollments could not. Those specialties with low-to-moderate faculty cost and low enrollment were also not able to generate enough revenue to cover the cost of their required faculty resources.

a. Add the number of faculty contact hours for program or specialty-specific courses offered during the year b. For each MSN specialty, also add core course contact hours proportionate to the specialty’s percentage of total FTE students c. Divide the sum contact hours by 108 (108 contact hours ¼ 1 FTE faculty) 4. Faculty-to-student ratio ¼ required # FTE faculty / mean # FTE students 5. Faculty-resource cost per student by program or specialty a. Standardized cost per faculty was derived from the total budgeted salaries and fringe benefits for the year. Total faculty-resource cost ¼ required # FTE faculty x $110 000 (This salary figure consists of an average faculty salary of $88 000, with a fringe benefits cost of $22 000). b. Divide total faculty-resource cost by # FTE students 6. Total revenue by program/specialty a. Obtain total college of nursing revenue in tuition and fees by program for the BSN, MSN, and PhD programs b. Allocate revenue to specialties within the BSN and MSN programs proportionate to percentage of total FTE students

FINDINGS During 2006-07, the mean number of students enrolled per semester was 301, including full-time and parttime students. When part-time and full-time enrollment was considered in the calculation, the mean number of FTE students was 273. However, size of enrollment varied considerably across programs and specialties. While the undergraduate programs were offered only as fulltime plans of study, the majority of students in the graduate programs were enrolled in part-time plans of study (Table 1). When the faculty resources required for teaching courses within programs were compared to the number of FTE students in the program, the faculty-to-student ratio increased as level of education increased. However, within the MSN program, the specialties with low enrollment had disproportionately high faculty-to-student ratios. For example, the faculty-to-student ratio for the neonatal nurse practitioner (NNP) specialty (1:3 or .333) was 4 times that for the family nurse practitioner (FNP) specialty (1:12 or .083). While there were roughly one-fourth as many FTE students enrolled in the NNP as FNP specialty (6.17 vs 22.67), the required faculty resources for their curriculums were approximately equal (1.93 vs 1.87) (Table 1). To assess whether there were programs or specialties too expensive to continue to offer them, we examined the cost of required faculty resources, faculty cost per 202

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DECISION-MAKING PROCESS The data were organized into tables and presented to faculty members at 2 forums. Faculty members teaching in the graduate programs were invited to the initial forum, as they would be most involved in development and delivery of a future DNP program. The second forum was a ‘‘think tank’’ that included all faculty members in the discussion. In this forum, each nursing program was analyzed based upon costs and revenues. Every option was considered, including closing or reducing the enrollment in each program offering. As each option was considered, the consequences of each decision were discussed. For example, if the total number of students was significantly reduced, a proportionate number of faculty positions would also be reduced. Most importantly, the discussion crystallized in an animated review of the college of nursing’s mission, vision, strengths and unique contributions. We affirmed that our educational priorities were to prepare nurses in accelerated baccalaureate and online graduate programs of study and actively promote BSN to doctoral study. Since many of our accelerated students have pursued graduate study, they serve as a ‘‘pipeline’’ to our doctoral programs. In contrast, while we were the leader O

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Table 1. Mean No. Students (Enrolled, FTE) & Faculty-to-Student Ratio by Program & Specialty 2006-07 Mean No. Students Program/Specialty All Students by Program BSN Program RN-BSN/MSN Program MSN Program PhD in Nursing Program All programs

Enrolled

FTE

Required No. FTE Faculty

Faculty-to-Student Ratio

125.66 39.00 117.32 19.0 300.98

160.56* 30.47 73.34 8.47 272.84

13.10 2.42 10.29 1.22 27.03

1:12 (.083) 1:13 (.008) 1:7 (.142) 1:7 (.142) 1:10 (.100)

1.93 1.93 0.48 0.39 0.41 0.63 0.76 0.99 0.81 1.87

1:3 (.333) 1:4 (.250) 1:5 (.200) 1:7 (.142) 1:8 (.125) 1:8 (.125) 1:8 (.125) 1:9 (.111) 1:10 (.100) 1:12 (.083)

MSN Students by Specialty** (Rank-Order by Faculty-to-Student Ratio) Neonatal nurse practitioner 8.33 6.17 Nurse midwife 10.33 6.83 Geriatric nurse practitioner 7.00 2.58 Adult nurse practitioner/palliative care 4.33 2.67 Adult nurse practitioner 5.33 3.25 Psychiatric/mental health nurse practitioner 8.00 5.08 Nurse administrator 11.67 6.17 Nurse educator 13.67 8.67 Pediatric nurse practitioner 14.33 8.25 Family nurse practitioner 32.33 22.67 FTE ¼ full-time equivalent. *BSN plan of study has 15-17 semester hours of coursework per semester.

