Table of Contents for Program Narrative

Table of Contents (not counted in page limit) ...... 1 INTRODUCTION ...... 2 NEEDS ASSESSMENT AND RATIONALE ...... 2 Demographics ...... 2 Infant Mortality and Low Birth Weight ...... 3 Heart Disease ...... 4 Suicide ...... 5 Summary ...... 6 Rationale Discussion ...... 6 Certified Nurse-Midwives ...... 7 The Midwifery Initiative ...... 7 Family and Psychiatric Mental Health Nurse Practitioners ...... 9 Relationship: HRSA BHPr Goals, Project Objectives and Activities ...... 9 Project Objectives and Linkages to National and State Goals ...... 11 METHODOLOGY AND WORKPLAN ...... 12 CURRICULUM ...... 16 Overview ...... 16 Plan of Study: Core and Each Specialty ...... 18 Course Information ...... 21 Clinical Experience ...... 21 Electronic Distance Learning Methodologies ...... 22 Education Program ...... 22 Equipment and Technical Support ...... 22 Experience and Financing ...... 23 Competencies ...... 24 Certification ...... 24 Program Accreditation and Approval ...... 24 DIVERSITY AND CULTURAL COMPETENCE ...... 24 FUNDING FACTOR – STATUTORY FUNDING PREFERENCE ...... 26 RESOLUTION OF CHALLENGES ...... 26 EVALUATION AND TECHNICAL SUPPORT CAPACITY ...... 27 ORGANIZATIONAL INFORMATION ...... 27 Project Management, Resources, and Capabilities ...... 27 Project Personnel ...... 27 Faculty Recruitment Plan ...... 28 Capabilities of Applicant Organization ...... 29 Institutional Resources ...... 29 Linkages and Community Support ...... 30 SUSTAINABILITY ...... 30 Challenges ...... 31 REPLICABILITY ...... 31 SUMMARY ...... 31 End Notes ...... 32

Shenandoah University – Program Narrative – Page 1 (Table of Contents)

Program Narrative: INTRODUCTION: The legislative purpose of Health Resources and Services Administration (HRSA) Bureau of Health Professions (BHPR) – to “prepare advanced education nurses through the enhancement of advanced nursing education and practice” – guides the objectives of this project, “Improving Access to Health Care in Rural and Medically Underserved Areas of Virginia with Advanced Practice Nurses.” To further the accomplishment of this purpose, Shenandoah University Division of Nursing (SUDON) will use its Family Nurse Practitioner (FNP), Psychiatric Mental Health Nurse Practitioner (PMHNP) and Nurse-Midwifery (NM) graduate program tracks to: (1) increase recruitment and retention of NM students willing to enter practice in rural underserved areas of Virginia by making the NM curriculum accessible through collaborative agreements with universities in these areas (BHPR Goal One: Eliminate Health Barriers), (2) promote training in cultural competence skills for faculty, preceptors, and all advanced practice nursing (APN) students in the NM, FNP, and PMHNP tracks (BHPr Goal Two: Eliminate Health Disparities), (3) use informatics technology to enhance dissemination of current information to preceptors and NM, FNP, and PMHNP students in rural underserved areas, and to disseminate curricula to these areas via distance learning (BHPR Goal Three: Assure Quality of Care).

The project’s activities that are directed to these goals will increase the supply of advanced practice nurses in Virginia’s predominantly rural communities in order to decrease the health disparities these populations bear due to the lack of access to an adequate supply of culturally competent health care providers. By doing so, this project will also honor Goal One of the Health and Human Services (HHS) Rural Task Force: Improving rural communities’ access to quality 1 health and human services.

NEEDS ASSESSMENT AND RATIONALE Demographics Five regions are the focus of this project: Blue Ridge, Central, Hampton Roads, Roanoke, and Southwest regions. They are home to 70% of Virginia’s population.2 All have many rural jurisdictions and are predominantly medically underserved areas (MUAs). The urban Northern Virginia Region is not included. See Attachment 4 for schematic representations of these regions, their rural and MUA designations, and their poverty rates in Figures 1-5. Table One below displays the percentages of MUA and rural jurisdictions in the five focus regions.

Table 1 Number and percentage of MUAs Counties and Cities in Each Focus Region Region* % Jurisdictions MUA * % Jurisdictions with Rural (%Partial/%Full) Designations** Blue Ridge 52 (14/38) 48 Central 85 (9/76) 50 Hampton Roads 95 (43/52) 28 Roanoke 58 (15/43) 48 Southwest 93 (29/64) 79 *Data Avail from Virginia Center for Healthy Communities, http://67.92.69.86/southwest.pdf , http://67.92.69.86/blueridge.pdf , http://67.92.69.86/roanoke.pdf , http://67.92.69.86/central.pdf , http://67.92.69.86/hamptonroads.pdf , Accessed 10/19/06 accessed November 18, 2006. **Office of Management and Budget: Rural Designations in Virginia

Shenandoah University – Program Narrative – Page 2 The poverty rate in rural Virginia in 2003 was 13.9% and in urban areas was 9.3%.3 The map in Attachment 5, Figure 5 shows that the Southwest and Central Regions consist of many counties with poverty levels greater than 15% and as high as 21%.

The rural poverty rate is compounded by minorities who are more vulnerable to factors contributing to poor health. Nationally, in 2004, those who defined themselves as black or another race than white had the highest poverty rates of about 24%. Among those of Hispanic origin (any race), the poverty rate was 21.4%.4 In Virginia, 20.4% of the population is black, 4.5% Asian, .5% Native American, and 5.3% Hispanic. The Hispanic population is the fastest growing minority group in Virginia and continues with substantial growth.5 Nationally, the population growth in rural areas from 2000 to 2005 was higher among Hispanics than non- Hispanic whites. The rural population under age 20 has declined for whites and blacks, but has increased for Asians and Hispanics, reflecting recent immigration of young Asian and Hispanic families. This indicates a high level of future growth.6 The rural Hispanic population in the U.S. 7 has doubled and is now the most rapidly growing demographic group in rural America.

According to Virginia Center for Health Communities (VCHC), Virginia’s overall health status has continuously declined since the late 1990’s: In 1996 Virginia ranked as the healthiest state in the nation, but in 2001 it ranked the 18th.8 Increases in heart disease, obesity, and diabetes contribute to Virginia’s declining health status. This Needs Assessment relates infant mortality, low birth rate, heart disease, and suicide to the need for the project’s activities. These indices were chosen because they are associated with factors that are more prevalent in rural areas such as poverty, lack of access, and unhealthy lifestyles.9 It has been shown that many of these contributing factors can be relieved by NP and CNM care through health promotion, disease prevention, health protection, anticipatory guidance and counseling.10 Therefore, this project is designed to increase NP and CNM numbers in rural, underserved areas.

Infant Mortality and Low Birth Weight (LBW): Table 2 displays each region’s infant mortality rate and the percent MUA/rural designations obtained from Table 1. Table 3 shows the percent LBW in each region by race compared to Virginia’s rate and the Healthy People (HP)2010 Goal.

Table 2: Infant Mortality: Regions’ ranges* Compared with State rate & HP2010 Goal** HP2010 Goal: 4.5 per 1,000 live births Virginia Rate: 7.3 per 1,000 live births Region Blue Ridge Central Hampton Roads Roanoke Southwest Range Low: 0 Low: 0 Low: 0 Low: 0 Low: 0 Median: 6.5 Median: 8.5 Median: 10 Median: 5.4 Median: 3.7 High: 16.2 High: 30.3 High: 23.4 High: 16.4 High: 16.1 Total %MUA 52 (14/38) 85 (9/76) 95 (43/52) 58 (15/43) 93 (29/64) (%Partial/%Full) % Rural 48 50 29 48 79 *Virginia Department of Health (VDH) (2004). Table 2: Resident Total Pregnancy Terminations, Live Births, Induced Termination of Pregnancy, and Natural Fetal Deaths, Infant Deaths under One Year of Age, and Total Deaths rates for 1,000 Females Ages 15-44, Live Births, and Total Population by Planning Districts and City or County and Virginia Center for Health Communities: Virginia Atlas of Community Health Avail: http://67.92.69.86/southwest.pdf , http://67.92.69.86/blueridge.pdf , http://67.92.69.86/roanoke.pdf , http://67.92.69.86/central.pdf , http://67.92.69.86/hamptonroads.pdf , Accessed 10/19/06 ** U.S. Department of Health and Human Services (DHHS) HP2010, ed

Shenandoah University – Program Narrative – Page 3 Table 3: LBW Rate by Region and Race,* compared to State & HP2010 Goal** HP2010 Goal: 5% of all births Region Total % % LBW % LBW % LBW Total % MUA LBW White Black Other (% Partial/% Full) Virginia 8.4 7.0 12.9 8.1 Blue Ridge 7.7 7.4 14.7 13.3 52 (14/38) Central 10.1 7.4 16.2 18.7 85 (9/76) Hampton Roads 8.8 7.7 11.5 13.7 95 (43/52) Roanoke 8.1 7.5 14.8 25.9 58 (15/43) Southwest 9.7 9.3 31.5 16.7 93 (29/64) *VDH, (2004). Table 10: Resident Low Weight Live Births & Very Low Weight Births by Race with % of Resident Total Live Births by Planning District and City or County. ** U.S. Department of Health and Human Services (DHHS) HP2010, ed

The infant mortality rate is a sensitive indicator often used as a reference point for defining a community’s quality of life and the quality and accessibility of prenatal care.11 12 See Attachment 4 for a schematic representation of the adequacy of prenatal care in the State. Socioeconomic factors that influence higher infant mortality rates are poverty, exposure to alcohol and other substances, cigarette smoking, short gestation, and LBW.13 According to “Healthy Rural People 2010,” there are increased rates of infant mortality among rural residents with evidence suggesting that the rates result from a disproportionate distribution of poverty, race/ethnicity disparities, age, education, and access to care.14 As shown in Table 2, all of the regions had areas with high infant mortality rates that were often more than twice the state’s rate. LBW is among four causes of more than half of all infant deaths, and the cost of LBW babies is more than half the health care costs of all newborns combined. The long term sequelae stress families, school systems and communities.15 The HP 2010 goal is to reduce LBW to 5.0% of all live . In the nation in 2001, 13% of black infants were LBW compared with 6.7% of whites. Following national and state health disparity trends, LBW rates in Virginia are 12.9% for blacks and 7% for whites. The Hampton Roads region had a LBW rate for blacks that was 50% more than for whites; in the Blue Ridge, Central and Roanoke regions, the LBW rate for blacks was two times that of whites; and for the Southwest Region (the most rural of the regions), the LBW rate for blacks was 3.4 times that of whites. Table 2 shows that other racial groups also suffer disparities in LBW, with the Roanoke region being the most dramatic: in that region the LBW rate for babies other than blacks or whites is 3.5 times that of whites. These data demonstrate that MUA status and rural designation are positively associated with higher LBW rates. Even though other risk factors disproportionately affect rural women, increasing access to high quality prenatal care would significantly decrease these poor outcomes.17 Heart Disease Table Four displays heart disease death rates per region and compares these rates with the state rate and the HP2010 Goal for the acceptable rate of deaths due to heart disease. It will be used to augment this narrative.

Shenandoah University – Program Narrative – Page 4 Table 4: Heart Disease Deaths per Region* Compared with State Rate and HP2010 Goal** HP2010 Goal: 166 per 100,000 Virginia Rate: 206 per 100,000 Region Blue Ridge Central Hampton Roanoke Southwest Roads Ave 273.2 279.1 283.9 327.8 353.7 Range Low: 155.3 Low: 124.5 Low: 125.2 Low: 123.8 Low: 225.9 Median: 250.4 Median: 244.3 Median: 257.7 Median: 291.2 Median: 338.7 High: 595 High: 608.6 High: 580.6 High: 604.9 High: 524.7 Total 52 85 95 58 93 %MUA % Rural 48 50 29 48 79 *Virginia Center for Health Communities: Virginia Atlas of Community Health Avail: ://67.92.69.86/southwest.pdf , ://67.92.69.86/blueridge.pdf , ://67.92.69.86/roanoke.pdf , ://67.92.69.86/central.pdf , ://67.92.69.86/hamptonroads.pdf ** U.S. Department of Health and Human Services (DHHS) HP2010, ed

Heart disease is the leading cause of death in the U.S. Virginia’s rate of heart disease fell between 1999 and 2002: with 279 deaths per 100,000, Virginia placed the lowest in the nation.18 Despite a decrease in heart disease, disparities among certain subgroups, including rural populations, are more exaggerated. For this reason, Healthy Rural People 2010 rated heart disease as second only to access as a top rural health concern.19 Rural populations may have an increased risk of heart disease due to behaviors, attitudes and access challenges such as smoking, high fat diets, and sedentary lifestyles. Factors that influence cardiovascular disease are high blood pressure and high blood cholesterol as well as diabetes, tobacco use, physical inactivity, poor nutrition, and overweight and obesity (Note that many of these factors are similar to those for infant mortality and LBW). Also, rural women tend not to perceive their heart disease risk. Other factors that may increase heart disease risk are long travel distances for care, limited access to screening, and less access to technology and specialists.20 Racial and ethnic disparities exist: the death rate due to heart disease for black males is 42% higher than white males, and it is 65% higher for black females than white females. Similarly, older Hispanic males and people of low socioeconomic levels are also vulnerable.21 Table 4 shows that every region had a higher average rate of heart disease deaths compared to the State as a whole, with the Southwest Region (the one with the highest percent of rural designations, poverty levels, and MUAs) having the highest rate. Also, Table 4 shows that some jurisdictions in the regions have extremely high rates of death from heart disease – between 520 and 608 per 100,000! According to the Rural Healthy People 2010, evidence-based health care measures can decrease risk factors such as smoking, high cholesterol, hypertension, obesity, diabetes and stress.22 Prevention strategies increase the likelihood of early diagnosis through screening and disseminating warning sign information to rural communities.23 Heart disease will continue to be a priority health issue until there is access to primary health care providers in the rural areas. Suicide Table Five displays suicide rates for each focus region, comparing these rates with the state rate and the HP2010 goal.

