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The Future of Nursing: Leading Change, Advancing Health 4 Transforming Education Key Message #2: Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression. Major changes in the U.S. health care system and practice environments will require equally profound changes in the education of nurses both before and after they receive their licenses. Nursing education at all levels needs to provide a better understanding of and experience in care management, quality improvement methods, systems-level change management, and the reconceptualized roles of nurses in a reformed health care system. Nursing education should serve as a platform for continued lifelong learning and include opportunities for seamless transition to higher degree programs. Accrediting, licensing, and certifying organizations need to mandate demonstrated mastery of core skills and competencies to complement the completion of degree programs and written board examinations. To respond to the underrepresentation of racial and ethnic minority groups and men in the nursing workforce, the nursing student body must become more diverse. Finally, nurses should be educated with physicians and other health professionals as students and throughout their careers.
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The Future of Nursing: Leading Change, Advancing Health Major changes in the U.S. health care system and practice environments will require equally profound changes in the education of nurses both before and after they receive their licenses. In Chapter 1, the committee set forth a vision of health care that depends on a transformation of the roles and responsibilities of nurses. This chapter outlines the fundamental transformation of nurse education that must occur if this vision is to be realized. The primary goals of nursing education remain the same: nurses must be prepared to meet diverse patients’ needs; function as leaders; and advance science that benefits patients and the capacity of health professionals to deliver safe, quality patient care. At the same time, nursing education needs to be transformed in a number of ways to prepare nursing graduates to work collaboratively and effectively with other health professionals in a complex and evolving health care system in a variety of settings (see Chapter 3). Entry-level nurses, for example, need to be able to transition smoothly from their academic preparation to a range of practice environments, with an increased emphasis on community and public health settings. And advanced practice registered nurses (APRNs) need graduate programs that can prepare them to assume their roles in primary care, acute care, long-term care, and other settings, as well as specialty practices. This chapter addresses key message #2 set forth in Chapter 1: Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression. The chapter begins by focusing on nurses’ undergraduate education, emphasizing the need for a greater number of nurses to enter the workforce with a baccalaureate degree or to progress to this degree early in their career. This section also outlines some of the challenges to meeting undergraduate educational needs. The chapter then turns to graduate nursing education, stressing the need to increase significantly the numbers and preparation of nurse faculty and researchers at the doctoral level. The third section explores the need to establish, maintain, and expand new competencies throughout a nurse’s education and career. The chapter next addresses the challenge of underrepresentation of racial and ethnic minority groups and men in the nursing profession and argues that meeting this challenge will require increasing the diversity of the nursing student body. The fifth section describes some creative solutions that have been devised for addressing concerns about educational capacity and the need to transform nursing curricula. The final section presents the committee’s conclusions regarding the improvements needed to transform nursing education. The committee could have devoted this entire report to the topic of nursing education—the subject is rich and widely debated. However, the committee’s statement of task required that it examine a range of issues in the field, rather than delving deeply into the many challenges involved in and solutions required to advance the nursing education system. Several comprehensive reports and analyses addressing nursing education have recently been published. They include a 2009 report from the Carnegie Foundation that calls for a “radical transforma-
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The Future of Nursing: Leading Change, Advancing Health tion” of nursing education (Benner et al., 2009); a 2010 report from a conference sponsored by the Macy Foundation that charts a course for “life-long learning” that is assessed by the “demonstration of competency [as opposed to written assessment] in both academic programs and in continuing education” (AACN and AAMC, 2010); two consensus reports from the Institute of Medicine (IOM) that call for greater interprofessional education of physicians, nurses, and other health professionals, as well as new methods of improving and demonstrating competency throughout one’s career (IOM, 2003b, 2009); and other articles and reports on necessary curriculum changes, faculty development, and new partnerships in education (Erickson, 2002; Lasater and Nielsen, 2009; Mitchell et al., 2006; Orsolini-Hain and Waters, 2009; Tanner et al., 2008). Additionally, in February 2009, the committee hosted a forum on the future of nursing in Houston, Texas, that focused on nursing education. Discussion during that forum informed the committee’s deliberations and this chapter; a summary of that forum is included on the CD-ROM in the back of this report.1 Finally, Appendix A highlights other recent reports relevant to the nursing profession. The committee refers readers wishing to explore the subject of nursing education in greater depth to these publications. UNDERGRADUATE EDUCATION This section begins with an overview of current undergraduate nursing education, including educational pathways, the distribution of undergraduate degrees, the licensing exam, and costs (see Appendix E for additional background information on undergraduate education). The discussion then focuses on the need for more nurses prepared at the baccalaureate level. Finally, barriers to meeting undergraduate educational needs are reviewed. Overview of Current Undergraduate Education Educational Pathways Nursing is unique among the health care professions in the United States in that it has multiple educational pathways leading to an entry-level license to practice (see the annexes to Chapter 1 and Appendix E). For the past four decades, nursing students have been able to pursue three different educational pathways to become registered nurses (RNs): the bachelor’s of science in nursing (BSN), the associate’s degree in nursing (ADN), and the diploma in nursing. More recently, an accelerated, second-degree bachelor’s program for students who possess a baccalaureate degree in another field has become a popular option. This multiplicity of options has fragmented the nursing community and has created 1 The summary also can be downloaded at http://www.iom.edu.
