Safe Table Forums
Safe Table Forums
Moving from ADN to BSN:
What Works for Washington RNs?
Briefing Paper &
Forum Follow-up
Cate Clegg-Thorp, MPH Patricia Lichiello, MAUniversity of Washington Health Policy Center
Number 18 June 12 and 13, 2013
University of Washington Health Policy Center 4333 Brooklyn Ave NE, 14th Floor
Seattle • WA 98195-9455
University of Washington School of Public Health Department of Health Services
This briefing paper is supported through a collaboration with the University of Washington Center for Health Workforce Studies, with financial sponsorship provided by the
Washington Center for Nursing through a grant from the Robert Wood Johnson Foundation Academic Progression in Nursing initiative.
accalaureate-level education for practicing nurses has been the topic of vigorous discussion and debate for several decades. The conversation was opened in 1965 by the American Nurses Association (ANA) when it called for a distinction between professional nursing practice – a Bachelor of Science in nursing (BSN) – and technical nursing practice, which includes either an Associate Degree in Nursing (ADN) or a Nursing Diploma. The ANA recommended the baccalaureate degree as the minimum preparation for professional nursing practice to ensure that the profession was in a position to meet nursing practice changes, including “major theoretical formulations, scientific discoveries,
technological innovations, and the development of radical new treatments.”1
By 2001, professional nursing organizations such as the American Association of Colleges of Nursing and the National Advisory Council on Nurse Education and Practice were still making the case for increasing the numbers of baccalaureate-educated nurses – as well as for considering the BSN as a minimum requirement for professional practice.1 Today, the Patient Protection and Affordable Care Act (ACA) is giving added impetus to the nurse academic progression conversation. The ACA is challenging the U.S. health care
system to find new, improved ways to provide patient-centered and evidence-based care
that is seamless, affordable, accessible, and of high quality. To achieve this transformation various components within the health system will need to be restructured. This includes a re-evaluation of the roles, responsibilities, and relationships within and across many health care professions and practice settings.
Nurses are in a strong position to be leaders in helping this transformation move forward. In its 2011 report, The Future of Nursing, the Institute of Medicine (IOM) observed that nurses’ “regular, close proximity to patients and scientific
understanding of care processes across the continuum of care give them a unique ability to act as partners with other health professionals and to lead in the improvement and redesign of the health care system and its many practice environments.”2 The IOM asserted that realizing the nursing profession’s full potential to help improve both the health care system and its outcomes will require transforming the work
environment, scope of practice, education, and even number of America’s nurses – and nurses already comprise the largest portion of our nation’s health care workforce.2 The IOM noted that nurses must be encouraged, educated, and mentored to become leaders within the
B
Nurses...are poisedto help bridge the gap between coverage and access, to coordinate increasingly complex care for a wide range of
patients, to fulfill their potential as primary care providers to the full extent of their
education and training, and to enable the full economic value of their
contributions across practice settings to be
changing health system, and must apply these competencies collaboratively across health care and other appropriate settings and professions.2
Baccalaureate-Level
Nursing Education
Other comparable health professions in the U.S., such as medicine, social work, pharmacy, and occupational and physical therapy, require at least a baccalaureate degree. Although nursing has established a firm basis of professional knowledge through nursing science, it does not currently require a baccalaureate degree, even while nursing education in other countries is moving to the baccalaureate level.1,3 A baccalaureate-level degree can better prepare nurses to meet the demands of a changing health care system. The IOM observes, for example, that a baccalaureate-level education gives the profession a stronger foundation to advance nursing science, and provides nurses the tools they need to position themselves “to be effective change agents and to adapt to evolving models of care.”2The proportion of nurses in the U.S. graduating with a pre-licensure BSN degree has seen some increase in the past 10 years. In its 2008 National Sample Survey of Registered Nurses, the U.S. Health Resources and Services Administration reported that
between 2005 and 2008, nurses graduating with a pre-licensure BSN degree rose from approximately 31 to 34 percent. This proportion was essentially unchanged from the period 2001-2004, but was higher than the rate for nurses who graduated with a pre-licensure BSN in 1996 (26 percent).4 The National League for Nurses reports a similar proportion for the three-year period from 2005 to 2008 among pre-licensure BSNs: a steady 37 percent (36.9, 36.6, and 36.5 percent, respectively).5 In 2008, the total proportion of practicing nurses with a BSN degree or higher (including both pre-licensure BSNs and RN-to-BSN nurses) was 50 percent – a marked change from 43 percent in 2000.4
Suggested Benefits
of a Baccalaureate
Education for the
Individual Nurse
