Introduction

Graduate nursing education has encountered rapid expansion within our School of Health Professions and Wellness (SHPW). Currently, online graduate nursing programs at a small rural university includes a Master’s Science in Nursing (MSN) in Population Health program with concentrations in Population Health, Nursing Education, and Emergency Management. The Doctor of Nursing Practice (DNP) program comprises a PostMaster’s DNP track and BSN-DNP track [Family Nurse Practitioner (FNP) and Adult-Gerontology Acute Care Nurse Practitioner (AGACNP)]. The MSN program was originally approved in 1998 as an MSN in Community Health Nursing and the inaugural class was admitted in Fall of 1999. In 2016, in order to keep up with trends and issues; the name and program was changed to an MSN in Population Health Nursing with additional concentrations offered. The MSN program has had enrollment numbers ranging between 35-83 from Spring 2016 until Spring 2020. The MSN in Population Health curriculum is rigorous, innovative, and nationally recognized. One of the distinct roles of the Advanced Population Health Nurse is to function as a leader and change agent in clinical agencies. Leadership is integrated throughout the MSN curriculum as faculty use diverse and innovative strategies to develop this key attribute in students prior to program completion.

The DNP program was developed based upon data obtained from a need’s assessment conducted in the tri-county area. A proposal for development of a DNP program was supported by the University’s Board of Trustees and approved by the state accrediting body in 2016. A task force was created to design the leadership-based DNP curriculum reflecting desirable workforce competencies, which prepare graduates for a rapidly changing healthcare environment. Curriculum was created with a focus on advanced clinical practice, leadership, informatics, outcomes improvement, and translation of evidence to clinical practice. The leadership focused DNP Program was implemented in the fall of 2017. Enrollment numbers range between 64–221 from Fall 2017 until Fall 2020. The curriculum focuses on leadership, applied learning and integration of best practices in nursing/nursing education. Creative approaches are used by faculty to foster leadership skills in students throughout the curriculum.

With this rapid expansion and growth, administration has recognized the importance of soliciting student feedback to create a culture of shared governance and open dialogue between student and faculty, where student satisfaction is at the forefront. The PULSE program is designed to empower students and provide autonomy as well as a sense of responsibility related to ongoing program improvement. Faculty use feedback received from students in the PULSE program for ongoing program improvement and to enhance the quality of curriculum. Graduate nursing education is the highest level achieved and culminates in a terminal degree. Upon graduation, graduate nursing students are expected to enter the workforce possessing skills which enable them to effectively problem solve, resolve conflicts, and interact professionally with patients, families, peers, leadership, and the community.

Background and Literature Review

Shared Governance and Student Satisfaction

Shared Governance is the empowerment of stakeholders to be actively involved in decision-making, to ensure processes are in place to achieve the desired outcomes, develop relationships, and to enjoy the position and responsibilities within a healthy, cohesive, respectful, trusting, caring, and collegial environment. Shared Governance opportunities in higher education give students an opportunity to learn concepts of leadership, problem-solving, and conflict resolution as well as be a part of a team promoting inclusiveness, integrity, and professionalism. The ultimate key to shared governance lies in continuous communication. Shared Governance is a system allowing for “Checks” and “Balances” in order to facilitate continued improvement. In an article about their mentoring program, Latham et.al. [1] wrote about shared governance stating it “Fostered leadership and positive proactive approaches…and affords students opportunity to gain experience in problem solving with administrators and increase skills involving accountability, organizational decision-making, and negotiation” (Pg. 607). These writers also found discussion between students and administrators foster understanding of each other’s perspectives as well assist in the development of trust [1]. One thought provoking insight from this article was that “Student perspective sharing has been shown to benefit underrepresented students who may not believe that they have a voice” (Pg. 607). [1]. Shared governance allows students to be involved with decision-making and quality improvement. In an article written by Akright, et al. [2] about their shared governance program at Blessing-Riemann College of Nursing and Health Sciences, the authors stated, “Shared governance will continue to be ingrained in our culture…It is the reason we’ve doubled our size over the years, improved processes, and increased student satisfaction and engagement” (Pg. 11).