**Ranked by faculty-to-student ratio. Specialties with < 1 FTE student enrolled omitted (Adult Clinical Nurse Specialist and FNP/ Palliative Care).

in initiating an online RN-BSN program in the state, other such programs now exist. Therefore, this program offering was not mission-critical. Faculty members then made a number of reasoned, strategic decisions. They voted to close our RN-BSN and RN-MSN programs. They voted to maintain the current level of enrollment for the accelerated BSN program. They also readily agreed that, given our current resources, we could not offer a DNP program without discontinuing one or more graduate specialties. Discussion of termination of selected specialties focused on financial viability and the college’s external communities of interest. Faculty examination of enrollment (student demand) and cost-revenue data recognized that only the FNP and pediatric nurse practitioner (PNP) specialties were financially selfsustaining (Table 3). We debated whether continuing other graduate program offerings could be justified by (a) the needs of their high-risk populations in medically underserved areas (elderly, pregnant women, seriously ill newborns, and the mentally ill), (b) the high rates of common episodic and chronic conditions among South Carolinians, or (c) that no other university in the state offered the particular specialty (NNP, nurse midwife).

It became evident that it would be very painful for faculty members to discontinue specialties in which there had been high personal investment over a long period of years. Faculty members were reluctant to target specific specialties for closure. Consensus finally formed around the option that all current MSN specialties would be discontinued in order to develop a DNP curriculum that would build upon primary care, which was a common strength among nearly all faculty teaching in the graduate program and an area of critical need for our state and region. It was decided that our DNP program would offer 2 entry points: post-BSN and post-MSN. In addition, a commitment was made to offer the DNP entirely online. This decision was based on the great success of our online PhD program and the faculty’s belief that learning for nurses in the future must be in an ‘‘anytime, anywhere’’ format. Equally important in this process was the decision that our DNP program would not simply be an ‘‘add on’’ of an additional year to our current nurse practitioner programs. Rather, the faculty committed to designing a new postbaccalaureate and post-masters entry DNP program based upon the DNP essentials.18

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Table 2. Total Faculty Cost & Cost of Required Faculty Resources per Student, by Program & Specialty 2006-07. Program/Specialty

Total Faculty Cost ($)*

Faculty Cost per Student ($)**

Faculty-to-Student Ratio

Cost by Program BSN RN-BSN/MSN** MSN PhD in nursing Total

1,441,000 266,200 1,131,900 134,200 2,973,300

8,975 8,736 15,379 15,844 10,887

1:12 (.083) 1:13 (.008) 1:7 (.142) 1:7 (.142) 1:10 (.100)

34,242 31,221 20,308 15,899 13,667 13,588 13,484 12,517 11,928 9,062

1:3 (.333) 1:4 (.250) 1:5 (.200) 1:7 (.142) 1:8 (.125) 1:8 (.125) 1:8 (.125) 1:9 (.111) 1:10 (.100) 1:12 (.083)

Cost by Specialty*** (Rank-Order by Faculty-to-Student Ratio) Neonatal nurse practitioner 212,300 Nurse midwife 212,300 Geriatric nurse practitioner 52,800 Adult nurse practitioner/palliative care 42,900 Adult nurse practitioner 45,100 Psychiatric/mental health nurse practitioner 69,300 Nurse administrator 83,600 Nurse educator 108,900 Pediatric nurse practitioner 99,000 Family nurse practitioner 205,700 *Total faculty cost ¼ Number required FTE faculty x $110,000. **Faculty cost per student ¼ Total faculty cost / number FTE students.

***Specialties with < 1 FTE student enrolled omitted (Adult Clinical Nurse Specialist and FNP/Palliative Care).

by taking courses from the DNP curriculum that qualify the student to sit for certification in their selected advanced practice specialization and qualifies the student for the Master of Science in Nursing degree. We envision that the MSN-exit option will be phased out as credentialing bodies require the DNP degree for advanced clinical practice and, consequently, student demand for this option diminishes. Because our DNP curriculum was designed with an MSN-exit option rather than with a separate MSN curriculum, students in all specialties share core courses that are taught at the doctoral level. In addition, DNP and PhD students share 2 selected core courses (Epidemiology and Health Policy). Doctor of Philosophy and DNP students are encouraged to take the master’s level nurse educator courses as electives if they wish to teach in the future. Nurse administrator students will use 3 of the DNP organizational and systems leadership courses as specialty courses for the MSN degree. In summary, sharing of coursework enables us to offer the ANP, nurse educator, and nurse administrator specialties that otherwise would be too costly and inefficient to offer. One question of concern to us was: Will graduate student enrollment decline along with the decrease in the number of specialties offered? It did not. Student enrollment in the first cohort of the new DNP/MSN curriculum