Commonly cited benefits accruing to nurses who receive a baccalaureate degree include: • A wider range of nursingcompetencies. BSN programs offer nurses additional
education in caring for patients along with education in health policy, health care financing, systems thinking, leadership, and quality improvement.2 Educators, practitioners, and employers cite the need for enhanced skills in interprofessional
collaboration, community/ public health nursing, clinical reasoning, information literacy, and critical thinking competencies that are all emphasized in BSN programs.6,7,8,9,10,11
• Increased opportunities for employment. The BSN is becoming the preferred degree for registered nurses (RNs). For example, the IOM reports that health care organizations are increasingly requiring BSNs for entry-level positions, especially for new graduates hired into acute-care settings.2 The IOM also notes that community and public health settings have for many years preferred the BSN as a minimum requirement for nurses.2
• Opportunities for career expansion. The baccalaureate degree is required for entrance to graduate education which opens the door to advanced nursing roles in education, program/organizational leadership and management, clinical practice and research. Graduate education prepares nurses to expand their careers and advance the IOM recommendations including: improving nursing education; providing opportunities for nurses to assume leadership positions and to serve as full partners in health care redesign and improvement efforts; and improving data collection for workforce planning and policy making.2
• Increased opportunities to work in federal
employment. The Veteran’s Administration, which is the nation’s largest employer of registered nurses, has made the baccalaureate degree the minimum requirement for nurses to be promoted beyond entry-level positions.3 The U.S. Army, Navy, Air Force, and Public Health Service all require a baccalaureate degree to practice as an active duty RN.3
• Higher job satisfaction. Several studies conducted in the mid-1990s and early 2000s suggest that higher education for nurses can lead to higher retention rates and job satisfaction. For example, a study by Rambur et al. in 2005 found that baccalaureate-level nurses were more likely to report higher job satisfaction specifically related to opportunities for autonomy and growth, and that they were more likely to remain in practice longer than other nurses.12
• Positioning for possible changes in licensure requirements. Stakeholders continue to be engaged in discussions about regulatory practices and licensure requirements for registered nurses.1 The 2008 Master Plan for Nursing in Washington State recommended ensuring that “all RNs newly licensed in Washington State hold
or obtain a BSN within 10 years of initial licensure, beginning in 2020.”13 In 2012 the National Council of State Boards of Nursing reported that discussion or actual initiatives for a “BSN in Ten” are in progress in 25 states. Two states, New York and New Jersey, have had legislation pending since 2011 and 2012, respectively.14
Benefits of a
Baccalaureate-Educated Nurse Staff
for Patient Outcomes
At the time The Future of Nursing was published in 2011, the IOM and other experts agreed that more research was needed to establish whether and how nurse education level and patient outcomes were related. The IOM observed that a “causal relationship between the academic degree obtained by individual RNs and patient outcomes is not conclusive in the research literature.”2 Since the report’s release, additional research has been published in the peer-reviewed literature that provides support for earlier, smaller studies on this topic. These findings suggest that hospitals with higher percentages of BSN prepared nurses in their aggregate staffingwere associated with lower mortality and failure-to-rescue rates.* For example:
• A 2011 study by Kendall-Gallagher, et al. found lowered mortality and failure-to-rescue rates among general, orthopedic, and vascular surgery patients who were cared for by nurses who held a specialty certification and also were BSN-educated. In the absence of the baccalaureate education, the researchers found certification to have no effect on outcomes.15
• A 2012 study by Aiken et al. examined data from 655 hospitals in four states: California, New Jersey, Florida, and Pennsylvania. The researchers found that increased percentages of BSN-educated nurses were directly associated with lower mortality and failure-to-rescue rates among patients.16
• A 2013 study by Blegen et al., which analyzed data from 21 hospitals, found that among hospitals with higher ratios of BSN-educated nurses, patients had shorter lengths of stay, lower rates of heart failure-related mortality, decreased bed sores (decubitus ulcers) and failure-to-rescue rates, and a decreased chance of post-operative deep vein
*Failure to rescue means failure to prevent a clinically important deterioration, such as death or permanent disability, from a complication of an underlying illness (e.g., cardiac arrest in a patient with acute myocardial infarction) or a complication of medical care (e.g., major hemorrhage after thrombolysis for acute myocardial infarction). (Source: AHRQ Patient Safety Network: http://psnet.ahrq.gov/popup_ glossary.aspx?name=failuretorescue)
“I do not feel it’s worth it. I have a management level
job and feel I have a strong knowledge
base.”25 thrombosis or pulmonary
embolus.17
This more recent evidence begins to offer a picture of an association between BSN-educated nurses and the health outcomes of hospitalized patients. Additional research could strengthen the evidence for such an association.