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The Future of Nursing: Leading Change, Advancing Health confusion among the public and other health professionals about the expectations for these educational options. However, these pathways also provide numerous opportunities for women and men of modest means and diverse backgrounds to access careers in an economically stable field. In addition to the BSN, ADN, or diploma received by RNs, another undergraduate-level program available is the licensed practical/vocational diploma in nursing. Licensed practical/vocational nurses (LPNs/LVNs) are especially important because of their contributions to care in long-term care facilities and nursing homes.2 LPNs/LVNs receive a diploma after completion of a 12-month program. They are not educated or licensed for independent decision making for complex care, but obtain basic training in anatomy and physiology, nutrition, and nursing techniques. Some LPNs/LVNs continue their education to become RNs; in fact, approximately 17.9 percent of RNs were once licensed as LPNs/LVNs (HRSA, 2010b). While most LPNs/LVNs have an interest in advancing their education, a number of barriers to their doing so have been cited, including financial concerns, lack of capacity and difficulty getting into ADN and BSN programs, and family commitments (HRSA, 2004). Although this chapter focuses primarily on the education of RNs and APRNs, the committee recognizes the contributions of LPNs/LVNs in improving the quality of health care. The committee also recognizes the opportunity the LPN/LVN diploma creates as a possible pathway toward further education along the RN and APRN tracks for the diverse individuals who hold that diploma. Distribution of Undergraduate Degrees At present, the most common way to become an RN is to pursue an ADN at a community college. Associate’s degree programs in nursing were launched in the mid-20th century in response to the nursing shortage that followed World War II (Lynaugh, 2008; Lynaugh and Brush, 1996). The next most common undergraduate nursing degree is the BSN, a 4-year degree typically offered at a university. Baccalaureate nursing programs emphasize liberal arts, advanced sciences, and nursing coursework across a wider range of settings than are addressed by ADN programs, along with formal coursework that emphasizes both the acquisition of leadership development and the exposure to community and public health competencies. The least common route to becoming an RN currently is the diploma program, which is offered at a hospital-based school and generally lasts 3 years. During the 20th century, as nursing gained a stronger theoretical foundation and other types of nursing programs increased in number, the number of diploma programs declined remarkably except in a few states, such as New Jersey, Ohio, 2 While titles for LPNs and LVNs vary from state to state, their responsibilities and education are relatively consistent. LPNs/LVNs are required to pass the National Council Licensure Examination for Practical Nurses (NCLEX-PN) to secure a license to practice.