Shenandoah University – Program Narrative – Page 5 Table 5: Suicide Rates in each Region Compared with State Rate and HP2010 Goal** HP2010 Goal: 5.0 per 100,000 Virginia Rate: 10.95 per 100,000 Region Blue Ridge Central Hampton Roanoke Southwest Roads Range* Low: 0 Low: 0 Low: 0 Low: 0 Low: 11.28 Median: 12.4 Median: 10.1 Median: 9.1 Median: 11.6 Median: 21.58 High: 20.4 High: 45.6 High: 26.7 High: 39.2 High: 37.98 Total %MUA 52 85 95 58 93 % Rural** 48 50 29 48 79 *Virginia Center for Health Communities: Virginia Atlas of Community Health Avail: ://67.92.69.86/southwest.pdf , ://67.92.69.86/blueridge.pdf , ://67.92.69.86/roanoke.pdf , ://67.92.69.86/central.pdf , ://67.92.69.86/hamptonroads.pdf ** U.S. Department of Health and Human Services (DHHS) HP2010, ed

Virginia’s suicide rate of 10.95 is higher than the national average of 10.83.24 Factors that influence suicide rates are alcohol and substance abuse, history of a mental disorder (especially depression), suicidal thoughts, and isolation combined with barriers to accessing mental health treatment, including unwillingness to seek help because of the stigma attached to mental health.25 Even though the prevalence of mental disorders is similar in rural and urban areas, poverty, age and being a black male lowers the likelihood of receiving mental health care. The suicide rate among rural males is higher than for urban males.26 Rural areas are also disadvantaged when meeting the needs of children with serious mental health problems, and psychosis is classified as an ambulatory sensitive condition. Use of outpatient mental health services is lower in rural areas due to shortages in supply of mental health professionals and longer travel distances to receive care.27 Rural residents are also likely to under-report their treatment needs – perhaps again be due to the stigma associated with mental illness. State offices of rural health identified access to mental health care and concerns for suicide, stress, depression, anxiety disorders and substance abuse as major rural health concerns.28 Table 5 shows the focus regions have suicide rates that are typical of rural, underserved areas. The Southwest Region has the highest percent of MUA jurisdictions, rural counties, and counties with high poverty levels. It also has the highest average suicide rate: 21.9 per 100,000. The Roanoke Region follows with an average rate of 13.2 per 100,000. Blue Ridge, Central and Hampton Roads rates are all approximately 11%. All these rates are higher than that of the state and over twice the HP 2010 Goal of 5.0 per 100,000. With such high rates, the Rural Healthy People 2010 recommends improving training and recruitment of rural mental health 29 professionals and placing a greater reliance on primary care providers for mental health care. Summary In this Needs Assessment four indices were used to portray the health of the communities in the five predominantly underserved and mostly rural focus regions. These are: infant mortality, LBW, heart disease and suicide. The indices are associated with factors that disproportionately challenge rural communities: lack of access to care, greater distances to travel to seek care, high rates of poverty, inability to pay for services, poor nutrition, sedentary lifestyles, and exposure to substances such as alcohol and other substances, including tobacco. Rationale Discussion The above discussion highlights the need for access to culturally competent, cost effective primary providers in these regions of Virginia. NPs (of all specialties) are becoming more important in rural areas. The applicant pool substantiates the interest demonstrated by professionals in APN education. In 2005-2006 hundreds made initial contact

Shenandoah University – Program Narrative – Page 6 with SU, 187 furthered their inquiry and 47 were accepted into the program. It is anticipated that this applicant pool will increase as the Project Objectives are actualized. Certified nurse-midwives are essential in any strategy to increase access to qualified primary care professionals for the following reasons: • In their survey of 2,405 nurse-midwives in the United States, found that certified nurse- midwives (CNMs) were more likely than physicians to attend births of mothers who were African American or Hispanic. According to these authors CNMs are actively engaged in serving women at risk for poor pregnancy outcomes and, together with research that documents the safety of CNM practice, they recommend that access to midwifery services be expanded.30 • The Pew Health Professions Commission Taskforce on Midwifery states, "the midwifery model of care is an essential element of comprehensive health care for women that should be embraced by, and incorporated into, the health care system and made available to all women"31 According to the Commission, the midwifery model can increase the safety and quality of the U.S. maternity care system. • The American Nurses’ Association states that advanced practice nurses such as CNMs are instrumental for safe, quality, cost effective care and supports the expanded use of these

The Midwifery Initiative According to the HHS Rural Task Force Report, in order to meet Goal One, or to increase access to care, a fundamental change must be made in how we educate health care professionals. According to the Board, there must be a stronger commitment from health professions education programs to recruit students from rural areas, adoption of curricula appropriate for rural areas when educating and training students in those areas, and incentives for health professionals to seek and retain employment in rural communities.33 In 2004, the Institute of Medicine’s Board on Health Care Services recommended that health professions schools should collaboratively to establish outreach programs to rural areas to attract qualified applicants and locate a meaningful portion of the educational experience in rural communities. Further, universities and 4-year colleges should expand distance learning programs and/or pursue formal arrangements with community and other colleges. . .to expand rural-based education options while encouraging students to pursue higher levels of education.34 The Midwifery Initiative actualizes these recommendations and is the focus of Project Objective One. Created in 2003 by Dr. van Olphen Fehr, the Initiative is an effort to increase access to nurse-midwifery education throughout Virginia and neighboring states. Since SU’s NM Track is located the northwestern corner of the Blue Ridge Region, it can be difficult to access for nurses who live in other geographic regions of our state, especially those areas that are remote and rural. Since the NM specialty courses are isolated to the second year of study (core courses are in the first year of study), SU is in the unique position to allow students from collaborating universities (presently Old Dominion University (ODU) in Norfolk, VA, Radford University (RU) in Radford, VA, and Johns Hopkins University School of Nursing (JHUSON) in Baltimore, MD to take the core credits of their Master’s degree at their home universities in their first year of study and then take the 19 credits of midwifery courses at SU (See Attachment 7 for core curricula from these universities). Students attending SU for the entire MSN take their core courses in the first year at SU, the NM courses in the second year and receive an MSN from SU.

Shenandoah University – Program Narrative – Page 7 The Midwifery Initiative expands access to nurse-midwifery education in the five focus regions by strengthening already existing collaborative relationships with Old Dominion University School of Nursing (ODU) and Radford University School of Nursing (RU). Both of these universities are either located in or telebroadcast to, underserved rural areas: RU (located in the Roanoke Region, is accessible to applicants in surrounding rural counties) and ODU (located in the Hampton Roads Region and telebroadcasting to the Southwestern Region’s jurisdictions of Tazewell, Wythe, Charlotte, and Washington counties (all MUAs), as well as to Central and Hampton Road jurisdictions of Martinsville, Lynchburg, Richmond, Newport News, Portsmouth, and Virginia Beach, (all MUAs.). The following table displays areas reached by the collaborative agreements within the Midwifery Initiative. Regions of Virginia accessed by SU NM Track and its Midwifery Initiative, Region Blue Ridge Hampton Roads Central Roanoke Southwest Radford X ODU X X X SU X X

In 2006, JHUSON in Baltimore, MD, became the third collaborator in the Midwifery Initiative by signing a memorandum of agreement with Shenandoah University. JHUSON students are expected to enter the NM Track at SU in the Fall 2008 semester. Although this collaborative agreement is not in Virginia, JHUSON will be subcontracting with SU to train our students and faculty in cultural competence skills and will be providing consultation on the strategy needed to evaluate the effectiveness of this intervention with students, faculty and preceptors. It is also felt that the collaborative arrangement with Johns Hopkins is the beginning of a national effort to develop collaborative arrangements within state networks of schools of nursing to make nurse-midwifery education more accessible to all registered nurses. It is the intent of the Graduate Program that this model become a model for Virginia and surrounding states and eventually for the nation. Each state will have one nurse-midwifery program through which all other universities in the state or surrounding region with graduate programs in nursing can collaborate to increase access to nurse-midwifery education. It is the motto of the SU Nurse- Midwifery Track that increasing access to nurse-midwifery education will increase access the nurse-midwifery care. Therefore the Project Subobjective 1.1 – to increase recruitment and retention of nurse-midwifery students willing to enter practice in the rural underserved areas of Virginia by making the nurse-midwifery curriculum accessible through off-campus curricular delivery sites – will strengthen this already existing initiative; evaluative data collection and dissemination of information regarding this activity will enhance this framework for the adoption of the strategy nationwide. In summary, not only does the Midwifery Initiative assure the appropriate supply, and distribution of the nurse-midwifery workforce, it enhances the human resource capacity of rural communities by educating and training nurses who reside in those communities – thereby increasing the likelihood that they will stay in their communities when they become nurse-midwives. Also, by increasing the student applicant pool to include more applicants from rural areas and potentially other under represented applicant groups, and by placing students in rural sites the Midwifery Initiative increases the likelihood that the nurse- midwifery graduates will work in rural sites after As shown above, certified nurse-midwives are associated with increased quality of care. Therefore, this Initiative will have a positive effect on the populations of these Regions that will be served by SU's NM graduates.

Shenandoah University – Program Narrative – Page 8

Relationship: HRSA BHPr Goals, Project Objectives and Activities Goal One of HRSA’s Bureau of Health Professions (BHPr) Eliminate health barriers by assuring the appropriate supply, diversity, composition, and distribution of the health professsion’s workforce guides Project Objective One - to increase access to, and facilitate successful completion of, its NM Track to RNs in rural and underserved areas of Virginia through its Midwifery Initiative during the 2007-2010 funding cycle. The SUDON will do this by increasing enrollment of students participating in the Midwifery Initiative by 8 students per year totaling 16 students in both the NM Track and its Midwifery Initiative (Subobjective 1.1), and by strengthening already existing and new collaborative agreements between NM Track and other schools of nursing that are accessible to students from underserved, rural areas (Subobjective 1.2). The SUDON will add administrative support for the project (Subobjective 1.3), and utilize the consultation expertise of Dr. Laurel Garzon RN, PNP, PhD, Graduate Program Director at Old Dominion University, to enhance student recruitment and retention from these regions and to advise the PD on methods to implement and evaluate all Objective One activities. Finally, information regarding the activities of this objective will be disseminated in publication and/or conference format on the local, state, or national levels. It is the goal of this project, that when the funding period ends, the SUDON will be able to sustain this objective’s activities. HRSA’s BHPr Goal Two: to eliminate health disparities by assuring the availability of a full range of healthcare skills and services to populations bearing a disproportionate share of disease and disability guides Project Objective Two, to train 100% of its students and faculty in cultural competence skills annually during the 2007-2010 funding cycle. Utilizing Johns Hopkins School of Nursing in a grant subcontractor, SU seeks to establish a course (both for graduate credit and for continuing education credit) that will be taught by Johns Hopkins faculty for all students, faculty and preceptors to become culturally competent for all populations who suffer health disparities due to rural residence or racial/ethnic backgrounds (Subobjectives 2.1 and 2.5). To ensure sustainability beyond the funding period, Johns Hopkins faculty will train SU faculty to teach this course (Subobjective 2.2). Dr. Phyllis Sharps, PhD, RN, FAAN, Director of the Master’s Program at Johns Hopkins School of Nursing, will also act as a consultant to assist the graduate faculty in their effort to infuse all graduate courses with cultural competence knowledge and skills, and to evaluate the effectiveness of these efforts. The Theresa A. Thomas Center of the Eastern Virginia Medical School will supply standardized patients to cultivate student proficiency in culturally sensitive patient management and will evaluate student performance utilizing their evaluation tools (Subobjective 2.3). Students and faculty have access to their evaluations which provide valuable feedback. Finally, the SUDON Graduate Program will utilize a Clinical Coordinator faculty member to ensure that every graduate student has at least one clinical experience in a rural site that is also designated as a MUA area to enhance the likelihood that the student will locate in the same or similar site upon graduation and to coordinator preceptor support for cultural competence knowledge acquisition (Subobjective 2.4). Information regarding the activities of this objective will be disseminated in publication and/or conference format on the local, state, or national levels. BHPr Goal Three (Assure Quality of Care) guides the activities of Project Objective Three to incorporate the rural relevant core competencies of patient-centered care, working in interdisciplinary teams, practicing evidence-based care, and developing skill in the use of informatics in all of APN specialty courses. The SU Graduate Faculty seeks to improve the

Shenandoah University – Program Narrative – Page 9 knowledge, skills, competencies and outcomes of the health professions work force by dedicating significant portions of the curriculum to the attainment of these competencies and in all of its APN specialty courses (Subobjective 3.1). Faculty will work intensely to develop and apply informatics skills in dissemination of graduate courses to students and preceptors. Subobjective 3.2 is dedicated entirely to developing the knowledge and skills in the use of informatics throughout the curriculum with the advice and guidance from Informatics Consultant, Dr. Dee McGonigle, RN, PhD, FACCE, FAAN, Associate Professor of Nursing and Information Sciences & Technology at Pennsylvania State University and Editor-in-Chief of the Online Journal of Nursing Informatics. According to HP 2010, computerized or manual tracking systems, clinician reminders, guidelines, and information materials can help providers improve delivery of preventive care (HP2010, Vol 2., p.1-3). Also, LaSala (2000) found that nurse relationships (with other providers) were viewed as positive incentives for retention. Feeling “connected” to other professionals for information and professional support is a positive incentive to the retention in rural areas. This project’s use of informatics will create connections between advanced practice nurses and preceptors in the rural areas for consultation, collaboration, and referral with SU and providers in other regions. The role that the use of informatics can play in rural America is to provide regular access to training and continuing education services, enhanced communication between providers, ongoing support for rural professional practice and provision of specialist support for the rural primary care provider.37 IP connections through Blackboard Learning Systems, Ipod technology, and the various software programs that will be enhanced with funding from this grant will aid SU in meeting this subobjective. Finally, another faculty member for the PMH Track will be retained to teach two PMHNP courses so that the Coordinator can use her time to assure that all PMH courses coordinate with rural relevant core competencies as they pertain to mental health (Subobjective 3.3). The Coordinators of all three specialty tracks will work together to enhance course and clinical evaluation tools to assure that outcomes are measured and that all SUDON APN curricula maintain currency in IOM competencies by using ACNM Hallmarks of Midwifery & Core Competencies for Basic Midwifery Practice and NONPF Domains and Core Competencies of Nurse Practitioner Practice through promoting competency in informatics. It is the belief of the APN faculty that informatics has enormous potential to enhance health and health care over the coming decades. Therefore, information regarding the activities of this objective will be disseminated in publication and/or conference format on the local, state, or national levels.

