At a time when the nation's health care landscape was being transformed and increasing evidence pointed to the need for more highly educated nurses, the Institute of Medicine (IOM) released a landmark report, The Future of Nursing: Leading Change, Advancing Health. Issued in 2010, the report states1:
“Major changes in the U.S. health care system and practice environment will require equally profound changes in the education of nurses. An improved education system is necessary to ensure that the current and future generations of nurses can deliver safe, quality, patient-centered care across all settings, especially in such areas as primary care and community and public health.”
An improved education system must also ensure that the nursing workforce reflects the diversity of the populations it serves.
The Future of Nursing report set an ambitious goal: 80% of practicing RNs should be prepared with a bachelor of science in nursing (BSN) or more advanced degree by 2020. It also cited evidence to support the call for more highly educated nurses,1, 2 and subsequent studies have linked higher nurse education to improved patient outcomes.3-7 The report also provided a blueprint for action to advance nursing education and reframe the conversation around this goal.
The transformation has begun, and the early work to establish a new education infrastructure is described in this article. We also review the activities taking place to advance this complex transformation, including examples of initial progress, challenges, and successes, and a call to action seeking nurses’ assistance in the process.
A NETWORK OF SUPPORT
The need for change is clear: the current education system is not equipped to handle the large influx of students needed to meet the increased demand for highly skilled nurses. It also does not adequately support seamless academic progression, in which a national network of community colleges and universities offers improved access to advanced education.
Students currently have multiple ways they can enter the nursing profession and advance their education. Many RNs begin their careers as graduates of community college associate's degree in nursing (ADN) programs and do not achieve a BSN, master of science in nursing (MSN), or more advanced degree—often because they face insurmountable barriers, such as affordability and access.
In addition to increasing the number of BSN-educated nurses, schools of nursing must also improve their capacity to prepare more graduate-level students who can assume roles in advanced practice, leadership, teaching, and research. Only 13% of nurses hold graduate degrees, and less than 1% hold a doctoral degree.1 Nurses with doctorates are needed to teach future generations of RNs, provide care in advanced practice roles, serve in leadership positions, and conduct research that becomes the basis for improving nursing science and practice. Nurses with graduate and doctoral degrees are needed in direct patient care to meet the growing demand for chronic disease management and health promotion in today's complex health care system. The IOM committee that authored the Future of Nursing report recommends doubling the number of nurses with doctorates by 2020.1 The current rate of academic progression—particularly from the ADN to the BSN—is simply not high enough to meet future needs.
Seamless academic progression. National nursing organizations have been focused on improving access to seamless academic progression programs for some time. In May 2010, the Tri-Council for Nursing—representing the American Association of Colleges of Nursing (AACN), the American Nurses Association, the American Organization of Nurse Executives (AONE), and the National League for Nursing (NLN)—issued a statement on the educational advancement of RNs that included many of the same recommendations outlined in the IOM report (see www.aacn.nche.edu/Education-resources/TricouncilEdStatement.pdf). Leaders in nursing practice, education, and leadership have issued a powerful call to action by focusing on academic progression for all nurses, but it is not enough.
It is essential to build on current resources and structures to ensure that seamless academic progression exists. To this end, leaders of the AACN, the American Association of Community Colleges, the Association of Community College Trustees, the NLN, and the National Organization for Associate Degree Nursing have endorsed a shared goal of academic progression for nursing students and graduates (see www.aacn.nche.edu/aacn-publications/position/joint-statement-academic-progression). This statement emphasizes the common aim of these organizations to foster a well-educated, diverse nursing workforce to advance the nation's health. Building on this imperative by leveraging the successful cooperation between community colleges and university nursing programs will help to transform nursing education and provide the maximum benefit to health care consumers.
Another critical aspect of the transformation of nursing education is the need to produce a nursing workforce that is reflective of the rich diversity of the communities in which nurses practice. Using figures compiled from AACN data,8 the Integrated Postsecondary Education Data System,9 and the U.S. Census Bureau,10 the Future of Nursing: Campaign for Action compared the sex, race, and ethnicity of nursing graduates and found continuing disparities between graduates from both ADN and BSN programs and the populations they serve. As we transform our education system, we must build on the diversity of students in schools of nursing in community colleges and universities while accelerating progress toward specific diversity goals, such as providing patients with a nursing workforce that is similar to them in terms of race, ethnicity, sex, and socioeconomic status.
The need to accelerate academic progression and increase workforce diversity has also captured the attention of philanthropic organizations. For example, the Robert Wood Johnson Foundation (RWJF), the Gordon and Betty Moore Foundation, and the John A. Hartford Foundation have launched programs to boost faculty capacity and diversity and to increase capacity in geriatric care. These programs seek to ensure that enough qualified faculty is available to teach all levels of the nursing workforce.
