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Academic Progression in Nursing: Achieving an Eighty Percent BSN Prepared Workforce by 2020
This paper was prepared for Nursing 635: Leadership in Organizational Systems, taught by Dr. Holly Evans Madison.
In 2010, the Committee on the Robert Wood Johnson Foundation Initiative on the future of nursing published a report in conjunction with the Institute of Medicine (IOM) entitled, “The Future of Nursing: Leading Change, Advancing Health.” The report came at a very opportune time. Legislation had just been passed to expand health insurance coverage to an additional 32 million Americans. The committee recognized that nurses were the largest sector of employees in healthcare. There are approximately 3 million nurses in the United States. With the need to reform the way healthcare is delivered, the question was: How can the role of the nurse be transformed to meet the demand for safe, quality, and effective healthcare? (Institute of Medicine, 2010, p. xi).
The 672-page report outlined several major recommendations for transformation in nursing practice, education, and leadership. The committee recognized that the role of nursing includes health promotion, disease prevention, coordination of care, and palliative care. It was identified that the current nursing workforce lacks the diversity in gender, sex, ethnicity, and educational background that is needed to properly provide culturally relevant care to all populations. This paper will focus on the Institute of Medicine (IOM) recommendation that nurses achieve “higher levels of training and education through an improved education system that promotes seamless academic progression” (IOM, p. 4). In order to transform healthcare, it is recommended that 80% of the RN workforce be BSN prepared by 2020. Healthcare leaders today are charged with the issue of working to increase the educational preparation of nurses while facing both cultural and financial barriers. Budgets are lean and the belief system that a nurse does not need a university degree runs deep throughout the country, particularly in more rural areas and hospitals not affiliated with academic teaching centers.
Scope of the Issue
Historically, nurses have been trained in the acute care hospital setting. Nursing schools during the 20th century were sponsored by hospitals and the students lived on the campus in dormitory style housing. Education was in the classroom and on the wards. A diploma was conferred after the end of three years of rigorous training that often had the student nurses fully running the hospital wards. However, as early as the 1910s, it was identified that nurses were desperately needed in the public health sector and that training solely in a hospital ward was not adequate. There was a call to action then for nurses to be trained in disease prevention, public speaking, sanitation, and urban planning (Kulbok & Glick, 2014, p. 171). In 2012, a speaker at the Massachusetts General Hospital Training School for Nurses stated that nursing was “of the highest possible importance to the health and welfare of the community and the nurse today cannot fulfill adequately the larger demands now made of her without a sounder general education” (Kulbok & Glick, 2014, p. 173). One hundred years later, the battle cry remains the same.
In 1965 a Position Paper was published in the American Journal of Nursing. The author’s vision was for nursing education to shift away from hospital-based diploma nursing education programs to a two-level education system that would occur in institutions of higher education. There would be associate degree (AD) technical nurses and baccalaureate (BSN) professional nurses. After 1965 there was a shift away from the diploma schools to AD programs in community colleges. This was in part due to the economic burden of running these programs that the host hospital faced, as well as new laws that restricted the amount of free labor students could provide. However, the two-level system of licensure was never realized, as there were not enough BSN prepared students to fill all the bedside nursing roles (Hudspeth, 2016, p. 90-91).
According to the Department of Health and Human Services (2013), 55% of the current RN workforce is BSN prepared. However, this is only an increase of 5 percentage points since 2000 (p. 7). Unless masters prepared nurse leaders focus on the recommendation and make increasing the BSN rate at their organization or in their community a priority, we will fall short of the recommended 80% BSN rate by 2020.
