Kumm, Sharon MN, RN; Godfrey, Nelda PhD, RN; Martin, David MN, RN; Tucci, Martha MSN, RN; Muenks, Meredith BSN, RN; Spaeth, Tracy MSN, RN
There is an increasing national awareness regarding the need to foster academic progression among all levels of nursing education.1-4 While multiple barriers prevent ADN nurses from progressing seamlessly into BSN degrees, many nurse educators and nursing leaders are invested in reducing those barriers to ensure smooth transition. One major barrier is that no common language exists between accreditation standards and, by extension, in the expected outcomes of the national accreditation organizations within nursing education. This seriously limits conversations intended to clarify what is and what is not considered to be part of ADN or BSN education.
Academic accreditation begins with a discipline-determined set of outcome criteria against which individual programs are measured. In the United States, there are currently 2 groups that accredit schools of nursing: the Accreditation Commission for Education in Nursing (ACEN) and Collegiate Commission on Nursing Education (CCNE). ACEN’s mission is to accredit schools of nursing at many levels, from practical to graduate programs.5 CCNE’s mission is to accredit nursing baccalaureate, graduate, and residency programs.6
It is not unusual for academic disciplines to have more than 1 accrediting agency. For instance, in the accreditation of baccalaureate business schools, there are 3 agencies that the school can choose to use, depending on the focus of the school and mission of the college or university. If credible options for academic progression from ADN to BSN are to be developed, a common language is needed to better understand and compare accreditation standards and outcomes. ADN and BSN educators need a common language to understand what is being taught and what outcomes are expected in each educational pathway. Close7 suggested that alignment of nursing curricula to eliminate repetition and strengthen both ADN and BSN components is a critical step in developing seamless academic progression. The first step in alignment is a review of common content based on an accepted standard such as the American Association of Colleges of Nursing’s (AACN) The Essentials of Baccalaureate Education for Professional Nursing Practice (AACN Essentials).8
Starting the Conversation
In 1 Midwestern state, all eligible public ADN programs and 1 private ADN program are ACEN accredited. Systematic evaluation through accreditation has occurred in these programs for more than 2 decades. This group of ADN schools produces 92% of the ADN graduates in the state.9 In 2012, these 17 ADN programs partnered with 1 university to foster communication about seamless academic progression. This relationship expanded during a follow-up seminar and research study 8 months later, providing a forum for educators to examine which baccalaureate outcomes were being met in ADN programs statewide.
The purpose of this research was to (1) foster better understanding of the BSN outcomes by ADN educators in the state and (2) identify the outcomes that need to be met in the baccalaureate portion of an RN-BSN program. The specific aims of this study were to determine which of the AACN Essentials8 outcomes were fully met, partially met, and not met in ADN programs throughout the state.
Review of Literature
A literature review revealed no description of studies linking state and/or legislative collaborations of nursing programs to directly address systems changes or efficiencies. It is the case, however, that building partnerships and coalitions is a popular approach to bridging the ADN/BSN knowledge gap.10-15 A majority of the literature provides insight into RN-BSN student experiences and attributes, program components, and strategies. Meaningful program curriculum components include teaching strategies, professionalism, critical thinking, problem solving, evidence-based transformational learning, reflective teaching, informatics competencies, leadership, and community-based courses.16-19
A 2012 snapshot study of RN-to-BSN programs shows vast differences in program length and essential curricular distinctions including courses and content, how credits are earned, length of time for completion, grade point average requirements, prerequisite requirements, instructional format, clinical requirements, and evaluation methods.20 These findings support the need for clarification of RN-to-BSN program objectives and outcomes, including standardized evaluative and comparative measurements, an approach to eliminate redundancy, and an experience that meets the needs of students and employers.
Landry et al21 described a study by The Consortium for Academic Access, Leadership Development, Professional Practice, Research-Based Outcomes, Organizational Involvement and Systems Support in response to California legislation that mandated nursing schools assess their curricula to “identify and eliminate content redundancy across nursing programs and thereby reduce a major barrier to AD nurses continuing their formal education.”21(p587) They used curriculum mapping to assess the ADN curricula at 2 community colleges and in the BSN curriculum at 1 state university. Their assessment was based on “sample content” from each of the AACN’s Baccalaureate Essentials.21(p588) Results revealed redundant content between the ADN and BSN programs including health assessment, leadership, and pathophysiology. This redundant content was subsequently eliminated from their ADN-to-BSN program.