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The Future of Nursing: Leading Change, Advancing Health FIGURE 4-1 Trends in graduation from basic RN programs, by type, 2002–2008. SOURCE: NLN, 2010b. and Pennsylvania. Figure 4-1 gives an overview of trends in the distribution of nursing graduates by initial nursing degree. Entry into Practice: The Licensing Exam3 Regardless of which educational pathway nursing students pursue, those working toward an RN must ultimately pass the National Council Licensure Examination for Registered Nurses (NCLEX-RN), which is administered by the National Council of State Boards of Nursing (NCSBN), before they are granted a license to practice. Rates of success on the NCLEX-RN are often used for rating schools or for marketing to potential students. As with many entry-level licensing exams, however, the NCLEX-RN uses multiple-choice, computer-based methods to test the minimum competency required to practice nursing safely. The exam is administered on a pass/fail basis and, although rigorous, is not meant to be a test of optimal performance. Following passage of the exam, individual state boards of nursing grant nurses their license to practice. The content of the NCLEX-RN is based on surveys of what new nurses need to know to begin their practice. As with most entry-level licensing exams, the 3 See https://www.ncsbn.org/nclex.htm.
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The Future of Nursing: Leading Change, Advancing Health content of the NCLEX-RN directly influences the curricula used to educate nursing students. Currently, the exam is skewed toward acute care settings because this is where the majority of nurses are first employed and where most work throughout their careers. To keep pace with the changing demands of the health care system and patient populations, including the shift toward increasing care in community settings (see Chapter 2), the focus of the exam will need to shift as well. Greater emphasis must be placed on competencies related to community health, public health, primary care, geriatrics, disease prevention, health promotion, and other topics beyond the provision of nursing care in acute care settings to ensure that nurses are ready to practice in an evolving health care system. Costs of Nursing Education Although a limited number of educational grants and scholarships are available, most of individuals seeking nursing education must finance their own education at any level of preparation. Costs vary based on the pathway selected for basic preparation and through to doctoral preparation. The LPN degree is the least expensive to attain, followed by the ADN, BSN (accelerated program), BSN, master’s of science in nursing (MSN), and PhD/doctor of nursing practice (DNP) degrees. It is no surprise that educational costs and living expenses play a major role in determining which degree is pursued and the numbers of nurses who seek advanced degrees. To better understand the costs of nursing education, the committee asked the Robert Wood Johnson Foundation (RWJF) Nursing Research Network to estimate the various costs associated with pursuing nursing education, specifically at the advanced practice level, in comparison with those for a medical doctor (MD) or doctor of osteopathy (DO). The RWJF Nursing Research Network produced several comparison charts in an attempt to convey accurately the differences in costs between alternative nursing degrees and the MD or DO degree. This task required making assumptions about public versus private and proprietary/for-profit education options, prerequisites for entry, and years required to complete each degree. An area of particular difficulty arose in assessing costs associated with obtaining an ADN degree. In most non–health care disciplines, the associates degree takes 2 years to complete. In nursing, however, surveys have found that it takes students 3 to 4 years to complete an ADN program because of the need to fulfill prerequisites necessary to prepare students for entry into degree programs and the lack of adequate faculty, which lead to long waiting lists for many programs and classes (Orsolini-Hain, 2008). Box 4-1 illustrates the challenges of this task by outlining the difficulty of comparing the cost of becoming a physician with the cost of becoming an APRN. The task of comparing the increasing “sticker costs” of nursing and medical education was complicated further because much of the data needed to compute those costs is either missing or drawn from incomparable years. In the end, the committee decided not to include detailed discussion of the costs of nursing education in this report.