Synthesis of Current Literature
A synthesis of the current literature uncovers several common themes. There is strong evidence of an acknowledgement that the current system of nursing education must be transformed in order to meet the IOM’s recommendation of an 80% BSN-prepared workforce by 2020 (Perfetto, 2015, p. 34). Additionally, the IOM also recommended changes and innovation in the delivery of registered nurse education (Giddens, Keller, & Liesveld, 2015, p. 446). However, there is agreement that the educational advancement of AD nurses has been slow and the country as a whole may not make the 80% BSN by 2020 recommendation. Seamless academic progression from AD to BSN is needed (Perfetto, 2015, pp 34-35). There is an agreement that a BSN is needed to transform healthcare and allow nurses to take on the expanded roles recommended by the IOM. A suggestion seen in the literature is that adding more BSN-prepared nurses to the pipeline will, in turn, add more MSN-prepared nurses which are needed to decrease the shortage of qualified nursing professors and clinical instructors (Peltzer, Teel, Cline, & Cromwell, 2016, p. 44).
A good deal of the literature focuses on identifying the common themes expressed by nurses who are either contemplating or are already enrolled in RN to BSN programs. Perfetto (2015) synthesized thirteen studies and through thematic analysis uncovered seven overarching themes. 1. Many RNs are ready for the challenge to go back to school and advance their education. 2. RNs who enroll in a BSN program expect credit for their years of experience as practicing nurses. College acceptance of their previous AD credits along with the ability to receive credit for experience are major factors in what school RNs chose. 3. There is concern over work-life balance and new demands on nurses that may already be caring for children and/or aging parents. 4. The program must fit in with their life. There must be work schedule flexibility along with class schedule flexibility. 5. Many nurses are looking for the camaraderie of onsite programs and the collaboration and support that comes with attending school in a cohort. 6. Mentorship is desired from faculty, the employer’s professional development department, and fellow nurses. 7. There is recognition for professional and personal growth that comes with academic progression with many studies citing increased confidence, better time management skills, and acknowledgment for use of evidence-based practice (pp 38-40).
There are common barriers as well. Rural areas may lack face-to-face education options. Nurses that have not been in school for a long time may fear technology, the ability to adjust to being a student, and the ability to manage the time it will take to complete the work (Peltzer, Teel, Cline, & Cromwell, 2016, p. 45). Nurses also cite a lack of role differentiation between AD and BSN prepared nurses. Many return to school in order to gain new employment or due to the demands of their current employer, but do not have an understanding of what, if any, practice differences there will be once they graduate (Matthias & Kim-Godwin, 2016, p. 208).
The literature also supports the assertion that hospitals that employ higher numbers of baccalaureate prepared nurses have better patient outcomes. Linda Aiken has done extensive research into the topic of the benefits of having a BSN-prepared workforce. Aiken (2014) notes that the value of employing a predominately baccalaureate workforce points to the benefits in decreasing lengths of stay and readmission rates (cost savings) and improved patient mortality (p. 862). Kutney-Lee, Sloane, & Aiken, 2013 report a 10-point increase in a hospital’s percentage of nurses with BSN degrees was associated with an average reduction of 2.12 deaths for every 1,000 patients (p < 0.01) (p. 582).
The stakeholders in this issue are registered nurses, hospital administrators, and healthcare consumers. The trend toward preferentially hiring BSN-prepared nurses is growing. Pittman, Bass, Hargraves, Herrera, & Thompson (2015) note that there has been a significant increase in the number of employers that prefer to hire a BSN nurse. Nine percent of hospitals in 2010 reported this trend. By 2013, nineteen percent were reporting these hiring practices (p. 94). Healthcare is complex and nurses must be able to meet the challenges by having coursework that includes research, statistics, community based care, leadership, and liberal studies (Haverkamp & Ball, 2013, p. 144). In order for nurses to have an equal partnership with interprofessional colleagues such as physicians, physical therapists, pharmacists, and nutritionists, they must have similar educational preparation. It is imperative for our profession to progress to the level it deserves.