Building on this growing consensus for change, the RWJF and AARP partnered to establish the Future of Nursing: Campaign for Action in late 2010 to implement the recommendations made in the Future of Nursing report. Although many of these recommendations have been made before at different times by different groups, the Future of Nursing report reframed the conversation. The Campaign for Action has provided the resources and support to move the work forward.
BUILDING AN INFRASTRUCTURE
The Center to Champion Nursing in America (CCNA), a national initiative of AARP and the RWJF, has been improving educational opportunities for nurses and nursing capacity since it launched in 2007.11 It provides assistance to the Campaign for Action's 51 action coalitions, representing all 50 states and the District of Columbia. These coalitions implement the work of the campaign at the state level.12
The CCNA's education work began with 30 state coalitions addressing education capacity. A multistate event was held by the CCNA in Oregon in 2009 to explore nursing education capacity for future workforce needs. Following the release of the Future of Nursing report, the CCNA hosted four regional Webinars in 2010 and 2011, followed by four regional face-to-face meetings to identify what was working in education transformation.
This CCNA education learning collaborative—the concept of which was based on the work of Gajda and Koliba13—formalized a state- and national-level network of nursing leaders and stakeholders, leveraging the 51 action coalitions and facilitating the sharing of resources and lessons learned. Learning collaborative members engaged community colleges, universities, health care providers, and the business community (to include nontraditional employers of nurses) to communicate the value of highly educated and trained nurses.14
Four educational models. After this extensive grassroots outreach, the rich interaction framework of the learning collaborative was analyzed, and four educational models were identified as having the potential to help ensure that 80% of practicing RNs have a BSN or more advanced degree by 2020.
First is an ADN-to-BSN program in which the degree is conferred by a community college. It offers ADN nurses an opportunity to continue their education and receive a BSN in a community college setting. This model can be a less expensive and more accessible alternative to university BSN programs—for both students and financers.
The second model is the competency- or outcomes-based curriculum, in which university and community college partners develop a shared understanding, common goals, and a framework that provides students with a smooth transition from an ADN to a BSN program.
Third is an accelerated ADN-to-MSN program, which offers a shorter timeline to completion than traditional MSN programs. Its popularity has been driven by a shift in the nursing labor market, which now comprises more ADN graduates who are returning to school with the intention of obtaining an MSN. It is an accelerated model that values ADN practice, meets BSN criteria, provides seamless progression, and is university based.
The fourth model is a shared statewide or regional curriculum, which fosters collaboration between universities and community colleges, enabling students to transition automatically and seamlessly from an ADN program in a community college to a BSN program at a university. The schools share a curriculum, simulation facilities, and faculty. The implementation of this model requires adjustments to prerequisite and nursing curricula.15
Forty-four of the 51 action coalitions are working on some aspect of academic progression using these four models, and schools in 30 states are enrolling students in programs that use at least one of the four.
The Academic Progression in Nursing (APIN) program is an initiative of the RWJF—in partnership with the Tri-Council for Nursing and administered by the AONE16—that collaborates with the CCNA, and with the state action coalitions and their partners, to help states move toward their goals. Currently, APIN is supporting nine action coalition projects that are refining and testing these four promising educational models as well as exploring additional innovative practices.17, 18 (To learn about one APIN project, see An Academic-Practice Partnership.)
The CCNA also serves as the national program office for the RWJF's State Implementation Program (SIP), which supports 17 projects focusing on education initiatives. Thus, this powerful national network includes two major programs (SIP and APIN) with focused support for 26 specific projects. (For more information, see http://campaignforaction.org/apin and www.rwjf.org/en/grants/programs-and-initiatives/F/future-of-nursing--state-implementation-program0.html.)
In addition to the strong collaboration between community colleges and universities, the collaboration between entities in academic-practice partnerships is important in ensuring the sustainability of education transformation. Effective academic-practice partnerships, in which educational and clinical practice institutions cooperate to achieve mutual goals, create systems for nurses to achieve educational and career advancement, prepare nurses to practice and lead, and provide mechanisms for lifelong learning.
Employers should use data from a variety of sources to guide them in the development of a balanced mix of strategies and policies that promote academic progression in their workforce. It's especially important that academic-practice partners collaborate in the design and execution of programs to ensure the delivery of high-quality care to meet the health care needs of the communities they serve. APIN advises that in addition to evaluating educational outcomes, the analysis of employer practices, such as providing employees with financial and professional incentives to advance their education, should be part of this work.19 The work of APIN and the AONE has strengthened the active role of practice partners in transforming nurse education.16
Online and simulation education. The explosion of online and simulation education technology has increased nurses’ access to higher education through flexible delivery formats and increased capacity. Online education has increased access for students in rural areas and provided flexible scheduling for practicing nurses.20 The National Council of State Boards of Nursing found strong evidence supporting the use of simulation as a substitute for up to 50% of traditional clinical time.21 Since a lack of clinical practice opportunities is one of the major reasons nursing schools limit enrollment, clinical simulation could increase nursing education capacity significantly. Continuing to maximize online and simulation education strategies is an essential factor in providing nurses with better access to higher education.