IMPLEMENTATION Over a period of months, a new integrated DNP curriculum evolved that greatly increased our teaching efficiency and cost-effectiveness. During the transition period between the old and new curricula, 21 new courses were phased in, while 65 specialty and core courses were to be deactivated within 2 years (allowing all students in the current programs to graduate). The large decrease in the number of graduate-level courses to be offered was due to reconfiguration of the curriculum design. In the redesigned graduate curriculum, the 12 MSN specialties and subspecialties (listed in Table 1) were replaced by 5 specialties: 3 DNP specialties (adult nurse practitioner [ANP], FNP, PNP) and 2 MSN specialties (nurse administrator and nurse educator). In the curriculum being phased out, only 4 out of 29 clinical courses were shared by 3 of the 12 specialties and subspecialties. In the new curriculum, the 7 clinical courses are shared by all clinical specialties, with the exception that ANP and PNP students exclude courses outside their scope of practice pertaining to age (PNP students exclude 2 adult courses; ANP students exclude 3 pediatric courses). The DNP curriculum accommodates ANP, FNP, and PNP students who wish to exit with a master’s degree rather than a doctoral degree. This can be accomplished 204

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Table 3. Difference in Cost of Required Faculty Resources and Student Revenue, by Program & Specialty 2006-07. Program/Specialty

Total Faculty Cost ($)

Difference in Cost by Program BSN RN-BSN/MSN** MSN PhD in nursing Total

Total Revenue ($)*

Difference ($)

1,441,000 266,200 1,131,900 134,200 2,973,300

745,364 228,366 900,510 182,242 2,056,482

(695,636) (27,834) (231,390) 48,042 (916,818)

205,700 99,000 108,900 45,100 69,300 83,600 42,900 52,800 212,300 212,300

278,355 101,298 106,455 39,905 62,375 75,759 32,784 31,679 83,862 75,759

72,655 2,298 (2,445) (5,195) (6,925) (7,841) (10,116) (21,121) (128,438) (136,541)

Difference in Cost by Specialty*** Family nurse practitioner Pediatric nurse practitioner Nurse educator Adult nurse practitioner Psychiatric/mental health nurse practitioner Nurse administrator Adult nurse practitioner/palliative care Geriatric nurse practitioner Nurse midwife Neonatal nurse practitioner *Total revenue ¼ Actual tuition, program fees, and online fees.

**The RN-BSN/MSN program was offered entirely online, generating higher fee revenue than the BSN program in which very few courses were offered entirely online. ***Ranked by cost-revenue difference. Specialties with < 1 FTE student enrolled omitted (Adult Clinical Nurse Specialist and FNP/ Palliative Care).

that was initiated fall 2009 was 65% higher than the previous year (66 vs 40) and 33% higher than the 3-year mean for 2006-09 (M ¼ 53). Among the 66 students who enrolled in the first cohort, 83% (55) were postBSN and 17% (11) were post-MSN. Among the 55 post-BSN students, 62% (34) elected to complete a DNP degree while 38% (21) elected the MSN-exit option. Applications for admission to the second cohort have more than doubled (296 vs 124) without any additional marketing efforts. A second question of concern related to faculty members teaching in the specialties that would be phased out: Would their jobs and faculty status be retained? We confirmed that our goal was to sustain or increase graduate student enrollment. Thus all current faculty members would be needed and no positions would be terminated. It was emphasized that faculty members in the discontinued specialties (nurse-midwifery, geriatrics, mental health, neonatal) had clinical expertise that would make significant contributions to the DNP curriculum. In the subsequent work groups these faculty members enriched the newly developed courses with their sharply focused expertise. For example, the psychiatric-mental health faculty members stimulated our acknowledgment that all graduate nursing students need advanced content related to behavioral health issues. As a result, a core course in Behavioral Therapeutics was developed, and clinical courses

were infused with significant content related to mental health assessment, diagnosis, and treatment.

CONCLUSION All colleges of nursing struggle with strategic planning and allocation of scarce resources. For most colleges of nursing there are 5 ways to generate new income: (1) cut educational costs by eliminating programs; (2) increase tuition; (3) design new programs to recruit new students; (4) increase other grant, clinical revenue or new program funding; and (5) reduce infrastructure and process costs. Deciding among these options has never been more critical than in the current economic environment. While this is a universal challenge, we found few articles in the literature documenting methods or procedures used to cost-out nursing programs. If our experience in any way mirrors that of other nursing programs, then the profession needs to ask some critical questions such as: What is the true cost of educating nurses at the baccalaureate, masters and doctoral levels? Why do we have so many nursing programs in this country offering graduate specialties, some of which having relatively few students? Would it not be better to have a few national ‘‘centers of academic excellence’’ offering nursing programs in J