Hospital administrators are feeling the push to increase their proportion of BSN prepared nurses as they look at achieving Magnet® status. The American Nurses Credentialing Center (ANCC,) requires Magnet® accredited facilities to demonstrate their plan to reach the 80% BSN rate recommended by the IOM (ANCC, 2016). Hospital administrators cannot deny the mounting evidence that suggests having a workforce with a higher percentage of baccalaureate prepared nurses leads to better outcomes. In this time of value-based purchasing, hospitals have no choice but to closely monitor their quality indicators and put in place a strong staff that can implement evidence-based best practices to influence outcomes in those areas. One study showed that patients in an urban medical center that receive at least 80% of their care from BSN prepared nurses had significantly lower mortality, lower episodes of readmission and shorter lengths of stay (Winokur, Rutledge, & Hayes, 2016, p. 283). Nurses with higher levels of education equal better outcomes for the most important stakeholder of all—the patient.
Why is This Issue Important?
Snavely (2016) notes: “If America is to continue to be a leader in health care delivery throughout the world, a perpetual supply of highly trained and qualified nursing personnel is essential” (p. 98). Large numbers of nurses are aging and heading toward retirement. While many men have entered the profession over the last two decades, nursing remains a predominantly female profession. Of the 3.5 million RNs in the United States in 2011, 3.2 million were female and 330,000 were male (United States Census Bureau, 2013). Unlike previous generations, today’s women have many choices regarding their careers and vocations. In order to ensure sufficient numbers of educated, professional women are attracted to the profession, the baccalaureate degree should be the preferred entry into the field. Nurses must be elevated to equal standing with our colleagues in finance, law, and education.
Nurses with advanced degrees are needed to work as faculty in nursing schools. Along with a shortage of bedside nurses, there is a shortage of nursing faculty. Over 75,000 applicants that are qualified are turned away from nursing schools because of lack of faculty, sites to do clinical, and less than adequate education department budgets (Nardi & Gyurko, 2013, p. 317). More BSN nurses must be added to the pipeline so that some may progress to the MSN and PhD level and fill critical faculty positions.
The Role of the Nurse Related to Academic Progression
Nurse leaders, with the direction set by their CNO, nurse educators, and clinical nurses themselves must form a triad in order to see progression on this issue. Nurse leaders must provide avenues for staff to return to school by advocating for hospital tuition reimbursement and committing to flexible scheduling. The CNO must make the business case for investing in staff education by linking higher levels of nursing education to better outcomes for patients. Many nurses do not want to go back to school for their BSN because there is no financial benefit perceived. The CNO and Nurse leaders must propose budget requests to increase the rate of pay for nurses with their BSN (Sarver, Cichra, Kline, 2015, p. 154). This can be done with an hourly increase and/or through the clinical ladder or professional advancement program. Many hospitals are requiring baccalaureate preparation to be elevated to the highest or “expert” level. A barrier to return to school that has been identified in the literature is the lack of vision or purpose an organization gives its staff for going back to get a BSN. Often there is no role differentiation and this makes the degree seem less important to some. Different role responsibilities can be incorporated into bedside clinical nurse roles to reward and recognize the BSN (Winokur, Rutledge, & Hayes, 2016, p. 284). The Nursing education department has a unique role. They must act as mentors and facilitators to staff wanting to go back to school. Some nurses just do not know how or where to get started. An innovative idea is to have a one-stop site on the hospital intranet that can house all the appropriate tuition reimbursement forms and policies along with lists of colleges the hospital may have affiliations or tuition agreements with, and contact information for the schools (Sarter, Cichra, & Kline, 2015, p. 155). Seminars and inservices on technology, literature searches, and evidence-based practice would facilitate an atmosphere that demonstrated the hospital’s commitment to helping staff attain their goals.
Nursing peers must support each other in their quest for higher education. CNOs and Nurse leaders can role model academic progression by modeling the behavior. Continuous learning applies to all positions and leaders can achieve MSNs, DNPs, or PhDs. Warshawsky, Wiggins, Lake, & Velasquez (2015), report that hospitals that have CNOs with graduate degrees have a modest association with increased BSN rates, perhaps due to increased value placed on higher education (p. 586). Increasing the BSN rate of staff should be on all nursing strategic plans until we reach and exceed the recommended 80% rate.