Student-Faculty Collaboration and Student Satisfaction in Online Education

Satisfaction is emphasized to be one of the most important factors that determines quality in online instruction. It is to this end, that as faculty members we must ensure student satisfaction by connecting and collaborating with our students to ensure they understand we value and respect them, appreciate their culture and viewpoints, as well as foster an open, honest, trusting, and inclusive environment for them to learn and thrive in [3]. In 2018, Terzic, et al. [4] wrote about their study on the influence of student’s satisfaction in regard to communication with teaching staff on overall satisfaction with higher education. The researchers conducted a quantitative research study in a private higher education institution with 226 students using a linear regression model to approximate relation of student satisfaction with student-faculty communication and the student’s overall satisfaction within the higher education institution. Several variables were identified which influenced student satisfaction including: a student’s relationship with the faculty, support extended, and feedback received. The researchers postulated that satisfied students result in a return to the university as well as recommendations for others to attend the university. Their research on the importance of communication with faculty leading to increased student satisfaction yielded positive results with statistical significance (0.01). The findings suggested student satisfaction with faculty communication contributes to overall satisfaction within the higher education institution.

Suzic, et al. [5], wrote an article about student-teacher communication in university teaching. The research relayed that communication in teaching must be improved at the university level. The researchers also suggested the facultystudent relationship is both professional and social and that first impressions are a crucial component as they form the relationship and further influence development of the relationship. As changes occur in higher education the role of the instructor and student have evolved. The learning environment is now based on a student-centered approach. Students are the focus of learning and empowered to share insights and feedback with faculty and in turn faculty appreciate and value these opinions. Mead, [6] conveyed there are several benefits from student-faculty collaboration. As communication and collaboration occurs, the relationship becomes one of commitment and support; thus, enhancing facultystudent understanding of one another. When given an active voice in educational experiences, students have the potential to become distinguished scholars. Allowing students to provide feedback strengthens commitment and promotes student ownership [6].

Utilizing Student Feedback for Program Development

Historically, institutions of higher learning have collected a large amount of data regarding student feedback. This has often been due to institutional standards and accreditation requirements. However, the actual implementation of data for program improvement has been lacking. This has led to a recognized need for systems to broaden their ability to listen to the voices of students by implementing a partnership between those students and institutions in order to make program changes based on their feedback to promote quality education [7].

Using the TIPS Problem-Solving Model to Address Conflict

Team-Initiated Problem-Solving (TIPS) is a framework used during meetings which focuses on data-based decisionmaking to improve student outcomes. The TIPS process allows a team to identify a problem with precision, develop a goal for change, choose a high integrity solution, and monitor the impact of the solution on the established goal. Effective teams follow a data-based decision-making process and include critical features in meetings. Critical features of team meetings include minutes, review of previous problems and implementation of solutions, as well as evaluation of progress [8].

Horner, et al. [8] conducted a study with thirty-eight positivebehavior support teams to assess the impact of professional development utilizing the TIPS problem solving model. The researchers found when TIPS was implemented, teams functioned differently than their baseline, meetings began with a central focus, operated without sidebar conversations, reviewed data, and were able to identify problems with greater precision and improve in problem-solving practices of school teams.

Conflict Resolution and Problem Solving Related to the Development of Leadership Skills

Leadership skills are essential in the nursing profession. These should be woven into curriculum, beginning at a foundational level, in order to provide future nurses with the required concepts they will need in order to function as successful leaders in their institutions [9]. As a necessary portion of those leadership qualities, educators must assist with the development of student abilities to problem solve and be active in conflict resolution [10]. This will be required when working with interdisciplinary team members, as well as with patients and families. To send nurses into the profession without the ability to manage these two areas serves as an injustice to patients and institutions.

The need to address the above issues becomes even more important when working with graduate nursing students, who are likely to have leadership roles during or after the completion of their programs of study. When addressing these areas, it is essential for nurse educators to acknowledge the role of civility in the educational environment. The NLN, [11], in a vision statement for the future, stressed that a part of the organization’s mission for our role as nurse educators “Is creating and sustaining a culture of civility and respect in nursing education, so that both faculty and students may thrive and students may develop the skills necessary to transform clinical practice environments” (para. 1). In order to do this, educators must develop effective methods of “hearing” their students without those students fear of retaliation for providing feedback. The PULSE program serves to provide graduate students with leadership skills and an opportunity to collaborate with peers, faculty, and administration in an effort to develop initiatives and provide recommendations for continual program improvement.