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The Future of Nursing: Leading Change, Advancing Health BOX 4-1 Costs of Health Professional Education Depending on the method used, the number of advanced practice registered nurses (APRNs) that can be trained for the cost of training 1 physician is between 3 and 14. Assessing the costs of education is a multidimensional problem. Manno (1998) has suggested that costs for higher education can be measured in at least four ways: “the production cost of delivering education to students; the ‘sticker price’ that students/families are asked to pay; the cost to students to attend college, including room and board, books and supplies, transportation, tuition, and fees; and the net price paid by students after financial aid awards” (Starck, 2005). While the first of these measures, the production cost to the institution, is the most complete, it is the most complex to derive. One study attempted to compare the educational cost for various health professions. This study, sponsored by the Association of Academic Health Centers (Gonyea, 1998), used the 1994 methodology of Valberg and colleagues, which included 80 percent essential education and 20 percent complementary research and service (Valberg et al., 1994). The conclusion reached was that for every 1 physician (4 years), 14 advanced nurse practitioners or 12 physician assistants could be produced (Starck, 2005). If one examines simply the cost to students of postsecondary training (the “sticker price”), the differences among professions are slightly less dramatic. The cost to students is defined as the tuition and fees students/families pay. This measure does not include costs associated with room and board, books, transportation, and other living expenses. Nor does it include those costs incurred by the educational programs that may be beyond what is covered by tuition revenues. Residency programs for physicians are not included in this estimate because students do not pay them. Medical residencies are funded largely by Medicare, and in 2008, totaled approximately $9 billion per year ($100,000 on average for each of about 90,000 residents) for graduate medical education (MedPAC, 2009). Some of the Medicare expenditures are for indirect costs, such as the greater costs associated with operating a teaching hospital. Estimates of the average cost per resident for the federal government are difficult to establish because of the wide variation in payments by specialty and type of hospital. In addition, residency costs vary significantly by year, with the early years requiring more supervision than the later years. Why More BSN-Prepared Nurses Are Needed The qualifications and level of education required for entry into the nursing profession have been widely debated by nurses, nursing organizations, academics, and a host of other stakeholders for more than 40 years (NLN, 2007). The causal relationship between the academic degree obtained by RNs and patient outcomes is not conclusive in the research literature. However, several studies
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The Future of Nursing: Leading Change, Advancing Health support a significant association between the educational level of RNs and outcomes for patients in the acute care setting, including mortality rates (Aiken et al., 2003; Estabrooks et al., 2005; Friese et al., 2008; Tourangeau et al., 2007; Van den Heede et al., 2009). Other studies argue that clinical experience, qualifications before entering a nursing program (e.g., SAT scores), and the number of BSN-prepared RNs that received an earlier degree confound the value added through the 4-year educational program. One study found that the level of experience of nurses was more important than their education level in mitigating medication errors in hospitals (Blegen et al., 2001). Another study performed within the Department of Veterans Affairs (VA) system found no significant association between the proportion of RNs with a baccalaureate degree and patient outcomes at the hospital level (Sales et al., 2008). This debate aside, an all-BSN workforce at the entry level would provide a more uniform foundation for the reconceptualized roles for nurses and new models of care that are envisioned in Chapters 1 and 2. Although a BSN education is not a panacea for all that is expected of nurses in the future, it does, relative to other educational pathways, introduce students to a wider range of competencies in such arenas as health policy and health care financing, leadership, quality improvement, and systems thinking. One study found that new BSN graduates reported significantly higher levels of preparation in evidence-based practice, research skills, and assessment of gaps in areas such as teamwork, collaboration, and practice (Kovner et al., 2010)—other important competencies for a future nursing workforce. Moreover, as more nurses are being called on to lead care coordination efforts, they should have the competencies requisite for this task, many of which are included in the American Association of Colleges of Nursing’s (AACN’s) Essentials of Baccalaureate Education for Professional Nursing Practice.4 Care within the hospital setting continues to grow more complex, and nurses must make critical decisions associated with care for sicker, frailer patients. Care in this setting depends on sophisticated, life-saving technology coupled with complex information management systems that require skills in analysis and synthesis. Care outside the hospital is becoming more complex as well. Nurses are being called upon to coordinate care among a variety of clinicians and community agencies; to help patients manage chronic illnesses, thereby preventing acute care episodes and disease progression; and to use a variety of technological tools to improve the quality and effectiveness of care. A more educated nursing workforce would be better equipped to meet these demands. An all-BSN workforce would also be poised to achieve higher levels of education at the master’s and doctoral levels, required for nurses to serve as primary care providers, nurse researchers, and nurse faculty—positions currently in great demand as discussed later in this chapter. Shortages of nurses in these positions continue to be a barrier to advancing the profession and improving the delivery of care to patients. 4 See http://www.aacn.nche.edu/education/pdf/BaccEssentials08.pdf.