Project Objectives and Linkages to National and State Goals: The SUDON will increase access to its NM Track to RNs in rural and underserved areas of Virginia through its Midwifery Initiative during the 2007-2010 funding cycle. HRSA Goal 1: Improve Access to Health Care, Objective 1.2: Promote development of culturally diverse and representative health care workforce HP 2010 Objective: To increase proportion of pregnant women who receive early and adequate prenatal care: 90% of live births should be subsequent to care beginning in first trimester of pregnancy, and to early and adequate prenatal care. Goal One HRSA HHS Rural Task Force: to improve rural communities’ access to quality health and human services Project Purpose: “to prepare culturally competent nurse-midwives . . . to work in rural communities to decrease the health disparities that these communities experience because of an inadequate supply of these primary health care providers.”

Shenandoah University – Program Narrative – Page 10 The SUDON Graduate Program will train 100% of its students and faculty in cultural competence skills annually during the 2007-2010 funding cycle. HRSA Goal 1: Improve Access to Healthcare. Subobjective 1.2 activity: facilitate infusion of cultural competence into health professions training BHPr Goal 2: Eliminate Health Disparities: Assure the availability of a full range of health care skills and services to populations bearing a disproportionate share of disease and disability. Healthy People 2010 Goals: Objective 11-6: Increase satisfaction with health care providers’ communication skills Institute of Medicine Board of Health Services Recommendation 5.8: Enhance patient- provider communication and State Recommendations: The Governor’s Working Group on Rural Obstetric care recommended that the VDH encourage cultural competence training for health care providers as part of the curricula in the allied health professions. Project Purpose: “to prepare culturally competent nurse-midwives, family nurse practitioners, and psychiatric mental health practitioners. . .” By the end of the 2007-2010 FY, the SUDON Graduate Program will show evidence of having incorporated the rural relevant core competencies of patient-centered care, working in interdisciplinary teams, practicing evidence-based care, and developing skill in the use of informatics in all of its APN specialty courses requiring clinical practice. HRSA Goal 1: Improve Access to Healthcare. Subobjective 1.2 activity: Promote distance learning and the use of information technology and telehealth by HRSA-funded grantees HRSA Goal 3: Improve the Quality of Care, Subobjective 3.4: Promote the implementation of evidence-based methodologies and best practices. BHPr Goal 3: Assure Quality of Care: Improve knowledge, skills, competencies and outcomes of health professions workforce IOM Board on Health Care Services: develop rural-relevant curricula including the core competencies of providing patient-centered care, working in interdisciplinary teams, employing evidence-based practice, and utilizing informatics, and investing in an information and communications technology infrastructure as part of a framework for an essential infrastructure to deliver quality health care services to rural communities.39 HP2010 Goals: Objective 1.14: Increase the proportion of persons who have a specific source of ongoing care, American Medical Informatics Association Vision (AMIA): “development of global health information . . . technology to meet the health needs of underserved populations.” 40 State Recommendation: The Governor’s Work Group on Rural Obstetric Care recommended that the VDH promote a model of care that is centered on evidence-based health care practices and outcomes. Wherever possible, evidence-based health care should be incorporated into decisions making or changing health Project Goals: “to prepare culturally competent nurse-midwives, family nurse practitioners, and psychiatric mental health practitioners to work in rural communities. . .”

METHODOLOGY AND WORKPLAN (BHPr Goals 1, 2) OBJECTIVE ONE: (Linkage) The SUDON will increase access to its NM Track to RNs in rural and underserved areas of Virginia through its Midwifery Initiative (MI) during the 2007-2010 funding cycle by:

Shenandoah University – Program Narrative – Page 11 Subobjective 1.1 increasing student enrollment in MI by 8 students per year, total 16 students per year in both NM Track & Midwifery Initiative; Subobjective 1.2 increasing collaborative agreements for MI with universities located in, or accessible to, five focus regions by end of 2007-2010 funding cycle; and Subobjective 1.3 securing .5 FTE administrative assistant at beginning of 2007-2008. OBJECTIVE 1: Timetable, Activities, Person(s) Responsible, Project Evaluation Plan* [1.1]With Dr. Garzon, MI Consultant, PD will develop strategies to recruit RNs into NM education (PD, MI Consultant) 8/07-9/07 Strategic plan will be completed; 9/07-6/10: Strategic plan activities occur & will be evaluated for effectiveness every Spring Semester utilizing admission and retention rates (Continual Improvement CQI) [1.1] Increase awareness to RNs residing and working in underserved areas through web-based outreach, & through recruitment and information sharing personal visits to collaborative universities and/or telebroadcast sites. (PD, Midwifery Initiative Consultant, CNM faculty) 7/07-6/10 PD visit to each collaborating university recruit for MI for will occur at least 1X/yr; 7/07-12/07 NM web site will be updated to include applicable recruitment information 12/07-6/10: Web site will be evaluated for currency annually (CQI) 7/07-6/10 Personal visits to at least 3 clinical facilities annually. 8/08, 8/09 Outcome Evaluation: # new enrollees to NM Track at least 8/year (FT + PT) [1.1] Assure retention of students within the NM Track (PD, MI Consultant, APN faculty) Fall, Spring & Summer Semesters, 2007-2010 Utilize NM Clinical Evaluation Tool, student performance, & SU Course and Faculty Evaluation Tools to assess student progress & satisfaction with course delivery and faculty for each course (CQI and Outcomes Evaluation) Fall, Spring & Summer Semesters, 2007-2010 • 90% of NM students will successfully progress to next semester (CQI) • 90% of NM students beginning NMT specialty courses will graduate successfully (Outcome) • Pass rate on NM national certification examination will be greater than 90% (Outcome) All Semesters 2007-2010: Exit interviews conducted upon completion of program to assess students’ perspectives of program strengths &challenges. (CQI) [1.2] PD will secure 2 more collaborative agreements with universities located in, or have access to students in five focus regions (PD, SUDON Director, SU Vice President (VP) for Finance) 7/07-6/08 At least one negotiation process ongoing in each funding cycle year (CQI). 6/08 and 6/09 A new collaborative agreement will be successfully achieved by end each of the first two funding years. (Outcome) [1.3] One .5 FTE administrative assistant will be hired and maintained through funding cycle & incorporated into the SUDON budget after 2007-2010 (PD, SUDON Director, SU Senior VP) 7/07-9/07 Administrative assistant will be hired 9/07-6/10 Administrative assistant position will be maintained 6/09 SUDON provide in-kind support for an additional .25 FTE for this position (Outcome) 6/10: Administrative assistant will be incorporated into DON budget (Outcome) Spring Semesters 2008-2010 Assistant evaluated annually using Staff Evaluation Tool (CQI)

(HP 2010) (BHPr Goal 2) OBJECTIVE TWO (Linkage): The SUDON Graduate Program will train 100% of its students & faculty in cultural competence skills to decrease health disparities annually during 2007-2010 funding cycle by:

Shenandoah University – Program Narrative – Page 12 Subobjective 2.1 maintaining contract with Johns Hopkins University School of Nursing to develop and teach cultural competence/health disparity course and utilize Dr. Phyllis Sharps, RN, PhD, FAAN, Cultural Competence Consultant to guide & evaluate infusion of APN curricula with cultural competence/health disparity awareness activities, and Subobjective 2.2 maintaining contract with Johns Hopkins University School of Nursing to assure that at least all SU faculty member receive training to teach cultural competence skills, Subobjective 2.3 maintaining contract with Eastern Virginia Medical School (EVMS) Theresa A. Thomas Professional Skills Teaching and Assessment Center to train students in culturally sensitive patient management, Subobjective 2.4 assuring that each APN student has at least one clinical experience in a site in a rural, underserved area, and Subobjective 2.5 teaching cultural competence skills to clinical preceptors through continuing education (CE) courses offered through distance learning technology OBJECTIVE Two Timetable, Activities, Person(s) Responsible, Project Evaluation Plan* [2.1] Plan cultural competence training with JHUSON Faculty & Dr. Sharps as consultant (PD, Consultant, JHUSON subcontract) Fall Semester, 2007 By the end of the semester one course will be developed on acquisition of cultural competence skills by Spring, 2008 semester. (Outcomes) [2.1] Cultural Competence and health disparity material will be taught to all APN graduate students in N580 Health Assessment course. (Consultant, APN faculty) 5/07 Graduate Curriculum Committee will approve incorporation of cultural competence training program into existing N580 by the end of Fall semester, 2007 (Outcome) [2.1] Cultural Competence and health disparity material will be infused into all specialty courses (Consultant, APN faculty) 6/08 100% of all APN students will receive health disparity & cultural competence training before entering their specialty courses. (Outcome) 6/09 All courses will have objectives addressing cultural competence. (Outcome) 6/09, 6/10 All APN students will achieve goals of training program with at least an 80% competency level and will be evaluated utilizing pre-test and post-test format. (Outcome) Spring Semesters 2008-2010 APN students will present a culturally sensitive research project applying culturally sensitive approaches to practice at annual SU Research Day. (Outcome) [2.1] The SUDON Graduate Program will utilize Typhon Group Software for students to track their use of cultural competence skills in patient management (APN & NM Clinical Faculty) Fall Semesters 2007-2009: Students will use Typhon Group Software and will be proficient by the end of each fall semester as evaluated by APN faculty and student self evaluation. (Outcome) [2.2] SUDON APN faculty members will complete JHUSON training program to teach knowledge acquisition in rural health disparities & cultural competence skills within the 2009- 2010 FY (PD, Consultant, JHUSON subcontract) Spring Semester 2008 Training Program will be available for APN faculty enrollment and all SU APN faculty will have successfully completed training program (Outcome) [2.3] The SUDON Graduate Program will utilize the EVMS standardized patients to train students in the management of diverse clients. (PD, Co-PD, APN faculty, EVMS) Fall Semester 2007-2009 and Spring Semesters 2008-2010: All APN students enrolled in specialty courses will participate in EVMS Standardized Patient activities & will demonstrate satisfactory performance on patient management as measured by contractor evaluation (CQI) [2.4] SUDON will secure .50 FTE Clinical Coordinator that meets ACNM requirements for

Shenandoah University – Program Narrative – Page 13 CNM faculty and who, with APN faculty will manage and maintain clinical sites (PD, Co-PD) Fall Semester 2007: Orientation to clinical coordination will be completed (Outcome) Beginning Spring Semester 2008: Clinical Coordinator assume responsibility for coordination of clinical sites (Outcome) and 7/07-6/10: Clinical Coordinator continues to develop and maintain clinical sites & student placement (CQI) 6/10: .50 FTE Clinical Coordinator will be incorporated into the SUDON budget. (Outcome) [2.4] SUDON will obtain & maintain adequate number of clinical sites MUA rural areas throughout the funding cycle. (Clinical Coordinator, APN faculty) Fall Semester 2007: SUDON will secure at least 8 sites in MUA & rural areas. (Outcome) 2007-2010: At least 15 sites will be in MUA or rural areas. (Outcome) [2.5] SUDON Graduate Program will support preceptors with cultural competence training & distance learning methods (PD, JHUSON subcontract, Dr. Sharps, Clinical Coordinator) Spring Semester 2008: By semester end, continuing education course (CE) on cultural competence with CEUs will be ready to be disseminated to clinical preceptors. (Outcome) Fall Semester 2009: 80% of clinical preceptors will be enrolled in the cultural competence continuing education course and 50% will complete (CQI) Spring Semesters 2010: By the end of semester faculty will evaluate CE course (Outcome)