An extensive network of stakeholders is sharing best practices and using a common language to describe these promising practices, with the goals of improving the nursing education system and ensuring that all nurses will be prepared to deliver safe, quality, patient-centered care across all settings. Sustaining the momentum, building on practice partnerships, and promoting the appropriate use of technology will be critical in ensuring that real and sustained change occurs.
The barriers and challenges to transforming the nursing education system are varied and complex, but there is currently a powerful drive to find and implement solutions. Both community college and university educators, as well as those working in practice settings, regulatory agencies, state boards of nursing, and professional nursing and education organizations, were convened by APIN in April 2014 in Washington, DC, to develop innovative sustainable solutions. Specific challenges documented in the literature that were discussed include defining national professional education standards,22 rapidly increasing capacity while maintaining quality,23 and reducing and avoiding confusion in the application of accreditation standards. Solutions were proposed for each challenge, and action steps were outlined.
A small group representing community college and university nursing programs, employers, regulators, and grantees were invited to analyze the data and suggest an ideal set of BSN program prerequisites and general education requirements for broader national consideration. A national standard of foundational courses for a BSN was proposed and disseminated, providing a framework for consistency across programs and smooth academic progression. There are wide variations in requirements, particularly for ADN and RN-to-BSN students. Programs can use national standards to ensure consistent professional foundations while streamlining both ADN-to-BSN and RN-to-BSN curricula. Additional bold and innovative solutions and strategies were proposed and will be implemented after further vetting.
Achieving the needed transformation will be a marathon, not a sprint, so it is important to identify markers of success in order to sustain the momentum and keep fatigue and burnout at bay. How we prepare and motivate our professional colleagues in the first step of their education journey will affect each step they take thereafter.24, 25
The first success stories are about people who advanced their education after feeling supported in their initial educational journeys.
Kayla is a home health nurse employed at a county health department who thoroughly enjoys her position and her patients. She believed that her associate's degree education provided her with a strong foundation, yet she also knew that continuing her education “would offer broader opportunities and expand my knowledge level.” She found that scheduling challenges were minimal when pursuing a BSN—she was able to take classes once a week at the hospital where she worked, and many classes were offered online.
Kayla ultimately plans to obtain a school nurse certificate and perhaps a master's degree. The strong partnership between Kayla's ADN-to-BSN and RN-to-BSN programs, coupled with the support of her employer, provides her with a smooth pathway to academic progression, setting the stage for lifelong learning.
Miguel, a retired veteran, developed an interest in nursing as a career after seeing fellow veterans struggle with mental health issues after discharge. Miguel was accepted into the ADN program at the community college he had previously attended. While pursuing his degree, a faculty member who recognized his potential and knew of his interests suggested he consider a future as an advanced practice nurse. This person helped him find a nearby university nursing school that offered an ADN-to-MSN program with a concentration in psychiatric–mental health nursing. Miguel was accepted into the program immediately.
Miguel earned a bachelor's degree while in the program and graduated with an MSN, with the intention of becoming a mental health NP in only three years. Miguel believes that having the option to participate in this ADN-to-MSN program is the only reason he can now care for his fellow veterans in an advanced practice role.
Significant progress has also been made in the number of nurses with doctoral degrees and graduates of RN-to-BSN programs. According to AACN survey data, enrollment in doctor of nursing practice (DNP) programs increased by 21.6% from 2012 to 2013; during that same time, the rate of enrollment in research-focused doctoral (such as PhD or DNSc) programs increased by 1.7%.8 Figures compiled by the Campaign for Action based on this data8 show that the number of graduates from doctoral programs, including DNP and research doctoral programs, have more than doubled, from 1,227 in 2009 to 3,069 in 2013.
The AACN data include the number of graduates of 512 RN-to-BSN programs accredited by the Commission on Collegiate Nursing Education, which increased by 12.4% last year.8 Accelerating this initial progress and sustaining positive change will be the next challenge.
CALL TO ACTION
The nursing profession is coalescing around action steps to meet the urgent need for a more highly educated nursing workforce. First and foremost, nurses should commit to being lifelong learners who seek to attain the highest possible level of education. Now is the time to advance nursing education and take advantage of a renewed emphasis on streamlined curricula, accessible delivery formats, financial support, and employer incentives. Second, joining a state action coalition and at least one professional nursing organization is one way to support the many developments occurring at this time. Finally, nursing colleagues should aim to provide support, mentorship, coaching, and encouragement to one another as they engage in this important work.
There is growing evidence that patients benefit from a more highly educated nursing workforce.3, 5-7 More highly educated nurses can also help to address the shortage of primary care and public health providers, nurse scientists, and nurse faculty; care for an older population with more complex health care needs; and promote wellness.
It's going to take all of us working together to give nursing students—and nurses already in the workforce—more options and opportunities and easier pathways to continue their education. We will all benefit when the nation has the diverse nursing workforce it needs.