The Baccalaureate Essentials for Professional Nursing Practice8 identifies the 3 roles of a baccalaureate generalist nurse: (1) provider of care, (2) designer/coordinator/manager of care, and (3) member of the profession. These roles formed the theoretical understanding for this project. The 9 AACN’s Baccalaureate Essentials are further defined by 109 associated outcomes. As providers of direct and indirect care, nurses are patient advocates and educators, requiring nurses to deliver high-quality care, evaluate care outcomes, and provide leadership in improving care. As designers, coordinators, and managers of care, nurses function autonomously and interdependently within the healthcare team and are accountable for their professional practice and image as well as for outcomes of their own and delegated nursing care. As members of the profession, nurses are advocates for patients and the profession. Nurses are knowledge workers with strong critical reasoning, clinical judgment, communication, and assessment skills.8
A mixed-methods, descriptive approach was used to identify the AACN outcomes8 that are met in accredited ADN programs in 1 state in the United States. To accomplish this, a 1.5-day seminar for the ADN educators was hosted by the university. This facilitated face-to-face conversation and understanding of the research project objectives. Representatives from all accredited ADN programs were solicited, with a specific request for the dean or director of the ADN program and a faculty member familiar with the curriculum to attend. A document containing the 9 AACN Essentials8 and the corresponding outcomes was developed as a survey and distributed to each participant in advance of the seminar.
The author-designed instrument consisted of 114 structured questions, including 5 demographic questions and 109 questions asking if each AACN outcome was met, partially met, or not met in the ADN educator’s program. Open-ended statements provided a means to collect qualitative data about outcomes that were partially met or not met.
After Human Subjects Committee approval, the link to the questionnaire was e-mailed to participants 1 week prior to the conference. During the conference, small groups (6-8 members) of educators from different schools discussed each item on the questionnaire and as a group determined if a particular outcome was met. On day 2 of the conference, after all 109 outcomes had been discussed in small groups of associate degree directors and faculty, participants individually completed the questionnaire. The data were compiled and aggregated to determine which outcomes were met in the ADN programs. All study data were collected and managed using REDCap (Research Electronic Data Capture) tools.22
Demographic and quantitative analyses were completed using REDCap survey analysis tools. These descriptive statistics included frequency tables to convey study results. Analysis of the qualitative data from the comment section was completed using content analysis methods identified by Elo and Kyngas23 and Graneheim and Lundman.24
All 17 nationally accredited ADN programs in the state were represented in the findings. There were 30 educators who attended the workshop and completed the survey; 21 of these were either program deans or directors. Most educators had 16 to 25 years of teaching experience, with a range from less than 5 to more than 35 years.
Outcomes Met by ADN Programs
When analyzing the data, investigators noted the data clustered above 80% and below 70%. Based on this finding, investigators decided to use 80% as the cutoff indicating an outcome was met by a substantial number of ADN programs. This resulted in 42 outcomes being met (See Table, Supplemental Digital Content 1, http://links.lww.com/NE/A148), and 12 outcomes were not met (See Table, Supplemental Digital Content 2, http://links.lww.com/NE/A149), with the remaining outcomes being partially met. Sixteen of the outcomes were met in all of the ADN programs (See Table, Supplemental Digital Content 1, http://links.lww.com/NE/A148).
The majority of outcomes reported as met were situated in 3 of the 9 AACN’s Baccalaureate Essentials: information management and application of patient care technology, professionalism and professional values, and baccalaureate generalist nursing practice. Technology outcomes that were rated as met by 80% of the ADN programs centered on bedside technology, the electronic health record, and information gathering to provide safe, quality care. Twelve of the professional outcomes (86%) were met. Professional outcomes not met related to history of nursing and contemporary issues, solving ethical dilemmas, and lifelong learning. Generalist nursing practice outcomes met focused on providing bedside care. Generalist outcomes not met included assessment of environmental factors, genetics and genomics, providing care in all settings, supervising other healthcare team members, emergency preparedness, and tolerance for ambiguity. Educators provided comments to explain their decisions to mark categories as partially met or did not meet the outcomes.
Narrative Comments About Outcomes
Participants provided narrative comments on how their program partially met or did not meet each outcome. The depth and breadth of the outcomes were frequently cited as the reason an outcome was marked partially met. Examples include the following: “Partially met items reflect the inability to implement or employ these practices within a variety of settings. QI tools are presented, but students do not develop, implement, or evaluate a quality improvement project” (Essential II: basic organizational and systems leadership), and “Our curriculum focuses on assessing patients and families; it does not extend to groups, communities, or populations” (Essential IX: generalist nursing practice).
Narrative comments that follow illustrate how ADN programs met the Essential outcomes in the 3 areas that correspond with the quantitative data. In relation to information management and application of patient care technology, ADN educators explained that their students are exposed to technology and its uses in providing bedside nursing care. This learning occurs in classrooms, clinical learning laboratories, and simulation and clinical sites. One educator reported:
Even though our college is rural and all our clinical sites are critical access hospitals, we have sufficient exposure to the latest technology. Our students use smart IV infusion pumps, syringe pumps, electronic medication administration systems, and electronic medical records.
In relation to professionalism and professional values, educators indicated that professionalism is emphasized in ADN programs from the very beginning and is modeled throughout the program. Professional behavior is expected in the classroom, clinical, and community. One educator reported:
ADN students aptly demonstrate and promote professional standards, ethical behavior, and decision making. They recognize the impact of personal bias as well as impact of attitudes and values across the lifespan. Privacy issues are taught through all levels in multiple course content.