(BHPr Goal 3) OBJECTIVE THREE (Linkage): By the end of 2007-2010 funding period, SUDON’s Graduate Program will have incorporated rural relevant core competencies of patient-centered care, working in interdisciplinary teams, practicing evidence-based care, and developing skill in use of informatics in all APN specialty courses requiring clinical practice. Subobjective 3.1 assuring that at least 85% of students successfully demonstrate three rural relevant competencies in patient-centered care, working in interdisciplinary teams, and employing evidence-based practice, and Subobjective 3.2 utilizing curricular dissemination and practice support for preceptors and students in clinical sites and, Subobjective 3.3 obtaining part-time PMHNP instructor to teach two courses in the PMH Track that emphasize rural relevant competencies. OBJECTIVE Three Timetable, Activities, Person(s) Responsible, Project Evaluation Plan* [3.1] The APN faculty will assure that all graduate courses enhance NONPF and ACNM core competencies to assure rural relevant competencies (PD, Co-PD, APN Faculty) Fall Semester 2007: All course & clinical evaluation tools will be revised to assess student acquisition of rural relevant competencies at appropriate level for course taken. (CQI) All Semesters 2007-2010: Competency attainment will be assessed in each semester midterm and final utilizing specialty clinical evaluation tools and final exams. Students will demonstrate proficiency in rural relevant competencies as evaluated on these tools, & end of program specialty comprehensive exams. (Outcome) All Semesters 2007-2010: SUDON Exit Interview administered to graduating students will include questions on perceptions of adequacy of curricular activities to attain these competencies; preceptors will demonstrate competencies as assessed through SUDON Clinical Faculty Evaluation Tool. (Outcome) [3.1] The Graduate Program will hire .25 FTE CNM/FNP clinical faculty to monitor student journals & provide feedback on rural relevant competencies utilizing Typhon Group Nurse Practitioner Tracking System (PD, Co-PD, SUDON Director)

Shenandoah University – Program Narrative – Page 14 7/07: faculty will be hired 7/07-9/07: Typhon Group Software Program (Typhon) will be custom designed to include questions to survey students on their use of evidence-based practice and cultural competence skills in each patient visit. Clinical faculty will develop a journal evaluation tool assessing student progress in rural relevant competencies (CQI). Spring Semesters 2008-2010: Data collected through Typhon Group questions & journal evaluation tool will be evaluated (Outcome) [3.1] The Graduate Program will provide preceptors with support to maintain currency in rural relevant competencies by supporting related CE activities (PD, Co-PD, Clinical Coordinator) Fall Semester 2007: By the end semester, preceptors will have received support through SU informatics & appropriate CE activities for currency in rural relevant competencies. (CQI) All semesters 2007-2010: Clinical preceptors will evaluate the effectiveness of SU’s Graduate Program to provide support by completing the Clinical Preceptor Evaluation of Program Tool. This tool will be analyzed at the end of each academic year by APN Faculty. (CQI) [3.2] The SU Graduate Program will utilize the services of Dee McGonigle, PhD, RN, FACCE, FAAN as the project’s Informatics Consultant to guide PD & Co-PD to develop & evaluate curricular dissemination of rural relevant competencies through portable digital devices, Blackboard Learning System (Blackboard), patient tracking/management software, and evidence-based practice software (PD, Co-PD, Informatics Consultant) Fall Semester 2007: By the end semester the Graduate Program will have completed a strategy for curricular dissemination through informatics and develop evaluation tools to assess effectiveness of informatics methodologies. (Outcome) Spring Semester 2008: 50% of all specialty courses will utilize informatics to enhance student learning (Outcome) Spring Semester 2008: Data from evaluation tools analyzed (CQI) Fall Semester 2009-Spring Semester 2010: 75% of all specialty courses will utilize informatics in instruction (Outcome) Spring Semester 2010: Data from evaluation tools analyzed (CQI) [3.2] The Graduate Program will maintain contracts with Typhon Group, & “Epocrates” software vendors, & supply these software programs for students while enrolled in specialty courses, & will maintain contracts with Apple and “I Tunes U” to facilitate utilization of Ipod technology for curricular dissemination. “Up-to-Date” software will be available to faculty (PD and Co-PD) Fall Semester 2007: All contracts will be finalized (Outcome) Spring Semesters 2008-2010: Contracts maintained (CQI) All Semesters 2007-2010: Students evaluate software in course and faculty evaluation tools at the end of each semester (CQI) All Semesters 2007-1010: Exit interviews conducted with graduating students will incorporate questions regarding the effectiveness of these tools. (Outcome) [3.3] The SU Graduate Program will secure a .25 FTE PMHNP instructor to assist PMHNP Coordinator by teaching at least two 3credit courses in PMHNP Track to include rural relevant competencies & distance learning methodologies (PD, PMHNP Coordinator, SUDON Director)

Shenandoah University – Program Narrative – Page 15 7/07-9/07: PMHNP instructor will be employed for 6 credit hours of instruction (Outcome) Fall Semester 2007-Spring Semester 2010: PMHNP Instructor evaluated utilizing course and faculty evaluation tools at end of each semester. Peer evaluation will occur annually. (CQI) Spring semester 2008-Spring Semester 2010: Position will be increased to .75 FTE, with in- kind support from SU of .25 FTE. Spring Semester 2010: 1 FTE PMHNP instructor incorporated into SUDON budget. (Outcome)

*Project Dissemination Plan: Each year information will be disseminated on above activities locally, statewide, or nationally* & copies of all materials will be provided to Division of Nursing & HRSA Division of Grants Management Operations (PD, Co-PD) Spring 2008, Spring, 2009, Spring 2010: At least 2 presentations on this Project’s activities will occur in publication, or conference format locally, statewide, or nationally * (Outcome) *SUDON will use HRSA Acknowledgement and Disclaimer on all materials disseminated

CURRICULUM Overview: Students selected for the Graduate Program in the Division of Nursing find themselves in an innovative, clinically based curriculum that facilitates their professional development as expert advanced practitioners capable of providing safe and innovative care for specialized populations. In addition, they participate in leading the profession during periods of unprecedented demand for nurses capable of advanced practice and clinical management. Alternative teaching-learning experiences that go “beyond the walls” of the classroom enrich students, faculty, clients and communities and facilitates a unique opportunity to meet the goals of the project. The Graduate Program in Nursing offers several options to obtain a graduate credential in these specialty tracks: Nurse-Midwifery (NM)*, Family Nurse Practitioner (FNP)*, Psychiatric Mental Health Nurse Practitioner (PMHNP)* (* These three are the project tracks), and Health Systems Management (HSM). The options are: • A Master of Science in Nursing (MSN) generic degree option. • A Master of Science in Nursing (MSN) in the RN to MSN degree option • A Post-Master’s Certificate option in NM, FNP, and PMHNP specialties • A Certificate of Completion option in the Nurse-Midwifery Track through the Midwifery Initiative. Through this initiative, students receive their MSN from their home universities and a Certificate of Completion of NM courses through SU The Graduate curricula were developed, and undergo continual revision, to honor the interplay between the specialty core competencies and the rural demographics of Virginia. Also, the logical sequence of the curricula provides for the theoretical and clinical experiences needed to achieve APN competencies. Finally, distance learning technology responds to the lived experience of adults desiring to attend school while staying close to home holding a job. All of these components fit together to provide a dynamic, responsive and flexible curriculum that allows the student to successfully become an APN – reflecting a commitment to students living at a distance. Refer to the following table for a summary of the On-Campus requirements of the Graduate Curricula and its Specialty Tracks: Course Full Time (PT) Progression* On Campus Requirement, All specialties Type Core 1st 3 Semesters (4-6 semesters)** One day a week

Shenandoah University – Program Narrative – Page 16 Specialty 2nd 3 Semesters (4-6 semesters) NM: 1 week in Fall & Spring Semesters Only FNP: One day a week PMHNP: One day a week * The Graduate Program’s definition of full-time study during Core is a minimum of 9 credit hours per semester and a minimum of 7 for summer. Part time study is 3-6 per semester and summer. During the specialty year, full time study is a minimum of 6 credit hours, and part-time study is between 3 and 5 credit hours. **The First Three Semesters (4-6 semesters PT) will hereafter be termed “first year” and the Second Three Semesters (4-6 semesters PT) will hereafter be termed “second year.” How Project relates to Graduate Curriculum: The Graduate curricular delivery has historically focused on students who live at a distance and need to maintain a job but who are close enough to to attend school on campus at least one day a week. These students have typically come from Virginia, West Virginia, and Maryland; because of the rural nature of these areas, and clinical sites have characteristically been in the rural areas. In response, there has always been an intention to promote rural cultural competence skills; now that rural areas are becoming increasingly diverse in race and ethnicity, the faculty has decided to enhance cultural competence knowledge and skills in all courses to alleviate health disparities. As outlined in the Methodology Section of the Project Narrative, Objective Two is dedicated to enhancing the curriculum with these changes. The NM specialty track, through its Midwifery Initiative (MI), has led the Graduate Program in strategies to make curricula more accessible to students living and working in rural areas. Since the NM specialty courses are isolated to the second year of study (discreet from the core courses for the Master’s degree which are in the first year of study), SU is in the position to allow students from collaborating universities (presently Old Dominion University in Norfolk, VA, Radford University in Radford, VA, and Johns Hopkins University in Baltimore, MD) to take the core credits of their Master’s degree at their home universities in their first year of study and then take the 19 credits of NM courses at SU (Attachment 8 for MI university core curricula). Of course, students electing to attend SU for the entire MSN take their core courses in the first year at SU, coming to campus only one day a week in the first year of study. In their second year, all students (MI or NM students enrolled in the SU Graduate Program), take their NM courses through SU. In this academic year, students come to SU campus for one week in the Fall and Spring semesters, for the remainder of these semesters including summer, they are placed in clinical sites of their choosing or close to home. On completion of these two elements, MI students receive a Master of Science in Nursing from their home universities with a certificate of completion of NM Track courses from SU, SU students receive their MSN from SU, and post-master’s students receive their post-master’s certificate from SU. Although the NM specialty curriculum is more grounded in distance learning delivery methods, the FNP and PMH specialty tracks are following close behind. Through this project, they will incorporate a variety of forms of informatics technology to enhance advanced nursing practice curricular dissemination via distance learning, adopting some of the NM strategies. Already, all core and specialty courses are on Blackboard Learning System and the FNP and NM tracks are collaborating on developing delivery of coursework through Ipod and other portable digital devices. (See discussion on electronic distance learning methodologies). The evaluative data on the success of the NM students (100% pass rate on the national certification exam since beginning the second year strategy in 2004 and student satisfaction) has prompted these two specialty tracks to utilize a variety of forms of informatics technology in order to enhance advanced nursing practice curricular dissemination via distance learning, (Subobjective 3.2).

Shenandoah University – Program Narrative – Page 17 These distance learning strategies will undergo continual enhancement in order to include preceptors who are associated with SU so they will feel connected to their professional peers while staying in their communities. Plan of Study: Core and Each Specialty Students in all three specialty tracks take core courses together, facilitating familiarity and collegiality among the advanced practice nursing professions. The following table identifies the total number of clinical and didactic clock hours in the curriculum for each specialty for which support is requested: Generic MSN Specialty Credits(Clinical) Total # Clinical Core Specialty Hours NM 21(1) 10(12) 31(13)=44 >720** FNP 21(1) 13(13) 34(14)=48 720 PMHNP 21(1) 14(12) 35(13)=48 500 Post Master’s Certificate* NM ----- 7(12) 19 >720** FNP ----- 10(10) 20 ~540 PMHNP 10(5) 15 400 MI Certificate of Completion Core Specialty* Total ODU: 31 19 50 >720 RU: 24 19 43 >720 JHU: 33 19 52 >720 *3 credit elective taken during specialty is not included in Post-Master’s nor MI Credit Allotment **Minimum # of hours, however extended due to unique nature of NM care (1 birth/many hours)

SU Core Curriculum Plan of Study^ “N” Course Title Credit Requisite Status Session 510 Advanced Research Methodologies 3 F 1 520 Advanced Nursing Theory 2 F 1 560 Advanced Concepts in Physiology and 3 Pre/Co to N580 F 1 Pathophysiology 580 Adv. Health Promotion & Assessment 3(1) F 1/Sp 1 500 Data Analysis 3 S 1 532 Roles and Issues in Advanced Practice 3 Pre/Co specialty Sp1/Su1 550 Advanced Pharmacology & Therapeutics 3 Sp 1 590 Nursing Research Project 1 Sp 2 Total 21(1) ^ Courses reflect Core Competencies for Master’s Education by the American Association of Colleges of Nurses (AACN). Students in all tracks are required to complete core graduate courses prior to enrolling in their specialty courses (except N532 and N590). One credit clinical experience at a 4:1 ratio. (F=Fall, Sp=Spring, Su=Summer)

NM Plan of Study: Second (or Specialty) Year of Study There are six courses in the NM Track; three, NM610, NM620, and NM630, have didactic components in modular format, making distance education possible. Each course module contains units and each unit contains objectives that focus on ACNM competencies. Modules are