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The Future of Nursing: Leading Change, Advancing Health Some health care organizations in the United States are already leading the way by requiring more BSN-prepared nurses for entry-level positions. A growing number of hospitals, particularly teaching and children’s hospitals and those that have been recognized by the American Nurses Credentialing Center Magnet Recognition Program (see Chapter 5), favor the BSN for employment (Aiken, 2010). Depending on the type of hospital, the goal for the proportion of BSN-prepared nurses varies; for example, teaching hospitals aim for 90 percent, whereas community hospitals seek at least 50 percent (Goode et al., 2001). Absent a nursing shortage, then, nurses holding a baccalaureate degree are usually the preferred new-graduate hires in acute care settings (Cronenwett, 2010). Likewise, in a recent survey of 100 physician members of Sermo.com (see Chapter 3 for more information on this online community), conducted by the RWJF Nursing Research Network, 76 percent of physicians strongly or somewhat agreed that nurses with a BSN are more competent than those with an ADN. Seventy percent of the physicians surveyed also either strongly or somewhat agreed that all nurses who provide care in a hospital should hold a BSN, although when asked about the characteristics they most value in nurses they work with, the physicians placed a significantly higher value on compassion, efficiency, and experience than on years of nursing education and caliber of nursing school (RWJF, 2010c). In community and public health settings, the BSN has long been the preferred minimum requirement for nurses, given the competencies, knowledge of community-based interventions, and skills that are needed in these settings (ACHNE, 2009; ASTDN, 2003). The U.S. military and the VA also are taking steps to ensure that the nurses making up their respective workforces are more highly educated. The U.S. Army, Navy, and Air Force require all active duty RNs to have a baccalaureate degree to practice, and the U.S. Public Health Service has the same requirement for its Commissioned Officers. Additionally, as the largest employer of RNs in the country, the VA has established a requirement that nurses must have a BSN to be considered for promotion beyond entry level (AACN, 2010c). As Table 4-1 shows, however, the average earnings of BSN-prepared nurses are not substantially higher than those of ADN- or diploma-prepared nurses. Decades of “blue ribbon panels” and reports to Congress on the health care workforce have found that there is a significant shortage of nurses with baccalaureate and higher degrees to respond to the nation’s health needs (Aiken, 2010). Almost 15 years ago, the National Advisory Council on Nurse Education and Practice, which advises Congress and the secretary of Health and Human Services on areas relevant to nursing, called for the development of policy actions that would ensure a minimum of 66 percent of RNs who work as nurses would have a BSN or higher degree by 2010 (Aiken et al., 2009). The result of policy efforts of the past decade has been a workforce in which approximately 50 percent of RNs hold a BSN degree or higher, a figure that includes ADN- and diploma-educated RNs who have gone on to obtain a BSN (HRSA, 2010b). Of significant note, the Tri-Council for Nursing, which consists of the American Nurses Association, American Organization of Nurse Executives, National
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The Future of Nursing: Leading Change, Advancing Health TABLE 4-1 Average Earnings of Full-Time RNs, by Highest Nursing or Nursing-Related Education and Job Title Position Earnings Diploma ($) Associate’s Degree ($) Bachelor’s Degree ($) Master’s/Doctoral Degree ($) Overall Average ($) All nurses 65,349 60,890 66,316 87,363 66,973 Staff nurse 63,027 59,310 63,382 69,616 61,706 First-line management 68,089 66,138 75,144 85,473 72,006 Senior/middle management 74,090 69,871 79,878 101,730 81,391 Patient coordinator 62,693 60,240 64,068 71,516 62,978 NOTE: Only those who provided earnings information to surveyors are included in the calculations used for this table. SOURCE: HRSA, 2010b. League for Nursing (NLN), and AACN, recently released a consensus policy statement calling for a more highly educated nursing workforce, citing the need to increase the number of BSN-prepared nurses to deliver safer and more effective care (AACN, 2010a). In sum, an increase in the percentage of nurses with a BSN is imperative as the scope of what the public needs from nurses grows, expectations surrounding quality heighten, and the settings where nurses are needed proliferate and become more complex. The formal education associated with obtaining the BSN is desirable for a variety of reasons, including ensuring that the next generation of nurses will master more than basic knowledge of patient care, providing a stronger foundation for the expansion of nursing science, and imparting the tools nurses need to be effective change agents and to adapt to evolving models of care. As discussed later in this chapter, the committee’s recommendation for a more highly educated nursing workforce must be paired with overall improvements to the education system and must include competencies in such areas as leadership, basic health policy, evidence-based care, quality improvement, and systems thinking. Moreover, even as the breadth and depth of content increase within prelicensure curricula, the caring essence and human connectedness nurses bring to patient care must be preserved. Nurses need to continue to provide holistic, patient-centered care that goes beyond physical health needs to recognize and respond to the social, mental, and spiritual needs of patients and their families. Other fundamental elements of nursing education, such as ethics and integrity, need to remain intact as well. The Goal and a Plan for Achieving It In the committee’s view, increasing the percentage of the current nursing workforce holding a BSN from 50 to 100 percent in the near term is neither practical