In terms of generalist nursing practice, ADN graduates are expected to be strong bedside nurses, confident in their physical assessment skills. The graduate is expected to be familiar with bedside technologies, recognize and be accountable for unsafe practice, and be comfortable sharing these issues with instructors. One educator reported:
This Essential is the “meat and potatoes” of our curriculum. ADN education trains the generalist nurse. They are educated specifically to be the nurse that goes out into the working world and can “hit the ground running.” Students are able to conduct comprehensive and focused assessment, implement patient-centered care with compassion, demonstrate patient teaching, and implement safe nursing care and interventions. They are expected to create and implement a plan of care and evaluate it.
Topics Reserved for BSN Programs
When asked about topics that would be better taught in a baccalaureate program, many of the educators mentioned the area of community and population healthcare. Evidence-based practice, genetics, quality improvement, finance, and policy were also frequently mentioned as content better taught at a baccalaureate level.
From a mixed-methods research perspective, a substantial number (42 of 109) of the outcomes identified in The Baccalaureate Essentials for Professional Nursing Practice8 are met in ACEN-accredited ADN programs, representing 92% of the state’s ADN nurse graduates. Met outcomes clustered into 3 categories: information management and application of patient care technology, professionalism and professional values, and generalist nursing practice. Content analysis of descriptive data revealed that ADN graduates are expected to be strong bedside nurses who can manage the demands of direct patient care.
These findings are not surprising, given that knowledge, skills, and attitudes in patient care technology, professional values, and the complex aspects of nursing practice itself are rewarded in clinical and future employment environments. Consistent with our findings, Sportsman et al25 report the categories most useful to the practice organizations were provider of patient-centered care and member of the healthcare team. Our results revealed that while ADN education addresses the microsystem directly related to bedside nursing, these ADN graduates are unable to tackle the dynamics of building and maintaining a cohesive nursing unit. Educators in this study report a lack of variety in clinical settings and clinical populations. Some students were not able to experience a realistic patient load in clinical settings because of a low census at their clinical sites and had limited interaction with diverse populations.
Findings from this research support the AACN’s Baccalaureate Essentials8 as the theoretical framework in effectively explaining the 3 roles of the baccalaureate generalist nurse as provider of care, designer/manager/coordinator of care, and member of the profession. The provider of care role also may correspond with the ADN educational outcomes identified in this study (information management and patient care technology, professionalism and professional development, and generalist nursing practice). This connection could prove useful in providing language to increase the understanding of the ADN and BSN educational outcomes. The roles of designer/manager/coordinator of care and member of the profession may correspond with the remaining 6 AACN Essentials categories not met in this study.
Knowing what is taught in ADN programs, BSN educators can construct outcome-based, value-added RN-BSN programs that contain the remaining 67 outcomes, predominantly in the 6 areas that ADN programs reported they do not teach: (1) liberal education; (2) basic organizational and system leadership for quality care and patient safety; (3) scholarship for evidence-based practice; (4) healthcare policy, finance, and regulatory environments; (5) interprofessional communication and collaboration for improving patient health outcomes; and (6) clinical prevention and population health.
While reliable data on differentiated practice among new ADN and new BSN graduates have been hard to capture,25,26 some of the work completed by Texas research shows congruence with the findings of this study. Hooper et al26 place the Texas BSN Differentiated Essential Competencies in 4 broad categories: leadership and management skills, expanded clients (communities and populations), broadened perspective of interdisciplinary collaboration, and utilization of research findings. It is of note that these 4 areas correspond with the data from this study. The lack of evidence-based information regarding differences in ADN and BSN educational outcomes negatively affects seamless academic progression.20,25-27
A common language in understanding ADN and BSN educational outcomes can provide the research foundation for Hooper and colleagues’26 recommendation that “RN-BSN programs should include a specific course or content related to role differences and effective role-transition experiences commensurate with traditional BSN programs and in compliance with accrediting guidelines.”26(p37)
Both BSN and ADN educators gained new insights from this research project. One ADN educator summed up the benefits of this collaboration: “This was a valuable exercise to better understand the BSN curriculum by taking a reflective look at our ADN curriculum. We need to embrace the similarities and provide an intelligent, evidence-based approach that allows our students’ academic movement through programs and degrees.”
This study was completed in 1 state where all of the public ADN programs are nationally accredited. These findings may not be generalizable to states in which the majority of ADN programs are not nationally accredited and thereby systematically evaluated against a set of nationally recognized standards.
ADN nurse educators examined the outcomes from AACN Essentials of Baccalaureate Education8 and determined that 42 of the 109 baccalaureate outcomes were met in the accredited ADN programs in their state. The majority of the met outcomes were in the areas of information management and application of patient care technology, professionalism and professional values, and generalist nursing practice. The 67 baccalaureate outcomes reported not met in ADN programs provide the evidence needed to construct outcomes-based RN-to-BSN curricula.
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