Shenandoah University – Program Narrative – Page 18 accessed on Blackboard Learning System. All three modules have 30-35 units covering different competency categories. During the first two weeks of the semester students update the units, each student being assigned 5 units to update. For example, when a student enrolls in the fall, s/he is assigned 5 units in NM610 and 5 in NM620. The student visits Blackboard, finds the units, updates and reinserts them into the system before the week of class (third week of semester). All students come to class with completed and updated modules. The third week consists of lecture, hands on skills, discussion, and management of standardized patients. This format allows the students to come to class at SU during a concentrated time (five days in the third week) and be placed with clinical preceptors for the next ten weeks for clinical application of knowledge. Students then return to campus for two days in the last week for review and exam. Students who live at a prohibitive distance may take a proctored exam close to home. These students do not attend review sessions. This challenge is new and the NM Coordinator will use Blackboard’s Discussion Board to alleviate this. Courses in the NM Track are arranged to provide a logical sequence for attaining the ACNM “Core Competencies of Basic Midwifery Practice.” The courses are presented in a hierarchical fashion: Primary Care of Women (NM610) and Comprehensive Antepartal Care (NM620) in the Fall 2 semester; Midwifery Practicum (NM630) and Comprehensive Intrapartal Care (NM640) in Spring 2 semester; internship, “Integrated Midwifery Practicum” (NM650) and a one credit didactic course, “Advanced NM Role Development.” in Summer 2. Didactic/Clinical Credit Structure of Courses and Sequence in the NM Track “NM” Course Title Credits Clinical Requisite Session Hours 610 Primary Care of Women 2(1) 60 Pre NM630 F 2 620 Comprehensive Antepartal Care 2(1) 60 Pre NM630 F 2 630 Midwifery Practicum (3) 180 Pre NM650 Sp 2 640 Comprehensive Perinatal Care 2(1)* 60 Pre NM650 Sp 2 650 Integrated Midwifery Practicum (6) 360 Su2 660 Adv. NM Role Development 1 0 Su 2 Elective 3 Yr 2 Total 22 720 *1:4 Although the SUDON has a 1:4 clinical hour/clock hour ratio, the minimum # of hours is extended due to unique nature of NM care (1 birth/many hours)

Shenandoah University – Program Narrative – Page 19 FNP Plan of Study: There are nine courses in the FNP track; four are clinical (NP580, NP650, NP670, NP680); one has a clinical component (NP570); the other four are didactic. Courses are accessed via Blackboard and meet the duration of the semester. Clinical experiences are set up by the FNP coordinator, and efforts are made to keep travel at a minimum. Courses in the FNP Track are arranged to provide a logical sequence for attaining the National Organization of Nurse Practitioner Faculty Core Competencies of Family Nurse Practitioners (NONPF). Didactic/Clinical Credit Structure of Courses and Sequence in the FNP Track NP Course Title Credit Clinical Requisite Session Hrs* Sequence 570 Applied Pharmacology & Therapeutics 1.5(.5) 30 Pre N550 Su 1 580 Advanced Assessment Lab (1) 30 Pre N580 Su 1 610 Primary Care (PC) of Families I 3 0 Co NP650 F 2 620 PC of Families II 3 0 Core Spr 2 630 PC of Women & Children 3 0 Co NP610 F 2 650 PC of Families Practicum I (3) 180 Pre/Co F 2 NP610 670 PC of Families Practicum II (3) 180 Pre/Co Sp 2 NP620 680 PC Advanced Practicum (4) 240 Pre Su 2 NP650/670 690 Adv. NP Role Development 1 0 Pre NP650 Spr 2 Elective 3 0 Yr 2 Total 22 720 *Based on a 1:4 clinical hour/clock hour ratio

PMHNP Plan of Study Of the 12 courses in the PMHNP Track, four are clinical; one has a clinical component (NP570); seven are didactic. Courses are accessed via Blackboard. Classes are held one day per week throughout the semester which allows flexibility for students to schedule clinical days while completing courses. Clinical experiences are set up by the PMH Coordinator; efforts are made to keep travel at a minimum. Courses in the PMHNP Track are arranged to provide a logical sequence for attaining the NONPF Core Competencies of Psychiatric Nurse Practitioners. Didactic/Clinical Credit Structure of Courses and Sequence in PMH Track “PMH” Course Title Credit Clin Hrs Requisite Session NP570 Applied Pharmacology & 1.5(.5) 30 Pre:N550 Su1 Therapeutics 640 Individual Therapy Theories 3 0 F 2 650 Individual Therapy Practicum (3) 180 Co:PMH640 F 2 660 Group, Family, Community (3) 0 Co: PMH670 Sp 2 Theory 670 Group, Family, Community (3) 180 Co: PMH670 Sp 2 Practicum 685* Geriatric PMH Nursing 3 0 Su 1 or 2 686* Child & Adolescent PMH 3 0 PMH640,650660, F 2 Nursing 670

Shenandoah University – Program Narrative – Page 20 695 Advanced NP Practicum in 4 120 Pre PMH640, Su 2 PMH Nursing 650,660,670,685 HP576 Substance & Relationship 3 6 hrs Sp 1 or 2 Abuse observe NP690 Adv NP Role Development 1 0 Pre/co, PMH670 Sp 2 Elective 3 Yr 2 Total 530 * Those interested in taking the ANCC Family Psychiatric Nurse Practitioner Exam or Child and Adolescent Clinical Specialist Certificate Exam are required to take this course.

Course Information: See Attachment 8 for course descriptions, objectives, and topical outlines for Core and all Tracks. Core courses from MI universities are equivalent to SU core courses. Clinical Experience: NM: The schedule of curricular delivery allows NM students to immerse in their clinicals without being interrupted by scheduled classes. Also, clinical sites can be anywhere in the nation. This flexibility in clinical placement is essential to the project’s goal to place students in rural and underserved areas. Courtney, et al. states that rural clinical placement can have a positive influence on rural recruitment (2002). While at their clinical agencies, students continue to communicate with the nurse-midwifery faculty and fellow students via telephone, e-mail and the Blackboard Learning System for weekly quizzes, course materials, and group case studies, and through Typhon Group software for clinical journal delivery and NM faculty feedback. Clinical resources are sufficient to achieve the NM Track objectives and the ACNM suggested numbers of experiences. Most of the clinical sites in Virginia are in the five focus regions of this project; therefore students get experience working with rural and underserved populations. However, it is the goal of this project to secure more clinical sites in remote and/or more underserved areas. The PD’s leadership in the creation of the pilot projects of HB 2656 (see “Resolution of Challenges”) will insure more clinical sites for students residing in the underserved regions in communities with the greatest need and will increase the accessibility for potential students. FNP and PMHNP: Clinical experiences provide opportunities for students to apply advanced, specialized nursing knowledge, skills, values, meanings and experiences. Practicum experiences assist in the development of the NP role while under the mentorship of experienced preceptors. In clinical settings, students are given the opportunity to implement critical thinking strategies. Students are expected to analyze and influence health patterns, synthesize health promotion strategies, and provide specialized therapeutic nursing interventions, in partnership with patients to positively influence health. A variety of health care settings are utilized. The Graduate Program has 81 active clinical sites at this time; 34 are in other states/jursidictions such as West Virginia, Pennsylvania, Maryland, Massachusetts, Texas, and Washington, D.C. There are 47 clinical sites in Virginia, 22 of those in the focus regions of this project; 6 of these are in full MUAs and 5 are in partial MUAs, and of course, being in these regions, many are in rural areas. Twenty one are in Winchester and four are in Northern Virginia (Loudoun County, a MUA). Because Winchester is located at the northern tip of Virginia, it is in close proximity to West Virginia, Maryland and Pennsylvania. Twenty of the Graduate Program’s clinical sites are in Maryland. Three of the four counties these sites are in are MUA. The three sites in Pennsylvania are also MUA. Because many of our sites are in MUAs, the populations that will receive services from APN students during their clinical experience hours

Shenandoah University – Program Narrative – Page 21 are individuals, families, and communities regardless of age, race, gender, and ethnicity, and ability to pay in the Five Focus Regions and other surrounding regions. The APN faculty obtains each clinical site and insures that those utilized by the students have (or are supervised by) at least one MSN prepared FNP or a physician who meets all national certification and state licensing requirements. The NM Track also must meet the following ACNM requirements for preceptors: Master’s prepared CNM with at least one year of practice experience, current with continuing education requirements and current with student education methodologies. The clinical facilities themselves must have updated protocols for APN practice, an adequate number of patients to meet the students’ clinical objectives, practices aligned with the American Association for Nurse Practitioners (AANP) and ACNM Standards for Practice, and appropriate anti discrimination practices towards patients and students. The APN faculty visits each agency and student at least once a semester at which time NM faculty and the student evaluate the preceptor using the Clinical Preceptor Evaluation Tool and the site using the Clinical Site Evaluation Tool. See Attachment 10 for formal and informal linkages with national, state, local, rural and community-based agencies for clinical sites, a listing of the preceptors in their clinical sites and their credentials.

Electronic Distance Learning Methodologies Education Program While electronic distance learning methodologies are not the main mode of educational content delivery in the SUDON Graduate Program, the substantial use of these modes allows students and faculty to be separated by a distance. These components of Graduate Program were reviewed by College of Collegiate Nursing Education Accreditation site visit to the SUDON in 2004 and the ACNM during their 2005 Accreditation visit. The Graduate Program reviews, evaluates and approves all courses through its Graduate Curriculum Subcommittee, the SUDON Curriculum Committee, and the SUDON. The main distance learning method used for this project is Blackboard Learning Systems which is fully supported by the Shenandoah University throughout its campuses and is available to students regardless of geographic location. All students utilize Blackboard in all courses for course information, course materials, discussion boards for case study discussions, testing, and evaluation. Therefore, course development is the same regardless of the distance from campus: all students have the same coursework, course sequencing, and clinical experiences. The Blackboard’s discussion board is used in all Tracks to facilitate scholarly discussion of assignments and case study management. The Graduate Program disseminated its curricula electronically since the Program’s inception. Because ODU telebroadcasts its MSN curriculum and RU uses Blackboard, SUDON Graduate Program students and faculty are experienced users of this mode of curricular delivery. Employment of the administrative assistant will enable more extensive use of Blackboard for assignment management and improved CE access for preceptors (see Ipod discussion below). Students evaluate Blackboard each semester through course evaluations. During the semester, if students having problems are referred to the Blackboard Administrator in the Institutional Computing Department (IC). Faculty evaluate Blackboard and IC services annually. Equipment and Technical Support All faculty have PCs in their offices; faculty and students have access to Blackboard. SU supports distance technology through IC. (See Administrative Letters of Support in Attachment 6). IC employs a Blackboard Administrator for support and training. Students are trained in Blackboard use by APN faculty with the help of IC as needed.

Shenandoah University – Program Narrative – Page 22 SUDON uses two software programs: “Typhon Group Nurse Practitioner Student Tracking System” and “Up-to-Date.” Typhon allows electronic submission of student clinical journals and asynchronous communication for faculty feedback. Students and faculty can enter data and view tallies/charts of clinical experiences online. Faculty can also create custom searches. Typhon will be utilized for data collection by SUDON during and after funding periods. “Up-To-Date” (evidence based practice) is designed to answer clinical questions that arise in daily practice quickly and easily at the point of care. The content is updated continually and a new, peer-reviewed version is issued every four months. The published evidence is summarized and specific recommendations made for patient care. This is project-funded software and there will be one point of access for faculty and students. Students may request specialized searches. If student and faculty evaluations are satisfactory, it will be incorporated into the SUDON budget. Another project-funded software program is “Epocrates,” a mobile guide to drugs, diseases, and diagnostics software that provides up-to-the-minute answers on drug-drug interactions (including herbals), -drug interactions, lab differentials and follow-up, dosage calculations, disease basics, infectious disease treatment regimens, drug pricing and formularies, and IV therapies. The handheld computer used will be the Dell Axion X51 with Intel XScale PXA270 520 MHz Processor, with a Microsoft Windows Mobile 5.0 software with Windows Media Play 10 Mobile, 64 MB of SDRAM, and a 128MB Flash memory ROM. The display is TFT Color 16-bit, Touch Sensitive, Transflective LCD, 3.5 inches, with 240 x 320 resolutions at 65,536 colors (QVGA). Funding allows portable digital devices to be loaned to enrolled students. Technical support for the above software systems is provided through online tutoring and help programs. SUDON will provide in-class orientation to software and handheld computers. Experience and Financing Distance learning courses through Blackboard is funded by SU tuition. SU will continue to provide the financial infrastructure for the use of distance learning methodology through the IC and its Media Services throughout the funding period of this project. Ipod technology will be developed and adopted as a new distance learning during the project period. All faculty and students will be able to disseminate and receive selected curricular materials via Ipod. Lectures and demonstrations will be developed in “podcast” form that can be downloaded through SU’s contract with ItunesU. All downloadable material is Mac and PC compatible and is able to transfer from the Ipod to personal computers. Preceptors and students will be able to download curricular material through ItunesU onto their own PC or MAC computers. Podcasts will be in audio and/or audiovisual forms. SUDON has a JVC Everio hard drive camcorder based on HDD technology. It records in mpeg2 format. The IC’s Media Services will provide support to capture digital AV content for podcasting, translating it into mpeg4 format for Ipod use and downloading it on ITunesU until faculty become proficient. Project-funded Ipods will be available to students on loan. Preceptors can receive an Ipod and its associated connection capabilities through preceptor education and support activities. SU has equipped the SUDON Graduate Program with a hard drive camcorder and two 80gb video Ipods for the PD and Co-PD to begin curricular infusion of the technology in consultation with Dr. Dee McGonigle, Informatics Consultant. Project funding will support purchase of Macbook laptop computers needed to develop the Ipod podcasts for the PD and Co PD as well as the Informatics Consultant. In the first funding year, 15 Ipods will be purchased to loan to students. (With Ipods so versatile, some students already own or may purchase them for personal use). IC and Media Services will support the AV technology throughout campus during and after the funding

Shenandoah University – Program Narrative – Page 23 periods. Please see the Organization Information for a discussion of the resources that SU provides the SUDON Graduate Program. Competencies: SU NM Project Competencies (based on ACNM Core Competencies for Basic Midwifery Practice: 2003): Professional Responsibilities, Midwifery Management Process, Fundamentals of Primary Care of Women, Preconception, Gynecologic care, Perimenopausal, postmenopausal and aging periods, the Childbearing Family, Antepartum period, Intrapartum period, Postpartum period, Newborn care FNP & PMHNP Project Competencies (based on National Organization of Nurse Practitioner Faculties (NONPF) Domains and Core Competencies of NP Practice (2006): Domain 1 – Management of Patient Health/Illness Status, Domain 2: NP Patient Relationship Domain 3: Teaching-Coaching Function, Domain 4-Professional Role, Domain 5-Managing and Negotiating Health Care Delivery Systems, Domain 6-Monitoring and Ensuring the Quality of Health Care Practice, Domain 7- Culturally-Sensitive Care Specific competencies within nationally prescribed documents are utilized in all specialty Tracks’ Clinical Evaluation Tools and will be one of the mechanisms by which faculty assesses progress towards achieving rural relevant core competencies. Certification: • Graduates of the NM Track and the MI are eligible to sit for the national certification exam of the American Midwifery Certification Board to become Certified Nurse-Midwives. • Graduates of the FNP Track are eligible to sit for the Family Nurse Practitioner national certification exam, and PMHNP graduates are eligible to sit for the Adult Psychiatric and Mental Health Nurse Practitioner and Family Psychiatric and Mental Health Nurse Practitioner exams, all administered by the American Nurses Credentialing Center (ANCC) or the American Academy of Nurse Practitioners Program Accreditation and Approval • SU is accredited by the Southern Association of Colleges and Schools (1999-2009). • The SUDON is accredited by the Commission on Collegiate Nursing Education (2004-2009). • The NM Track is accredited by the ACNM Division of Accreditation (2005-2015).