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Stuart et al com/article/Fresh-Round-of-State-Budget/1244/. Accessed on February 12, 2010. 2. Rollet J. 2009 national salary & workplace survey: Good news in a troubled economy. Adv Nurse Pract 2010;18:24-30. 3. American Association of Colleges of Nursing. Nursing faculty shortage fact sheet March 2010;2. Available at: http:// www.aacn.nche.edu/Media/Factsheets/facultyshortage.htm. Accessed on June 4, 2010. 4. The College Board. 2009-10 College prices: Keep increases in perspective; 2010. Available at: http://www.collegeboard. com/student/pay/add-it-up/4494.html. Accessed on February 12, 2010. 5. Siegel M. When doctors opt out. The Wall Street Journal 2009 (April 17). Available at: http://online.wsj.com/article/ SB123993462778328019.html. Accessed on February 12, 2010. 6. News KH. Health IT incentive funding in stimulus package might not spur technology adoption, according to report. Available at: http://www.kaiserhealthnews.org/Daily-Reports/ 2009/March/10/dr00057395.aspx?referrer¼search. Accessed on February 12, 2010. 7. Stuart G. Raising $4,000 in 4 months. J Prof Nurs 2004;20: 5-6. 8. Starck P. The cost of doing business in nursing education. J Prof Nurs 2005;21:183-90. 9. Kummer K, Bednash G, Redman B. Cost model for baccalaureate nursing education. J Prof Nurs 1987;3:176-89. 10. Melvin N. A method for the comparative analysis of the instructional costs of three baccalaureate nursing programs. J Prof Nurs 1988;4:249-61. 11. Roberts P. An estimate of the cost of educating a BN graduate and graduates of other disciplines at a Canadian university: A case study. J Nurs Educ 1989;28:140-3. 12. Minnick A, Halstead L. Use of a faculty investment model to attain the goals of a college of nursing. J Prof Nurs 2001;17: 74-80. 13. Green A, Master Y, Cherry B. Managing resources and ensuring accountability: Understanding return on investment. Nurs Leadersh Forum 2005;9:163-8. 14. Barton A, Moritz P, Griffin J, Smith M, Magilvy K, Preheim G, et al. A model to identify direct costs of nursing education: The Colorado experience. Nurs Leadersh Forum 2005;9:155-62. 15. Donnelly G. A budget model to determine the financial health of nursing education programs in academic institutions. Nurs Leadersh Forum 2005;9:143-7. 16. Heynderickx R, Misener T. Contribution margin modeling by academic unit: An evidence-based approach to programmatic decision making. Nurs Leadersh Forum 2005;9:149-53. 17. Horns P. Surviving the enrollment growth funding formula. Nurs Leadersh Forum 2005;9:137-41. 18. American Association of Colleges of Nursing. The Essentials of Doctoral Education for Advanced Nursing Practice October 2006. Available at: http://www.aacn.nche.edu/dnp/pdf/ essentials.pdf. Accessed on June 4, 2010.

defined specialties as midwifery and neonatal nurse practitioner, rather than having many programs enrolling relatively few students? Where is the economy of scale in nursing education? With the availability of online learning, can nursing programs develop collaboratives to decrease the duplication of effort and enhance quality outcomes? These are compelling questions for nursing as we face educational and fiscal challenges of the future. Our college of nursing faced these issues directly in our strategic planning. We operate from 2 core principles: Shared governance and data-driven decision-making. This article described the process used to open a new educational program without new resources and suspend educational programs that were not financially viable. Our analysis of the faculty-to-student ratio, cost of required faculty resources, faculty cost per student, and student-generated revenue by program contributed substantially to our decision of whether to continue, expand, modify, or terminate our educational programs. While the process was difficult, the transparency of the data and a culture of trust and openness allowed faculty to make fully informed decisions. An additional outcome was that although faculty members with discontinued programs were saddened, when they fully understood the data analysis that led to the decisions, they endorsed those decisions and contributed their expertise to designing the new DNP curriculum and teaching in the program. During the decision-making process, it was emphasized repeatedly that programs were not being evaluated for quality or merit. In fact, each of the discontinued programs had demonstrated exceptional quality outcomes in certification rates of graduates and scholarship activities. Instead, the review was a financial analysis of program sustainability considering market demand and program delivery cost in light of dwindling financial resources. The final, and perhaps most important, outcome was that faculty were united in their decision and actively and energetically engaged in the development of a new DNP curriculum that built on all their strengths and expertise. It has often been said that academia changes slowly, if at all. What we experienced is that using data to drive change can be a powerful, timely, and effective change strategy. REFERENCES 1. Kelderman E. Fresh round of state budget cuts hits higher education. Chron High Educ 2008. Available at: http://chronicle.

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