The American Nurses Association Code of Ethics for Nurses with Interpretive Statements recognizes the ethical responsibility that nurses have to make contributions through research and scholarly inquiry. ANA (2015) states: “All nurses must participate in the advancement of the profession through knowledge development, evaluation, dissemination, and application to practice” (p. 27). Professional nurses commit to lifelong learning. The ethical responsibility of ensuring you are equipped to take care of patients in an ever-changing healthcare system has many implications. Nurses themselves have a duty to make this commitment.
Nurse educators must employ ethical principles when relating to students. Students rights must be respected and they must be treated fairly. Principles of professional ethics need to be taught to students. The main ethical principles related to the work of a nurse educator, whether it be in a formal school role or unit preceptor, are professionalism, justice, and trustworthiness (Salminen, et al., 2016, pp 19-20).
Current and Future Work by Nurse Leaders
Nurse leaders in education roles are recognizing the need for nurses to further their education. Professors are setting the expectation that the AD is not a terminal degree in nursing and that students must continue their education. AD faculty are responsible for setting the tone and relaying key messages about academic progression and can influence nurse behavior (Peltzer, Teel, Cline & Cromwell, 2015, p. 45).
All nurse leaders should be involved in some sort of advocacy surrounding academic progression for nurses. Formal roles on advisory boards, committees, and professional organizations help drive the movement forward. Political activism to promote the passing of legislation related to academic progression is needed. This activity can involve formal policy making or something as simple as writing key legislators to voice support for an upcoming bill. Even though nurses are the largest sector of employees in healthcare, they have not been quick to exercise political clout. Nursing faculty can serve as role models to students and introduce them to the importance of political advocacy (Zauderer, Ballestas, Cardoza, Hood, & Neville, 2008, pp 4-5).
Aspects of Effective Leadership & Strategies Needed
Effective leaders are students of change. In a rapidly changing healthcare environment, it is critical for nurse leaders to have a strong message and clear purpose. Stakeholders must understand the reasons for the change and be given a reasonable amount of time to adapt (Roussel, Thomas, & Harris, 2016, p. 18). For many nurses, the expectation of a BSN is a big change. Transformational leaders will involve the staff in the decision-making and change process. A good example of this a Nursing Professional Development Council revising the clinical ladder program and having them come to the decision that a BSN is required to achieve Level IV status. This is a decision that is coming from peers and will be easier to accept than a typical “top down” approach. Leaders need to inspire followers to unlock their self-potential through positive behaviors and role-modeling communication of changes is key (Kunnanatt, 2016, p. 33).
Garnering Support for Proposed Solutions
A CNO or other masters prepared nurse leader can gain support for increasing the percentage of BSN nurses in their organization by setting clear expectation and enacting an action plan. Accurate data reflecting the current rate of BSN nurses in the organization is key. A goal for percentage increase should be set realistically, taking into account factors that may affect the organization such as a rural setting, lack of funding available for tuition reimbursement, or a current state of disengagement. Expectations for hiring practices must be set. Job descriptions must clearly state education requirements and be strictly adhered to. There can be no mixed messages and exceptions. Every nurse manager and above will have to hold a BSN at minimum in order to role model the new requirements for clinical nurses. Ongoing tracking and trending of data will be required with regular progress reports on how the organization as a whole and each individual unit is doing meeting the set goal.
Nurses interact with many different professionals, but the nurse-physician collaboration can be the most important, as well as the most strained. The nurse-physician relationship began with hierarchal roots of male vs. female roles and high education vs. vocational training and these barriers continue to exist in many forms today. Organization-wide respect for academic progression in nursing is key and physicians should be supportive to their nursing peers. Ongoing education should be encouraged.
Running Head: ACADEMIC PROGRESSION IN NURSING 1
ACADEMIC PROGRESSION IN NURSING 13aught to students. The main ethical principles related to the work of a nurse educator, whether it be in a formal school role or unit preceptor, are professionalism, justice, and trustworthiness (Salminen, et al., 2016, pp 19-20).
All nurse leaders shoul