DIVERSITY AND CULTURAL COMPETENCE SU’s mission is to prepare individuals to be “. . . compassionate citizens who are committed to making responsible contributions within a community, a nation and the world. Its core value is a respect for diverse cultures, experiences, and perspectives.” SU’s strategic plan, policies and initiatives express commitment to diversity and cultural competence. SU is active internationally and has sister universities in China and Russia. SU has enrolled students from over 64 countries since 1985 and has graduated over 200 international students. Presently, Dr. James Davis, President, makes numerous trips to Japan to develop educational opportunities for students from both countries. Dr. Tracy Fitzsimmons, Senior Vice President, was the driving force behind the creation of a Cross-Cultural Center and she participated in the Salzburg Seminar, a leading forum for promoting global dialogue on issues of pressing international concern. SU’s orientation program has been translated into three different languages; Japanese, Chinese, and Korean. SU also has an alumni office in Taiwan. SUDON is also committed to diversity and teaches respect for individual differences. SUDON annually hosts Tamano University Nursing Program from Japan. During the visit, Tamano students participate in lectures and meet with SU students. Dr. Krauskopf, Co-PD,

Shenandoah University – Program Narrative – Page 24 traveled to Thailand with FNP students in 2006 to visit health care facilities. Dr. Wanida Wanant, originally from Thailand, consults with nursing schools there regularly. All SUDON faculty role model their commitment in their community service efforts. Faculty volunteer at free medical clinics, community health fairs, and local churches as parish nurses. Additionally, some faculty and students serve as advocates for underserved groups and influence local and state health policy. Dr. Fehr, as an extension of her appointment to the Governors Working Group on Rural Obstetric Care, was instrumental in the 2005 passage of HB2656, legislation to develop Pilot Project Birth Centers in MUAs and in SB488 in 2006, substituting the requirement for physician “supervision” for NM practice with “consultation, collaboration, and referral.” SU’s Board of Trustees awarded Dr. Fehr an International Resolution of Appreciation for teaching activities with Partners in Perinatal Care and “Promatoras de Salud” and work with ODU on educating culturally competent midwives. In 2005, she led a group of SU students, staff and faculty to The Netherlands as part of SU’s first annual Global Citizenship Project. All of these activities and SU’s support of this application reflect SU’s commitment to increasing diversity among health professionals. The table below shows three years of enrollment of SUDON students from minority and disadvantaged backgrounds. Enrollment in SUDON: Ethnic/Minority Backgrounds 2004 2005 2006-2007 Race/Ethnicity # % # % # % Asian/Pacific Islander 1 .4 1 .3 2 .6 Black Female 12 4.9 9 2.7 3 .9 Black Male 3 1.2 3 .9 0 0 Hispanic 0 0 0 0 0 0 Asian Female 4 1.6 4 1.2 1 .3 Asian Male 2 .8 1 .3 0 0 White Non- Hispanic Female 209 85 171 51.9 12 3.8 White Non-Hispanic Male 16 6.5 15 4.5 0 0 Unknown Race/Female 1 .4 111 33.7 263 84.5 Unknown Race/Male 0 0 14 4.3 29 9.3 Non-Resident Alien Male 0 0 0 0 1 .3 Total 245 329 311

Rural designation of residence is not officially tabulated by SU. However, many students reside in this project’s five focus regions and MUAs in West Virginia, Pennsylvania, and Maryland. SUDON faculty make personal visits to universities, high schools, health care facilities, and SU Open Houses. SU’s Department of Admissions replicates SUDON activities and visits facilities and career fairs in the project’s focus regions and conducts internet recruitment through allnursingschools.com. Recruitment covers a wide geographical area via mailings and personal presentations to national nursing organizations, hospitals, other nursing schools, high schools, and professional meetings. Specialty track recruitment brochures featuring minority persons providing care are disseminated throughout the state and nation. Project coordinators make personal contact with each potential applicant inquiring about the Graduate Program to answer questions. SUDON has one faculty member on call daily who is available to meet with interested persons who would like information regarding the SUDON.

Shenandoah University – Program Narrative – Page 25 To promote diversity among students in SUDON and its Graduate Program, it has also created methods of course delivery incorporateing distance learning methods to reach students in wide geographical areas and created the MI with state universities that serve a full range of geographical locations offering graduate classes at lower cost than a private institution, therefore increasing the access to nurse-midwifery education, and providing the infrastructure and in-kind support for this project’s activities. SUDON is committed to student success. Several mechanisms are in place to support progression of students with special needs through the SU Office of Academic Support (OAS) that provides evaluation and assistance to accommodate student needs. OAS provides support for all students through programs to improve math, study, and stress management skills. The SUDON faculty members are sensitive to diverse learning needs of students and have the ability to be flexible around student’s needs, such as allowing extra time for taking tests, giving extended time for completion of course requirements, use of complimentary teaching learning mechanisms (computer simulations), and reasonable faculty counseling and tutorials. In addition to the responsiveness to students with special needs on the part of the full-time faculty, the NM Track also offers an online preceptor education course to all preceptors of the Graduate Program to assure that preceptors acquire and maintain skill in individualized teaching strategy. This course offers .3 CEUs from ACNM and includes the following information to aid preceptors in student teaching and support. The SU Office of Financial Aid assists students with socio-economic. SU maintains a strong financial aid program to help students who qualify for aid. Approximately 80% of nursing students receive financial aid for BSN or MSN study. Financial Aid Policies and Procedures prepared by the Director of Financial Aid are available and located on the web at www.su.edu. SU has an active student-responsive Chaplain to support the spiritual growth and service. He arranges student break service experiences in underprivileged areas of the United States and foreign countries and local experiences with agencies such as Habitat for Humanity. Finally, all SUDON faculty participate in the development of our philosophy which includes a definition of Human Beings as an integrated whole who are existential and vary in age, gender, race, spirituality, culture, ethnicity, education, geographic region and socioeconomic status. Every effort is made to assure that all students are treated as individuals whose diverse needs and viewpoints are honored within a respectful and nonjudgmental learning environment. Graduate Program students are exposed to cultural sensitivity and health disparities through some graduate courses. For example, in N580 students apply health promotion and early disease detection strategies in the primary care of culturally diverse and underserved rural or urban settings. All specialty courses use Typhon to encourage students to consider different approaches based on awareness of race, ethnicity, and rural residence. All case studies have cultural competence/health disparity component. In NM610, NM students emphasize cultural issues in their women’s issue project. Standardized patients supplied by EVMS emphasize student awareness of diversity and provide feedback to the students in on online evaluation format.

FUNDING FACTOR – STATUTORY FUNDING PREFERENCE Project qualifies for statutory funding preference. Please see Attachment 5.

RESOLUTION OF CHALLENGES Challenges likely to be encountered in designing and implementing activities described in the Work Plan are similar to those noted in Program Narrative section. The first is the cost of private tuition which SU strives to resolve through increased traineeship stipends and utilizing

Shenandoah University – Program Narrative – Page 26 low cost approaches to education (distance learning where students can access SU with readily available technology). Second is the regulatory restrictions to NP practice that may hamper APNs tpractice in rural MUAs. According to Healthy Rural People 2010, NPs enjoy more autonomy in rural areas, but that autonomy can mean isolation. Project informatics and MI activities are intended to increase access to connections for providers and to encourage students to attend the program. The regulatory restriction has been lifted for CNMs with the passage of SB488 in 2006, substituting the physician “supervision” requirement with “consultation, collaboration, and referral.” Regulations were adopted in September, 2006. The third challenge is limited clinical sites. Project use of informatics for support, connection, and assimilation of knowledge through continuing education activities will connect more preceptors with SU. Dr. Fehr was a leader in the move to pass HB2656 in 2005 allowing pilot project birth centers operated and staffed by CNMs (without physician supervision) to be started in Virginia. There are now two centers developing (Emporia, and the Northern Neck) and receiving state funding. Budget amendments are being sought for 2006-2007. The sites are expected to open in 2007; they will serve as clinical sites for SU APN students.

EVALUATION AND TECHNICAL SUPPORT CAPACITY Please refer to “Organization Information,” for current experience, skills and knowledge of proposed and other SUDON personnel. Please refer to the “Methodology and Work Plan” for methods to monitor and evaluate project results. The plan for tracking graduates’ performance on the certification exam is already in place and will continue: The appropriate certification board sends a report on graduates’ exam performance with analysis on performance in each exam content area. Allowing graduate continued access to ItunesU will facilitate SU’s ability to track their practice locations and facility type more effectively. Program evaluation supported by the project is incorporated in SUDON’s existing evaluation plan: student evaluation of faculty and courses each semester, student evaluation of the SUDON and Graduate Program via exit interview, student and faculty evaluation of preceptors/clinical sites, faculty evaluation of student performance in the clinical evaluation tools and exams, and SUDON evaluation of faculty and staff with faculty and staff evaluation tools. Evaluations added with this project are student and faculty evaluation of the cultural competency program; faculty evaluation of student progress with cultural competence skills utilizing cultural competency survey tool; and student, faculty, and staff evaluations of the project informatics components through the course evaluation tool. The project will use the following measures to assess how it meets the needs of the population to be served by the graduates: track the number of employment placements in rural locations to assess access, graduate satisfaction with rural placement through one year post placement survey, and administering online questionnaires regarding successful use of informatics by APN graduates. Please refer to Organizational Information, Capabilities of Applicant Organization, and Institutional Resources for a discussion on Technical Support. Also refer to “Electronic Distance Learning Methodologies.” ORGANIZATIONAL INFORMATION See Attachment 11 for organizational charts reflecting project lines of communication. Project Management, Resources, and Capabilities Project Personnel* Other Personnel include:

*See Staffing Plan in Attachment 7 and Budget Justification for Roles and Responsibilities of Project funded Personnel.

Shenandoah University – Program Narrative – Page 27 Graduate Faculty: Dr. Wanida Wanant (100% in kind support): Qualifications: Phd prepared RN with over 20 years expertise in nursing and 10 years in research. Roles and Responsibilities: Responsible for all SUDON programmatic evaluation. Will aid PD and Co-PD prepare project reports for dissemination. Graduate Faculty: Dr. Jennifer Mathews (100% in kind support, Part-Time): Qualifications: PhD prepared RN with over 20 years nursing experience and over 10 years teaching experience. Responsibility: Teaches N540: Pathophysiology Graduate Faculty: Dr. Maureen Quinn (100% in kind support):Qualifications: PhD prepared RN with over 20 years of nursing, administrative and teaching experience. Roles and Responsibilities: Assistant Director for Student Affairs Graduate Faculty: Dr. Pamela Webber (100% in kind support): Qualifications: PhD prepared FNP, Responsibilities: Teaching Graduate Faculty: Dr. Martha Morrow (100% in kind support): Qualifications: Over 20 years in faculty and nursing experience. Responsibilities: Teaching *Half-time Administrative Assistant (100% project supported): Unknown

Faculty Recruitment Plan All faculty of the SUDON are recruited, appointed, and promoted in a non-discriminatory manner that abides by SU’s policy on non-discrimination and Accommodation of Persons with Disabilities. When recruiting faculty, vacancy notices for regular full-time faculty positions are published in a public forum. Every attempt is made to recruit persons with appropriate academic credentials, acceptable recommendations, and personal goals in harmony with the university’s purpose. The SUDON Faculty Search Committee will consult with the PD before hiring qualified faculty and will comply with the PD’s recommendation. For this project, the PD successfully recruited Dr. Phyllis Sharps, RN, PhD, FAAN, who is of a minority background, to consult regarding health disparities and cultural competence. Summary Graduate Program Faculty Table Faculty Academic Degrees Areas earned Area of teaching Juliana Fehr MS, PhD CNM NM & Core: Theory Patti Krauskopf MSN, PhD, FNP FNP Track Sheila Ralph MSN, PhD Nursing Director, SUDON Marian Newton MSN, PhD, PMHNP Pharmacology,PMHNP Wanida Wanant: MSN, PhD Nursing Research Martha Morrow MSN, PhD, FNP FNP, Data Analysis Pamela Webber MSN, PhD FNP Health Assessment Maureen Quinn MSN, PhD Nursing Issues Kathryn Ganske MSN, PhD Nursing Role, Ethics Jennifer Matthews MSN, PhD Nursing Pathophysiology Bonnie Darrell MSN FNP Preceptor, FNP, NM Deborah Forrest MSN FNP Preceptor, FNP Carol O’Leary MSN PMHNP Preceptor, PMHNP Jean Ruiz MSN PMHNP Preceptor, PMHNP Wendy Dotson BSN, MSN CNM Preceptor Karen Nguyen MSN, CNM CNM Preceptor Blair Conger MSN, CNM CNM Preceptor