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The Future of Nursing: Leading Change, Advancing Health nor achievable. Setting a goal of increasing the percentage to 80 percent by 2020 is, however, bold, achievable, and necessary to move the nursing workforce to an expanded set of competencies, especially in the domains of community and public health, leadership, systems improvement and change, research, and health policy. The committee believes achieving the goal of 80 percent of the nursing workforce having a BSN is possible in part because much of the educational capacity needed to meet this goal exists. RNs with an ADN or diploma degree have a number of options for completing the BSN, as presented below. The combination of these options and others yet to be developed will be needed to meet the 80 percent goal—no one strategy will provide a universal solution. Technologies, such as the use of simulation and distance learning through online courses, will have to play a key role as well. Above all, what is needed to achieve this goal is the will of nurses to return to higher education, support from nursing employers and others to help fund nursing education, the elevation of educational standards, an education system that recognizes the experience and previous learning of returning students, and regional collaboratives of schools of nursing and employers to share financial and human resources. While there are challenges associated with shortages of nurse faculty and clinical education sites (discussed below), these challenges are less problematic for licensed RNs pursuing a BSN than for prelicensure students, who require more intense oversight and monitoring by faculty. Additionally, most of what ADN-prepared nurses need to move on to a baccalaureate degree can be taught in a classroom or online, with additional tailored clinical experience. Online education creates flexibility and provides an additional skill set to students who will use technology into the future to retrieve and manage information. Over the course of its deliberations and during the forum on education held in Houston, the committee learned about several pathways that are available to achieve the goal of 80 percent of the nursing workforce having a BSN (additional innovations discussed at the forum on education can be found in the forum summary on the CD-ROM in the back of this report). For RNs returning to obtain their BSN, a number of options are possible, including traditional RN-to-BSN programs. Many hospitals also have joint arrangements with local universities and colleges to offer onsite classes. Hospitals generally provide stipends to employees as an incentive to continue their education. Online education programs make courses available to all students regardless of where they live. For prospective nursing students, there are traditional 4-year BSN programs at a university, but there are also community colleges now offering 4-year baccalaureate degrees in some states (see the next section). Educational collaboratives between universities and community colleges, such as the Oregon Consortium for Nursing Education (described in Box 4-2), allow for automatic and seamless transition from an ADN to a BSN program, with all schools sharing curriculum, simulation facilities, and faculty. As described below, this type of model is goes beyond the conventional articulation agreement between community colleges and universities. Beyond traditional nursing schools, new providers of nursing education are entering the
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The Future of Nursing: Leading Change, Advancing Health SOLUTIONS FROM THE FIELD This chapter has outlined a number of challenges facing nursing education. These challenges have been the subject of much documentation, analysis, and debate (Benner et al., 2009; Erickson, 2002; IOM, 2003a, 2009; Lasater and Nielsen, 2009; Mitchell et al., 2006; Orsolini-Hain and Waters, 2009; Tanner et al., 2008). Various approaches to responding to these challenges and transforming curricula have been proposed, and several are being tested. The committee reviewed the literature on educational capacity and redesign, heard testimony about various challenges and potential solutions at the public forum in Houston, and chose a number of exemplars for closer examination. Three of these models are described in this section. The committee found that each of these models provided important insight into creative approaches to maximizing faculty resources, encouraging the establishment and funding of new faculty positions, maximizing the effectiveness of clinical education, and redesigning nursing curricula. Veterans Affairs Nursing Academy In 2007, the VA launched the VANA—a 5-year, $40 million pilot program—with