The Future of Nursing: 2020-2030 report encourages the development of a diverse nursing workforce as key to reducing health disparities, providing culturally relevant care for all populations, and fostering health equity. The report states that diversifying the nursing student body and workforce requires additional work to reduce barriers to student success (National Academies of Sciences, Engineering, and Medicine, 2021).
The social determinants of learning(TM) (SDOL) framework developed by Sanderson et al. (2021) addresses the importance of reducing barriers to nursing student success in six main domains: physical health, psychosocial health, physical environment, social environment, economic stability, and self-motivation. Impacting the SDOL are the important factors of diversity, equity, and inclusion, which contribute to and influence each determinant of learning. Diversity targets differences in student characteristics including race, ethnicity, age, gender, socioeconomic status, culture, language, religious beliefs, and socioeconomics. Equity refers to access, opportunity, fair treatment, and advancement for all while eliminating barriers to full participation. Inclusion ensures everyone can participate in opportunities and share resources. Sanderson and colleagues propose that "ensuring educational justice means all students, regardless of ethnicity, race, culture, financial status, or other factors, have access to quality college education that leads to equitable careers" (Sanderson et al., 2021, p. 205).
One economic barrier for students is the skyrocketing cost of tuition and commercial textbooks. The average cost of college has more than doubled since the 1970s, with an annual growth rate of 7.1 percent (Hanson, 2022b). Textbook costs increased 1,041 percent between 1977 and 2015. The average college student spends between $628 and $1,471 annually on textbooks; 25 percent of students reported they worked extra hours to pay for their books and materials, and 11 percent reported they skipped meals to afford them. This financial burden for students is a significant concern. To compound the issue, 37 percent of postsecondary faculty are not aware of the cost of course materials when making their selections, which can exacerbate the financial challenge for students (Hanson, 2022a).
The principle of educational justice promotes affordable access to textbooks for all students. There has been a growing national movement regarding the creation, adoption, and reuse of Open Educational Resources (OER) to promote affordable education and enhance student success. OER are designated with a Creative Commons license; they exist in the public domain and are freely available online for faculty and student use. Creative Commons licensing is a standardized way to grant the public permission to use one's creative work under copyright law (Creative Commons, n.d.).
A synthesis of research published between 2015 and 2018 involving 121,168 students or faculty suggested students achieve the same or better learning outcomes when using OER while saving significant amounts of money. In addition, the majority of faculty and students who used OER reported a positive experience and would use these materials again (Hilton, 2019). A large-scale study of 21,822 students found that, in addition to improving affordability, OER improved end-of-course grades and decreased D, F, and withdrawal grades for all students. In addition, OER decreased the rates of D and F grades and withdrawals for Pell grant recipients, part-time students, and populations historically underserved by higher education (Colvard et al., 2018).
OER FOR NURSING
Based on OER research and a $2.5 million grant received from the US Department of Education, the Open Resources for Nursing (Open RN) project created five nursing textbooks and 25 virtual simulations with Creative Commons "CC-BY 4.0" licensing (Creative Commons, n.d.). Open RN textbooks are designed for use in specific nursing courses in the Wisconsin Technical College System (WTCS) and are based on statewide, prelicensure nursing curriculum and course competencies. Content is aligned with the NCLEX(R)RN test plan, American Nurses Association scope and standards of practice and code of ethics, and NLN competencies for graduates of nursing programs to ensure the clinical practice of nursing graduates is informed by a nursing body of knowledge and safe, quality care is provided to the public. It is projected that if all 16 colleges in the WTCS adopt all five Open RN OER textbooks, more than 5,700 students will save $1.5 million in textbook costs annually.
Five Open RN textbooks were published between June 2020 and August 2022; these include Nursing Pharmacology, Nursing Skills, Nursing Fundamentals, Nursing Management & Professional Concepts, and Nursing Mental Health and Community Concepts. More than 65 nursing faculty and registered nurses in clinical practice contributed to the development of the Open RN textbooks, and more than 300 peer reviewers provided feedback before the first editions of the textbooks were published. Free Open RN textbooks can be viewed or downloaded from http://www.cvtc.edu/OpenRN; affordable soft cover versions may be purchased from a print publisher in college bookstores or on Amazon for approximately $40 to $60 retail cost.
Open RN textbooks are created using universal design. They incorporate cultural responsiveness by using inclusive language as well as images and case studies depicting diverse patients and health care staff. Textbook chapters contain free interactive learning activities ranging from knowledge-based flash cards to NCLEX Next-Generation-style questions that provide immediate formative feedback. In addition, free virtual simulations that contextualize case studies with simulated patient and nurse handoff videos are designed to promote the development of clinical judgment.
STUDENT IMPACT AND OUTCOMES
Adoption of OER textbooks promotes equity and expands learning opportunities for all students by providing free course materials to students on the first day of class. Students can immediately view and interact with free online resources. They may also elect to purchase affordable print versions that do not require Internet access. By using OER, students are not required to order books from a bookstore or wait for financial aid to be able to pay for their books. OER eliminate the decision of whether to buy a textbook or pay for other expenses that historically underserved students must pay for, for example, meals, transportation, rent, or day care.
Sixty colleges across the United States and Canada have adopted one or more Open RN textbooks. There is also widespread international usage of online books, with over 8.8 million page views by more than 3.6 million international users. Countries with the top usage include the United States (45%), Philippines (14%), India (9%), Canada (5%), Australia (4%), United Kingdom (2%), and Nigeria (2%).
Student learning outcomes related to OER usage were analyzed across the 16 WTCS stand-alone colleges. During the first academic year (2020 to 2021), the Nursing Pharmacology textbook was adopted in 66 course sections and impacted 1,259 students. The OER course sections had a 5 percent higher successful course completion rate (A-C grades) compared to the WTCS benchmark for this course (75.7%).
Analysis of cumulative results through the 2020 to 2021 and 2021 to 2022 academic years demonstrate that 307 WTCS course sections adopted Open RN textbooks (Nursing Pharmacology, Nursing Skills, Nursing Fundamentals, or Nursing Management & Professional Concepts), impacting 3,364 nonreplicated students and 4,092 course enrollments. The average course completion rate (A-F grades without W) in OER sections was the same for all students as the WTCS average rate (92%). In addition, there was a 2 percent higher successful course completion rate (A-C grades) for non-White students in OER sections compared to the average WTCS rate for non-White students in these courses. The student outcome data support the hypothesis that OER adoption can reduce barriers associated with SDOL.
Perceptions of OER were gathered using a survey. Respondents (n = 201; 84% students, 14% faculty, and 2% "other") rated the Open RN textbooks compared to commercial textbooks using a 1-5 Likert scale (1 = much worse, 5 = much better). Survey criteria included quality, cost, ease of use, helpfulness of learning activities, inclusion of evidence-based practices, navigation to other credible sources, and application of content to patient care. The mean ratings for each criterion ranged from 3.83 to 4.49, with an average rating of 4.07, indicating the Open RN textbooks were considered better to much better than commercial textbooks. A second survey is provided within the free online virtual simulations. Of 798 respondents, 93 percent agreed or strongly agreed that the virtual simulations increased their interest in completing the learning experience compared to a traditional case study, the scenarios are clinically accurate, current, and relevant to nursing practice, and the virtual simulations encouraged the development of their clinical judgment.
PLANS FOR FURTHER DEVELOPMENT
Second editions of the Open RN textbooks will be published in 2023 and 2024 based on the 2023 NCLEX-RN test plan and will include additional Next-Generation-style formative assessments. WTCS student learning outcomes continue to be analyzed and trended.
REFERENCES