Shenandoah University – Program Narrative – Page 28 Consultants: Dr. Laurel Garzon, PNP, PhD (Midwifery Initiative Consultant) has expertise in managing and coordinating the telebroadcast sites for curricular dissemination of the ODU MSN core courses. She will advise on recruitment activities in off campus locations and web based outreach activities, evaluation of curricular dissemination with MI NM students through telebroadcast and evaluation of student transition between the collaborating universities. Dr. Phyllis Sharps, RN, PhD, FAAN (Cultural Competence, Health Disparity Consultant), is an expert in health disparities and cultural competence particularly in the maternal child and reproductive health areas and will be advising on Project Objective 2 activities and evaluation. Dr. Dee McGonigle, RN, PhD, FACCE, FAAN (Informatics Consultant) is an expert in nursing informatics. As Editor-in-Chief of the Online Journal of Nursing Informatics, Dr. McGonigle will through the activities of Project Objective 3 in the use of informatics to reach students and their preceptors in rural and remote locations. Please see Attachment 12 for letters of agreement. Biographical Sketches See Project/Key Person Profile for biographical sketch attachments. Capabilities of Applicant Organization Institutional Resources The SUDON is located in the SU Health Professions Building (HPB), a well equipped building with computer labs, clinical laboratories, a health professions library with extensive holdings and online database access, a bookstore, student lounge, technologically equipped classrooms, cafeteria, and private faculty offices. Resources for teaching and learning include media equipment for presentations (overhead and slide projectors, LCD panel, VCRs, video and audio-tapes, CDs and DVD’s). SU Media Services maintains media equipment. There are four support personnel positions in the SUDON. They are: a FTE receptionist/secretary, a FTE administrative assistant, a FTE data coordinator, and a 50% FTE administrative assistant. Work-study students are used to assist in selected activities. There is a large computer laboratory located in the HPB that is staffed by FTE computer support person and shared with the School of Pharmacy and is only accessible on campus. SU has a faculty media lab and a support person on main campus to provide technological support. SU has made a major commitment to update technology and provide technology and wireless service. In March 2003, SU received recognition as being of 50 ‘most wired’ small universities in the nation by Yahoo in conjunction with Petersons and Internet Life Magazine; Hewlett Packard and Cisco also note the leading-edge technology of SU. The IC department is responsible for supporting a wired and wireless infrastructure to gain access to SU’s Network (SUNet through SU Online). It strives to provide cutting edge technology for faculty, staff, and students to navigate through the professional curriculum, and to enhance the teaching and learning experience. Examples of electronic resources available to faculty, staff, and students include: . Standard computer-loaded programs for word processing, spread sheet creation and analysis, database maintenance, graphics, desk top publisher, and presentations with Microsoft Office, . Statistical packages using SPSS . Electronic communication using Microsoft Outlook . Synchronizing software for Personal Digital Assistants (Palm Pilots) . Blackboard Learning System-Basic Edition (Release 6) intranet classroom software (IC supports faculty in Blackboard through a dedicated specialist for this intranet service) . Library research databases (CINAHL, Medline, etc.)

Shenandoah University – Program Narrative – Page 29 The IC Department has a laptop support specialist available at the HPB. The HPB is both wired and wireless so students can use their laptops to access the intranet and internet. The HPB contains a health sciences library with a 1 FTE librarian and ancillary staff. Resources not available at SU are obtained through an extensive interlibrary loan network and online access to more than 13,000 journals. Faculty, staff, and students can access the library resources and databases from their homes using user name and password. If items are not available on-site, SU belongs to an extensive regional consortium for academic and research libraries and materials to obtain these resources. On-line access is also available to students and faculty. Video equipment is available for the students while they are on campus. The Division of Student Affairs complements the institution’s mission by creating a seamless learning environment that maximizes students’ development and learning. The Division advocates for all students and provides services that contribute to successful completion of educational pursuits. The Division offers: Academic Support Services, Career Services, First Year Experience, Residence Life and Housing, Student Activities and Recreational Sports, Public Safety, the Chaplain’s Office, International Cross Cultural Center, and the Wilkin’s Wellness Center. It is this project’s goal to secure more clinical sites in more remote and/or underserved areas of Virginia. The PD’s leadership in the creation of the pilot projects of HB 2656 will insure more clinical sites for students residing in the underserved communities with the greatest need and will increase the accessibility for potential students from in these areas. Linkages and Community Support: APN linkages are extensive (see discussion under “Curriculum: Clinical Experiences” for examples of formal and informal linkages between the NP and PMH faculty and local, state and national organizations that service the targeted populations). MI collaborative agreements with other universities in Virginia have been discussed. The PD’s governor-appointed membership on the Governor’s Working Group (GWG) in 2004 linked SU with the Virginia Rural Health Association, the Virginia Primary Care Association, the Virginia Regional Perinatal Councils, the Virginia Department of Health, and the Chairs of the University of Virginia and Medical College of Virginia’s obstetrics education departments. In 2004, NM Track students testified to the Governor’s Work Group, and in 2005 the students participated in the Pilot Project Working Group that Dr. Fehr leads. Dr. Fehr was a co-founder of the Virginia Chapter of the ACNM and is an active member. Last, but probably most important, is the very strong linkage between the Dr. Fehr and a consumer group of mothers that she co-founded called “Birth Matters, Virginia” (.birthmattersva.org.). Dr. Fehr teaches classes to the community for this group and also assists with grant writing. It is a 501(c)(3) organization with more than 400 members whose mission is to increase awareness of the midwifery model of care. They provide childbirth education all over the state and hold annual consumer education conferences. All of these linkages lay the groundwork for an organized, logical and extensive network of midwives, health care facilities, health care providers, policy experts, and mothers, dedicated to the health of mothers and babies. Budget: Please refer to discussion in Budget Justification Section. SUSTAINABILITY The successful achievement of the project objectives will allow the activities to continue beyond the funding period. Timetable for self sufficiency: Time Other sources of income Future funding initiatives and strategies table First Year SU increased financial support Continue web based recruitment strategies

Shenandoah University – Program Narrative – Page 30 through increased student base. Develop community linkages Add additional graduate Increase in subcontracting on other institution’s (DNP). initiatives Begin offering the Post BSN DNP for FNP and PMHNP in the 2007-2008 Academic Year. Second SU increased financial support Continue first year strategies and augment with Year through increased student base. funding requests through non federal foundations Develop interdisciplinary and other organizations. continuing education activities Development of interdisciplinary continuing for other health care education programs professionals Begin developing a Post Master’s DNP for the NM Track. Third Increase student base as above Begin offering a Post Master’s DNP for the NM Year Track. Challenges See discussion in “Resolution of Challenges.” Within SU, the nursing shortage has significantly increased enrollment in the SUDON in both Undergraduate and Graduate Programs and has placed a greater burden on the administrative staff, making it difficult to support Graduate Program expansion. However, project activities within all three Objectives will increase awareness of SU and will increase the base of students who would otherwise not have been able to get their Graduate Education (especially in NM). Also, the informatics activities solidify community and professional linkages throughout the state and nation. REPLICABILITY As discussed in the narrative above, the Midwifery Initiative is a strategy that can be used nationwide to expand access to NM education in the nation. Site visitors from the ACNM Division of Accreditation stated in their report to the DOA that the MI can be used as a national model for NM education. Dr. Fehr is already consulting with other universities (University of Indiana) regarding the possibility of creating a MI in that state. With the Midwifery Initiative, no matter where a nurse-midwifery program is, these collaborative arrangements are simple, direct and a low cost solution to the access crisis, especially in the rural areas. Cultural Competence training is easily replicable in the personal, web based, internet, and distance learning format. It is the hope of the SU faculty that as we disseminate information on the state and local levels, more universities will have the capabilities to follow suit. Project Objective 3 activities to commit the curriculum to more avenues of distance education methodologies can be easily replicated by other educational institutions. Ipod technology is widely available and podcasting has become the state-of-the-art method for communication. The Graduate Program will also develop other modes of web based and internet capabilities as faculty skill in these methodologies increases. SUMMARY The need for more APNs in Virginia necessitates the expansion of the SU’s Graduate Program which has committed itself to providing creative, cost effective, accessible APN education. • The tremendous growth of Virginia’s foreign born residents has made cultural competence training a necessity for an educational program. • As distance learning becomes more integrated in curricula in the rural areas, students and clinical preceptors must become proficient in informatics. • Cultural competence training will be incorporated into the curriculum. ______

Shenandoah University – Program Narrative – Page 31 HHS Rural Task Force Report to the Secretary: One Department Serving Rural America. Avail: ://ruralhealth.hrsa.gov/PublicReport.htm. Accessed 11/7/06 U.S. Census Bureau, Avail: ://www.census.gov, Virginia Population. Search #368, State & county populations estimates. Accessed 12/01/06 Economic Research Service, U.S. Department of Agriculture: State Fact Sheets: Virginia. Avail: ://www.ers.usda.gov/StateFacts/VA.htm Accessed 11/28/06 University of Wisconsin-Madison, Institute for Research on Policy (2005). Who was Poor in 2004? Avail: ://www.irp.wisc.edu/faqs/faq3.htm Accessed 11/28/06 Virginia Department of Health, Center for Health Statistics (2005). The health of minorities in Virginia, 2003: A report on vital events. Richmond, VA. Avail: http//www.vdh.state.va.us/healthpolicy/minorityhealth/minorityhealthreport.htm Accessed: 11/02/05 Kusmin, L. (ed) (2006). Rural America at a Glance, 2006 Ed: Economic Information Bulletin No. (EIB-18). U.S. Department of Agriculture. Economic Research Services, August, 2006. Avail: .ers.usda.gov/publications/EIB8/ Accessed: 11/15/06 Kusmin, L. (ed) (2006) Avail: ://www.ers.usda.gov/publications/EIB8/ Virginia Center for Healthy Communities in Collaboration with the Virginia Hospital and Healthcare Assocation, Avail: ://67.92.69.86/downloads/southwest.pdf , ://67.92.69.86/downloads/blueridge.pdf , ://67.92.69.86/downloads/hamptonroads.pdf , ://67.92.69.86/downloads/central.pdf , ://67.92.69.86/downloads/roanoke.pdf Accessed 10/30/06 Virginia Center for Healthy Communities, ://67.92.69.86/downloads/southwest.pdf , ://67.92.69.86/downloads/blueridge.pdf , ://67.92.69.86/downloads/hamptonroads.pdf , ://67.92.69.86/downloads/central.pdf , ://67.92.69.86/downloads/roanoke.pdf Accessed 10/30/06 Laurant, M. Laurant, M., Reeves, D., Hermens, R., Braspenning, J., Grol, R., and Sibbald, B. (2006). Substitution of doctors by nurses in primary care (Review). The Cochrane Collaboration: The Cochrane Library 2006, Issue 4. Wiley. Virginia Department of Health, Center for Health Statistics (2005). The health of minorities in Virginia, 2003: A report on vital events. Richmond, VA. Avail: http//www.vdh.state.va.us/healthpolicy/minorityhealth/minorityhealthreport.htm Accessed: 11/02/05 Virginia Performs: Health & Family: Infant Mortality. Avail: ://vaperforms.virginia.gov/i- infantMortality.php Accessed 11/6/06 Virginia Performs: Health & Family: Infant Mortality. Avail: ://vaperforms.virginia.gov/i- infantMortality.php Accessed 11/6/06 14 Gamm, L.G.; Stone, S.; Pittman,S. (2003). Mental Health and Mental Disorders – A Rural Challenge, Rural Healthy People 2010: A companion document to Health People 2010. Volume 1. College Station, TX: The Texas A&M University System Health Science Center, School of Rural Public Health, Southwest Rural Health Research Center. p. 151. U.S. Department of Health and Human Services. Healthy People 2010. ed. With Understanding and Improving Health and Objectives for Improving Health. 2 vol. Washington, D.C: U.S. Government Printing Office, November 2000 HP2010, Vol.1, p. 16.5. U.S. DHHS, HP2010, Vol.1, ed., p. 16.5. Gamm, et al., p. 134