the primary goals of developing partnerships with academic nursing institutes; expanding the number of faculty for baccalaureate programs; establishing partnerships to enhance faculty development; and increasing baccalaureate enrollment to increase the supply of nurses, not solely for the VA, but for the country at large. VANA also was aimed at encouraging interprofessional programs and increasing the retention and recruitment of VA nurses.24 Since the program’s inception, three cycles of requests for proposals have been sent to more than 600 colleges and schools of nursing, as well as to institutions within the VA system. Fifteen geographically and demographically diverse pilot sites were selected to participate in VANA based on the strength of their proposals. Each funded VANA partnership is required to have a rigorous evaluation plan to measure outcomes. Outcomes are expected to include increased staff, patient, student, and faculty satisfaction; greater scholarly output; enhanced professional development; better continuity and coordination of care; more reliance on evidence-based practice; and enhanced interprofessional learning. Each selected school is also expected to increase enrollment by at least 20 students a year. The program has already resulted in 2,700 new students, with 620 receiving the majority of their clinical rotation experiences at the VA. The graduates of this program may include students who have pursued a traditional prelicensure 24 This paragraph, and the three that follow, draw upon a presentation made by Cathy Rick, chief nursing officer for the VA, at the Forum on the Future of Nursing: Education, held in Houston, TX on February 22, 2010 (see Appendix C) and published in A Summary of the February 2010 Forum on the Future of Nursing: Education (IOM, 2010).
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The Future of Nursing: Leading Change, Advancing Health BSN, a BSN through a second-degree program, or a BSN through an RN-to-BSN program. The number of nursing school faculty has increased by 176 and the number of VA faculty by 264. In addition to the new nurses and faculty, educational innovations have encompassed curriculum revision, including quality and safety standards; DEUs (described earlier in Box 4-4); and a postgraduate baccalaureate nurse residency (see Chapter 3). Other changes include interprofessional simulation training and the development of evidence-based practice committees and programs. Beyond these specific changes and accomplishments, the VANA faculty has worked to develop the program into a single community of learning and to prepare students in a genuinely collaborative practice environment with clinically proficient staff and educators. Carondolet Health Network The Carondolet Health Network of Tucson, Arizona, is an example of how employers can offer educational benefits that improve both patient outcomes and the bottom line. Carondelet, which includes four hospitals and other facilities and employs approximately 1,650 nurses, is featured as one of seven cases studies in the Lewin Group’s 2009 report Wisdom at Work: Retaining Experienced RNs and Their Knowledge—Case Studies of Top Performing Organizations. After Carondelet became part of Ascension Health in 2002, the Tucson organization embarked on a strategic plan to recruit and retain more nurses. Arizona faces some of the severest nursing shortages in the nation, and most nurses prefer to live and work in higher-paying markets, such as Phoenix or southern California. When Carondelet instituted an on-site BSN program, which it subsidized in exchange for a 2-year work commitment, the response was dramatic. Instead of an anticipated class size of 20 nurses in the first semester of the program, it enrolled 104. Of interest, it was the business case—the opportunity to decrease the amount of money the organization was spending on costly temporary nurses—that tipped the balance in favor of action (The Lewin Group, 2009). Hospital Employee Education and Training The Hospital Employee Education and Training (HEET) program was developed through a joint effort of the 1199NW local affiliate of the Service Employees International Union and the Washington State Hospital Association Work Force Institute to help address shortages in nursing and nursing-related positions through education and upgrading of incumbent workers. The program is administered through the Washington State Board for Community and Technical Colleges. Across the state, HEET-funded programs support industry-based reform of the education system and include preparation and completion of nursing career ladder programs. HEET seeks to develop educational opportunities that support