Project Aim

The PULSE program was developed with a goal of instilling leadership skills in students while fostering shared governance where student’s voices are heard. Students are empowered to work closely in effective teams where they function as leaders and change agents. Crucial conversations occur between team members to problem-solve and resolve conflicts. Students work collaboratively with faculty to establish realistic visions and goals. The PULSE Program provides leadership opportunities for students where data driven decision making is utilized for program improvement.

PULSE in the Graduate program shall have the following functions:

• Facilitate opportunities for professional communication between faculty and students in an effort to provide student input and feedback on Department of Nursing (DON) initiatives, curricular changes, and program requirements.

• Create opportunities for student conflict resolution and problem solving by forming connections and interactions between peers, faculty, and administration in an effort to promote a student-centered learning environment that will enhance the Department of Nursing experience.

• Establish collaborative relationships to facilitate success in decision making abilities which embrace diversity and leadership attributes while fostering development of students to become responsible members of society.

• Utilize the Team Initiated Problem Solving (TIPS) model.

In the Graduate Nursing Program, the TIPS problem solving model assists in identification of problems, the development of hypothesis, discussion and selection of possible solutions, development and implementation of an action plan, and revision as necessary. A problem-solving worksheet is used by team members to create a problem statement based upon recurring themes. Next, an overarching Specific, Measurable, Achievable, Relevant, Timebound (SMART) goal for change is established with identification of a solution and the implementation of a deliberate plan. The leadership component of PULSE occurs when the PULSE representative addresses the identified problem and plan with the administrative team. This meeting time allows for dialogue and debate to foster discussion and brainstorming in order to implement a high integrity solution.

Method of Design

Institutional Review Board (IRB)

The IRB at the university is a specified committee charged with the responsibility of safeguarding the rights of human subjects. The nursing researchers proactively completed human subject training prior to submitting an application to the IRB committee. The certificate has been maintained throughout the research study. The nursing researchers submitted the proposed research application for initial review and were granted IRB approval from the university IRB committee.

Informed Consent and Confidentiality

Prior to participation in the PULSE program, online graduate nursing students are provided with knowledge related to the research study and are provided with clear instructions indicating their participation in the study is strictly voluntary and non-participation will not result in any negative consequences. Online graduate nursing students who elect to participate in the study review a consent form and acknowledge this consent by electronic signature. Students will then access and complete the Wufoo survey in an online format. Wufoo is a web application that creates online forms for data collection. Wufoo allows for authentication, encryption, decryption of data. The online graduate nursing students electronically signed informed consent forms are stored in a secure online interface. The interface can be customized and enforces secure collection of data, served across a protected 256-bit Secure Socket Layer (SSL) connection that encrypts the data before being sent to servers.

Study Setting and Population

The study was conducted at a small rural university in the southeast United States. Online graduate nursing students were recruited as a convenience sample. Inclusion criteria were online graduate nursing students that are actively enrolled in the graduate programs. Exclusion criteria were online graduate nursing students who were enrolled in the graduate programs; however, inactive.

Research Design

Online qualitative research is a primary research method of collecting information about a participant’s motivations, thoughts, and attitudes. The nursing researchers used a qualitative research design for this study. The qualitative research design was chosen because it allows participants the freedom to express their views in their own terms. The researchers developed semi-structured, predetermined, open-ended questions as an approach to foster the sharing of student ideas. Nurse researchers wanted to assess if participation in the PULSE program facilitated a sense of shared governance, enhanced teamwork and collaboration, fostered successful problem-solving and conflict resolution, ensured students have a voice and are able to provide honest feedback regarding educational experiences.

Data Collection and Instrumentation

Qualitative data which includes the collection of semistructured questions has been and will continue to be utilized as a method of collecting data each semester.

The online graduate nursing students are asked the following eight questions:

• How does participation in the PULSE program promote a sense of shared governance in the graduate nursing program?

• How does participation in the PULSE program promote problem-solving and conflict resolution in the graduate nursing program?

• What aspects of PULSE do you believe promotes engagement and the ability to provide meaningful, relevant feedback related to program improvement (i.e. midterm/ end of term surveys, PULSE virtual meetings/Town Hall meetings and the anonymous drop box)? Please elaborate on your choice(s).