Shenandoah University – Program Narrative – Page 32 Virginia Performs: Avail: ://vaperforms.virginia.gov/i-cardiovascularDisease.php Accessed 11/6/06 Gamm, et al., p. 134 Gamm, et al., p. 134 Gamm, et al., p. 134 Gamm, et al., p. 134 Gamm, et al., p. 134 Virginia Performs, Avail: ://vaperforms.virginia.gov/i-suicide.php Accessed 12/1/06 Virginia Performs, Avail: ://vaperforms.virginia.gov/i-suicide.php Accessed 12/1/06 Gamm et al, p. 165 Gamm et al, p. 166 Gamm, et al, pp. 165 & 223 Gamm et al, p. 165 Declercq, ER, Williams, Williams, DR, Koontz, AM, Paine, LL, Streit, EL, and McCloskey, L (2001). Serving women in need: Nurse-midwifery practice in the United States. Journal of Midwifery and Women’s Health; 46, 11-16. Paine, LL, Dower, CM, O’Neil, EH (1999). Midwifery in the century: Recommendations from the Pew Health Professions Commission/UCSF Center for the Health Professions. Journal of Nurse-Midwifery, 44(4)341-348. American Nurses Association ( ://nursingworld.org/readroom/position/practice/prmidwife.htm.) Accessed 12/05/06 HRSA: Rural Health Policy: One Department Serving Rural America: HHS Rural Task Force Report to the Secretary. Avail: ://ruralhealth.hrsa.gov/PublicReport.htm Quality Through Collaboration: The Future of Rural Health (2005). Avail: ://www.nap.edu/books/0309094399/html/1.html ) Accessed 11/15/06 Woloschuk, W. & Tarant, M. (2002). Does a rural educational experience influence students’ likelihood of rural practice? Victoria, AU: Blackwell Publishing Gamm, p. 45 Sawyer, D., Gale, J., Lambert, D. (2006). Rural and Frontier Mental and Behavioral Health Care: Barriers, Effective Policy Strategies, Best Practices Avail: ://www.narmh.org/pages/project.html Quality Through Collaboration: The Future of Rural Health. Avail: .nap.edu ) (Avail: ://www.nap.edu/books/0309094399/html/1.html ) Accessed 11/15/06 Quality Through Collaboration: The Future of Rural Health. Avail: .nap.edu ) (Avail: ://www.nap.edu/books/0309094399/html/1.html ) Accessed 11/15/06 Quality Through Collaboration: The Future of Rural Health. Avail: .nap.edu ) (Avail: ://www.nap.edu/books/0309094399/html/1.html ) Accessed 11/15/06 Governor’s Work Group on Rural Obstetric Care (2004). Executive Directive 2. Avail: .vdh.state.va.us/COMMISH/OBFinal_Report.pdf Accessed 11/23/06 Courtney, M., Edwards, H., Smith, S. and Finlayson, K. (2002). The impact of a rural clinical placement on student nurses employment intentions. The Collegian, 9(1), 12-18.

Shenandoah University – Program Narrative – Page 33 Budget Justification Table of Contents

Budget Justification Table of Contents (not part of page count) ...... 1 Personnel Costs ...... 2 Consultant Costs ...... 3 Laurel Garzon, Midwifery Initiative Consultant ...... 3 Phyllis W. Sharps, Cultural Competence and Health Disparities Consultant ...... 3 Dee McGonigle, Informatics Consultant ...... 3 Indirect Costs ...... 3 Fringe Benefits ...... 3 Travel ...... 3 Equipment ...... 4 Supplies ...... 4 Subcontracts ...... 4 Other Expenses ...... 5

Non-Federal Expenditures Table (not part of page count) ...... 6

Shenandoah University – Budget Justification – Page 1 Budget Justification

Personnel Costs* Name Position Title Percent Annual Amount of Request for each FTE Salary Year (salary + fringe benefits) J Project Director (PD) 07-08: 35% $ 2007-2008: $ & NM Coordinator 08-09: 30% 2008-2009: $ 09-10: 25% 2009-2010: $ Provides oversight for entire project; special emphasis on Subobjective 1.1, strengthen collaborative arrangements through the Midwifery Initiative and, Subobjective 3.2, assist FNP Coordinator and Informatics consultant in course restructuring to accommodate informatics technologies to facilitate use of informatics for students, faculty, and preceptors. P Co PD & FNP 15% $ 2007-2008: Coordinator 2008-2009: 2009-2010: Subobjective 2.4: Provides oversight in obtaining and maintaining clinical sites for FNPs in MUAs. Subobjective 3.2: With Informatics Consultant and PD, restructures courses to accommodate informatics technologies; With PD and clinical coordinator, oversees educational and training support for preceptors through continuing education delivery using informatics. M PMH Coordinator 10% $ 2007-2008: 2008-2009: 2009-2010: Subobjective 2.4: Provides oversight in obtaining and maintaining clinical sites for PMHNPs in MUAs. Subobjective 3.2: With Informatics Consultant and PD restructures courses to accommodate informatics technologies; With PD and clinical coordinator, oversees educational and training support for preceptors through continuing education delivery using informatics. A Clinical Coordinator 50% $ 2007-2008: 2008-2009: 2009-2010: Subobjective 2.4: Will obtain, evaluate, and maintain all clinical sites and assure an adequate number of available sites in MUAs and/or in Federal Health Centers. Unknown Administrative 50% $ 2007-2008: $ Assistant (50%) 2008-2009: $ 2009-2010: $ Subobjectives 1.1, 1.2, 1.3 Provides administrative support for all project activities with emphasis on midwifery. 6. Unknown Instructor-PMHNP 25% (25%) 2007-2008: specialty courses 2008-2009: 2009-2010: Subobjective 3.3: Assists PMHNP Coordinator by teaching at least two three credit didactic courses in the PMHNP Track to include the rural relevant competencies. 7. V Part-time NM clinical 25% (25%) 2007-2008: $ faculty 2008-2009: $ 2009-2010: $ Subobjective 2.1: Monitors and provides feedback on student clinical journals, evaluating attainment of rural relevant competencies and cultural competence skills.

* Annual salaries listed for personnel reflect current salary or salary expected in first year of project. For budget purposes, salaries are expected to increase by 3% annually.

Shenandoah University – Budget Justification – Page 2 Consultant Costs: How item supports the achievement of proposed objective: 1. Objective 1: Subobjectives 1.1: XXX, RN, PNP, PhD, graduate program director for XXX School of nursing, will serve as Midwifery Initiative consultant. She will advise the PD on development of strategies to recruit and encourage RNs to begin NM education. She will guide Web-based outreach activities to increase awareness of NM education in the focus regions. Compensation: $500/day x 10 days in 1st year of project, 7 days in 2nd year, and 3 days in 3rd year; travel expenses of $1,000 in 1st year and $500 in each subsequent year. (1st year total = $6,000; 2nd year = $4,000; 3rd year = $2,000.) 2. Objective 2: Subobjectives 2.1, 2.2, 2.5: XXX, PhD, RN, FAAN, Associate Professor, XXX School of Nursing, will consult on cultural competence and health disparities. She will advise PD on course development and information dissemination regarding rural health disparities, cultural competence, and evaluation. Compensation: 1st yr:$500/day x 5 days. 2nd yr: 4 days. 3rd yr: 3 days. Travel expenses of $1,000 in 1st year, then $500/year. (1st yr = $3,500; 2nd yr = $2,500; 3rd yr = $2,000.) 3. Objective 3: Subobjective 3.2: XXX, PhD, RN, FACCE, FAAN, Associate Professor of Nursing and Information Sciences and Technology, XXX University and Editor-in-Chief of the XXX, will advise and assist PD and co PD in development of graduate NM, FNP, and PMH specialty courses, and continuing education courses for preceptors for online dissemination through Ipod technology. Compensation: $500/day x 5 days in 1st year of project, 4 days in 2nd year, and 3 days in 3rd year; travel expenses of $1,000 in 1st year and st nd rd $500 in each subsequent year. (1 year total = $3,500; 2 year = $2,500; 3 year = $2,000.)

Indirect Costs Indirect costs are budgeted at 8% of modified direct costs. Each year, direct costs have been modified by $30,000 reduction (amount of subcontract with Johns Hopkins University)

Fringe Benefits: (Objective 1) Fringe benefit rate of 31% covers medical and dental insurance, life and long-term disability, 403(b) contribution, Social Security, unemployment and workers’ compensation. For persons employed less than half-time, benefits include only Social Security (7.65%). Fringe benefits charged to project are directly proportional to portion of personnel costs allocated for the project.

Travel (budgeted travel expenses below are per year for each year of the funding cycle.) Objective/Subobjective #, Reason Type of Travel Lodging Total (Personnel Completing Travel) Activity Costs† Expenses 1.1 Recruitment Local 2,000 mi $600 $1,490 (PD or Graduate Faculty) $890 2.4 Clinical Site Visits (CNM Faculty) LD (Long $500 $400 $900 Distance) (flights) 2.4 Clinical Site Visits (Clinical Local/ LD 1,000 mi $300 $745 Coordinator) $445 1 Semi Annual Meetings ACNM Ed Long $500 $500 $1,000 Directors (PD) Distance (flights) All objectives: HRSA meeting/ Share Local 200 mi $250 $339 experiences (PD/Co-PD) $89 Travel table continued from previous page

† Local travel costs are budgeted at 44.5 cents per mile.

Shenandoah University – Budget Justification – Page 3 Objective/Subobjective #, Reason Type of Travel Lodging Total (Personnel Completing Travel) Activity Costs‡ Expenses 1, 2, 3 Conference travel, dissemination (PD Long $600 500 $1,100 & consultant) distance (flight) 2.2 Cultural Competence Training Travel LD 540 miles $175 x $765 (Graduate Faculty) $240 3=$525 Travel Cost Totals $3,264 $3,075 $6,339

Equipment No purchase of equipment with acquisition cost of $5,000 or more is proposed for this project.

Supplies Obj # and Justification Approx Item(s) Costs/Year AllObjectives Needed for achievement of all project objectives $500 Office Supplies 3.1, 3.2 Utilized by five graduate faculty, Informatics 2007-2008: $5,250 15 80 GB Ipods consultant, and students while they are taking the specialty courses. The PD and the Co-PD have Ipods at this time. Request is for three Ipods for faculty use, 2008-2009: None one for consultant, and 11 that will be available for loan to students who do not already own Ipods. $350 x 15=$5,250. Ipods will be purchased in first year of 2009-2010: None project. 3.1, 3.2 Utilized by students for Epocrates, Typhon Group, and 2007-2008: $4,500 15 Handheld Blackboard. Budget allows for purchase of 15 computers handheld computers in the first year of the project for 2008-2009: None loan to students who do not already own one. $300 x 15=$4,500. 2009-2010: None

Subcontracts: Subobjectives and Justification 2.1, 2.2, 2.5 XXX Contractor will develop and teach cultural 2007-2000: $30,000 competence/health disparity courses for students, 2008-2009: $30,000 faculty, and preceptors 2009-2010: $30,000 2.3 XXX Contractor will supply standardized patients who 2007-2008: $5,487 present with health disparities; prepares students for 2008-2009: $5,487 direct patient care in areas where health disparities 2009-2010: $5,487 exist

‡ Local travel costs are budgeted at 44.5 cents per mile.

Shenandoah University – Budget Justification – Page 4 Other Expenses Item Justification Approx Costs/Year All Objectives To disseminate activities and products of project, 2007-2008: $900 Publication $900 is budgeted in each project year - $500 for 2008-2009: $900 Costs conference fee for PD or Co-PD who will present 2009-2010: $900 results and $400 for costs of documenting and preparing materials for dissemination through conferences and Web-based publishing. 3.1, 3.3 This support is for preceptors to increase their 2007-2008: $20,000 Preceptor clinical skills and expertise in IOM rural relevant 2008-2009: $20,000 Education and competencies including informatics; to enhance Training Support their continued education in informatics and 2009-2010: $20,000 cultural competence; and to connect with other providers for consultation, collaboration, and referral. Examples of expenses for this use are: cost of portable digital devices, cost of continuing education, cultural competence training, and patient teaching materials. A total of $20,000 is allocated for each project year. 3.1 Needed for PD, Co-PD, and Informatics Consultant 2007-2008: $3,900 Three Macbook to graduate NM, FNP, and PMH specialty courses, 2008-2009: None laptop computers and continuing education courses for preceptors for 2009-2010: None online dissemination through Ipod technology. (3 x $1,300). At the present time, PD and faculty have PC desktop computers; however, Mac laptops are needed to develop courses for Ipod dissemination. 2.4 and 3.2 Allows students to manage patient reporting, 2007-2008: $1,500 Typhon Group journal patient visits, collaborate with faculty on 2008-2009: $2,250 Student Tracking management. Allows faculty to monitor students’ 2009-2010: $2,250 System (software progress, design formats to collect data, gather data subscription) on specific project goals such as cultural competence and evidence-based practice. Will also be on handhelds and used at clinical sites.

2.4, 3.2 Software program that provides evidence based 2007-2008: $3,432 Up-to-Date practice information to be used by faculty when 2008-2009: none Evidence based designing curricular and continuing education 2009-2010: none practice system materials. One three-year subscription for each of (software three specialties @ $1,144 = $3,432 subscription) 2.4, 3.2 Guides students on differential diagnosis and 2007-2008: $3,300 Epocrates preferred pharmacological treatment; installed on 2008-2009: $4,200 (software handhelds and used at clinical sites. Cost is 2009-2010: $4,500 subscription) $150/yr/student in specialties (1st year = 22 students; 2nd year = 28; 3rd year = 30).

Shenandoah University – Budget Justification – Page 5 This table not counted in page limit

NON-FEDERAL EXPENDITURES

FY 2006 (Actual) FY 2007 (Estimated) Actual FY 2006 non-Federal funds, including in-kind, Estimated FY 2007 non-Federal funds, including in- expended for activities proposed in this application. If kind, designated for activities proposed in this proposed activities are not currently funded by the application. institution, enter $0. Amount: $______0______Amount: $______0______

Shenandoah University – Budget Justification – Page 6