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The Future of Nursing: Leading Change, Advancing Health both employer needs and the career aspirations of health care workers. It features cohort-based programs, distance learning, worksite classes, use of a simulation laboratory for nursing prerequisites, case management, tutoring support for those reentering academia, and nontraditional scheduling of classes to enable working adults to attend and address employee barriers to education. The findings for this union-inspired initiative demonstrate its potential to increase racial/ethnic diversity in the nursing population. HEET participants represent a pool of potential nurses who are more diverse than the current nursing workforce. Providing on-site classes at hospitals appears to support the participation of working adults who are enrolled in nursing school while continuing to work at least part time. Workers participating in the HEET program have had lower attrition rates and higher rates of course completion compared with community college students in nursing career tracks. The curriculum also blends academic preparation with health care career education, thereby opening the doors of college to workers who might not otherwise enroll or succeed (Moss and Weinstein, 2009). CONCLUSION The future of access to basic primary care and nursing education will depend on increasing the number of BSN-prepared nurses. Unless this goal is met, the committee’s recommendations for greater access to primary care; enhanced, expanded, and reconceptualized roles for nurses; and updated nursing scopes of practice (see Chapter 7) cannot be achieved. The committee believes that increasing the proportion of the nursing workforce with a BSN from the current 50 percent to 80 percent by 2020 is bold but achievable. Achieving this target will help meet future demand for nurses qualified for advanced practice positions and possessing competencies in such areas as community care, public health, health policy, evidence-based practice, research, and leadership. The committee concludes further that the number of nurses holding a doctorate must be increased to produce a greater pool of nurses prepared to assume faculty and research positions. The committee believes a target of doubling the number of nurses with a doctorate by 2020 would meet this need and is achievable. To achieve these targets, however, will require overcoming a number of barriers. The numbers of educators and clinical placements are insufficient for all the qualified applicants who wish to enter nursing school. There also is a shortage of faculty to teach nurses at all levels. Incentives for nurses at any level to pursue further education are few, and there are active disincentives against advanced education. Nurses and physicians—not to mention pharmacists and social workers—typically are not educated together and yet are increasingly required to cooperate and collaborate more closely in the delivery of care. To address these barriers, innovative new programs to attract nursing faculty and provide a wider range of clinical education placements must clear long-stand-
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The Future of Nursing: Leading Change, Advancing Health ing bottlenecks. To this end, market-based salary adjustments must be made for faculty, and more scholarships must be provided to help nursing students advance their education. Accrediting and certifying organizations must mandate demonstrated mastery of clinical skills, managerial competencies, and professional development at all levels. Mandated skills, competencies, and professional development milestones must be updated on a more timely basis to keep pace with the rapidly changing demands of health care. All health professionals should receive more of their education in concert with students from other disciplines. Efforts also must be made to increase the diversity of the nursing workforce. The nursing profession must adopt a framework of continuous lifelong learning that includes basic education, academic progression, and continuing competencies. More nurses must receive a solid education in how to manage complex conditions and coordinate care with multiple health professionals. They must demonstrate new competencies in systems thinking, quality improvement, and care management and a basic understanding of health care policy. Graduate-level nurses must develop an even deeper understanding of care coordination, quality improvement, systems thinking, and policy. The committee emphasizes further that, as discussed in Chapter 2, the ACA is likely to accelerate the shift in care from the hospital to the community setting. This transition will have a particularly strong impact on nurses, more than 60 percent of whom are currently employed in hospitals (HRSA, 2010b). Nurses may turn to already available positions in primary or chronic care or in public or community health, or they may pursue entirely new careers in emerging fields that they help create. Continuing and graduate education programs must support the transition to a future that rewards flexibility. In addition, the curriculum at many nursing schools, which places heavy emphasis on preparing students for employment in the acute care setting, will need to be rethought (Benner et al., 2009). REFERENCES AACN (American Association of Colleges of Nursing). 2005. Enrollment and graduations in baccalaureate and graduate programs in nursing, 2004-05. Washington, DC: AACN. AACN. 2006. Enrollment and graduations in baccalaureate and graduate programs in nursing, 2005-06. Washington, DC: AACN. AACN. 2007. Enrollment and graduations in baccalaureate and graduate programs in nursing, 2006-07. Washington, DC: AACN. AACN. 2008a. Enrollment and graduations in baccalaureate and graduate programs in nursing, 2007-08. Washington, DC: AACN. AACN. 2008b. The essentials of baccalaureate education for professional nursing practice. Washington, DC: AACN. Available from http://www.aacn.nche.edu/education/pdf/BaccEssentials08.pdf. AACN. 2009a. Advancing higher education in nursing: 2009 annual report. Washington, DC: AACN.
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