• How do you believe participation in PULSE provides students with a “Voice” for facilitating change and continual improvement in the graduate nursing program?

• Discuss your confidence level in using the TIPS problem solving model to facilitate conflict resolution?

• Describe how participation in the PULSE program has fostered teamwork and collaboration with your peer group and faculty members?

• Explain your current level of satisfaction with the PULSE program in providing feedback and suggestions for improvement.

• What aspect of the PULSE program do you believe is most beneficial, and why?

Data Safety and Monitoring

The researchers have a clear plan to protect the integrity of the data obtained from the semi-structured questions. Wufoo is a web application that creates online forms for data collection. Wufoo allows for authentication, encryption, decryption of data. The anonymous online graduate nursing student responses are maintained in the Wufoo application with secured access. The Wufoo survey results can only be accessed by the researchers.

Data Analysis Strategies

Data will be collected from semi-structured online questionnaires until saturation occurs. This will be determined by ongoing analysis during the collection process. As individual questionnaires are submitted, initial coding will occur in order to determine an overall understanding of the participants’ answers. When initial coding is completed, thematic coding will then begin to provide a comprehensive description of the data. When no new information is identified from questionnaires, saturation will be determined. A synthesis statement will be utilized in the conclusion section in order to provide a synopsis of the study findings. In order to reflect scientific merit within the study, Lincoln, et al. [12] concepts of credibility, transferability, dependability, and confirmability will be utilized. Credibility has been established with prolonged engagement and triangulation. The participants are familiar with the authors and have worked closely with the PULSE coordinator during their time in the graduate program. The authors will also spend prolonged time immersed in the data until an overall understanding of the information is obtained. Triangulation will occur during meetings between authors in order to reach agreement on the meanings behind the participants’ statements Transferability is left to the reader in order to determine whether or not the data are transferable into his or her setting. This study is most suited to assist other faculty in online graduate programs; however, it may be useful to other levels as well. While qualitative studies such as this one are often generalizable, the goal is not to be considered universal in nature. Dependability and confirmability will also be considered in this study. An audit trail will provide assistance in these areas. Electronic copies of participant answers will be kept by all researchers until the study is completed. Notations by each author will be shared as needed between the researchers.

Implementation of Study

This study was implemented in Fall of 2020 and involves a Wufoo survey with eight questions. These questions will focus on student involvement in a shared governance experience where students utilize problem-solving and conflict resolution. Student perceptions relating to using a problem-solving model, including having a “Voice” in program improvement, fostering teamwork and collaboration, in addition to student satisfaction, will be solicited. Thematic coding will be used to better understand the student feedback, and a synthesis statement will be provided in order to capture the student perceptions.

Results

Thematic coding is pending as data collection is ongoing. The researchers anticipate some limitations that must be considered when interpreting the results. These limitations could include a potential for bias as there is a risk associated with the use of convenience sampling. Another limitation is that MSN students did not begin participation in the PULSE program until Spring 2020. This, in addition to the occurrence of Covid-19, resulted in a low participation rate. Also, there are geographic limitations related to the research study being conducted in a department of nursing in a rural area.

Conclusion

Data collection is currently ongoing involving the graduate nursing student cohorts during their participation in the PULSE project. Current research regarding the benefits of student feedback in programs of nursing is strongly supportive and demonstrates the beginning steps in the path to promoting leadership, problemsolving, and conflict resolution in nursing education. Plans include exploring innovative options to capture student feedback as technology advances. The PULSE Project is well suited to be adapted and utilized in other nursing programs and other fields in higher education.

References

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2. Akright J, Crabtree J (2019) Shared governance in the academic environment. Nursing Management 50: 10-11.
3. Sparks S (2019) Why teacher-student relationships matter: New findings shed light on best approaches. Education Week 38: 8.
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5. Suzić R, Dabić T, Miladinović I (2013) Student-teacher communication in university teaching. Sino-US English Teaching 10: 65-71.
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10. Schneider S (2017) Education Methods for Conflict Resolution to Nursing Students [Unpublished doctoral dissertation]. University of North Dakota.
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12. Lincoln Y, Guba E (1985) Naturalistic inquiry. Beverly Hills, CA: Sage.