Barriers to Increasing
the Number of
BSN-Educated Nurses
Barriers to achieving a BSN degree arise at both the health system and individual level. System-Level Barriers• Patient outcomes. A stronger evidence base for a causal relationship between a BSN-level of education and patient outcomes would help support the professional argument – made to potential students, practicing nurses who do not have a baccalaureate-level education, current and potential employers, and health system colleagues – for attaining this education level.2
• Capacity. The current capacity of nursing schools cannot meet existing demand. The American Nurses Association reports that almost 60,000 qualified nursing school applicants were turned away in 2009.18 The IOM reports that a deficit in the supply of qualified faculty contributes to this capacity issue.2
• Geography. The location of BSN programs can be difficult to access for some potential students. For working nurses, an inability to access a nursing program near where they work or live can be a significant barrier to pursuing an advanced degree. The majority of BSN programs in the U.S. are located in highly populated urban areas. In Washington State, for example, the nursing education system is mostly concentrated in the Puget Sound region.13 The IOM reports that fewer nurses who practice in geographic areas distant from nursing programs hold BSN degrees. Research indicates that the distribution of BSNs is much lower in rural and medically underserved areas than in urban areas.2
Individual-Level Barriers • Value. Nurses’ perceptions
of the value of a BSN-degree are mixed. Various studies have found that while some nurses are highly motivated to achieve a BSN, others are not. A 2011 meta-analysis of 28 published studies on nursing attitudes toward returning to school for a BSN identified common personal and professional motivators among RNs who valued a BSN education. Improved self-esteem, for example, was a personal motivation for nurses to return to school. At a professional level, improved
clinical judgment and career mobility motivated RNs to return to school.
The study author also identified significant personal and professional disincentives for obtaining a BSN education. These included a belief that a BSN degree would not enhance clinical skills or would not benefit RNs in terms of salary increases or different treatment at work. In her meta-analysis, the author notes that she agrees with observations of other researchers on this topic: more rigorous research is needed to measure the attitudes and perceptions of registered nurses on returning to school for a BSN degree.19
• Compensation. Salaries among nurses with BSNs are not always higher than those of their nursing colleagues with an ADN or a nursing diploma, even though a BSN-level education requires more schooling and incurs more costs to the student.2 A 2006 study that examined several questions regarding cost and value of BSN-level education found that although earnings may be slightly higher among BSNs as compared to their ADN counterparts, overall the “costs of the BSN degree are greater than the cumulative increased earnings over the course of the nurse’s subsequent work life.”20 • Cost. The cost of a BSN
education can be prohibitive. The IOM points out that costs for potential students include both the costs for the educational program itself and the fiscal effects on the student’s living expenses. Costs for educational programs differ depending on the type of program; for example, an LPN (licensed practical nurse) degree is the least expensive to attain, followed by ADN, then the BSN-accelerated program, traditional BSN track, Master of Science in Nursing, and PhD/Doctor of Nursing Practice.2
• Time. For nurses currently in practice, work schedule and a need to maintain employment can hamper their ability to enter a traditional university-based BSN program.
Complicating factors for their work schedule include shift work, taking on extra shifts, and working overtime hours. Shiftwork, by its nature, can prevent a nurse from attending class on any given day or week.21,22
Ways to Increase BSNs
in the Workforce
In addition to creating more educational pathways, there are several other approaches for facilitating nurses advancement from an ADN or LPN to a BSN degree or higher. They involve transforming existing educational programs by reducing the barriers of access, Magnet Hospitals
Hospitals in the U.S. that aim for the Magnet Status desig-nation, which is
awarded by the American Nurses Credentialing system, require all nurse managers and nurse leaders to hold a baccalaureate or graduate degree in nursing by 2013.3 Hospitals with Magnet Status also are required to “provide nurses with opportunities to advance their education in an efficient manner in terms of time, cost and benefit for growth” and provide on-site educational advancement opportunities to encourage professional growth and excellence in care.26
including geographic location and enrollment capacity; educa-tional cost; and teaching pool. • Expand distance-learning programs. Distance learning is a common approach across many disciplines for increasing access to higher education. Distance learning has been viewed as an especially valuable tool for nursing education, to increase accessibility particularly for the ADN and diploma-prepared RNs. This educational approach also is an important option for individuals seeking a BSN in rural and underserved areas.23 Three examples illustrate this strategy:
Washington State University (WSU) offers multiple study options for RNs to continue working while completing
the requirements for a BSN degree from their location of residence. The program, which is offered at all five WSU College of Nursing locations, combines online and in-person instruction and allows part-time, full-time, or individual plans of study to complete program requirements.24
New Mexico instituted distance learning for BSN programs in order to offer increased accessibility for nurses in remote locations and to increase the overall level of BSN-prepared nurses in the state. The distance-learning partnership program uses interactive television, Internet-based Web courses, classes offered one day each week, the ability to complete nursing courses within nurses’
home communities, and the ability to accommodate working nurses’ schedules with advanced planning. The program successfully graduated over 100 nurses in its first three years.23
Western Governors University offers an online RN to BSN program in Washington State that has been regionally accredited by the Northwest
Commis-sion on Colleges and Universities – the same accreditation commission that has endorsed major institutions such as the University of Washington (UW) and the University of Oregon. This program is competency based, where credits are earned through the completion of assessments, virtual reality simulations, and in-person clinical rotations.25
Eye on Washington State: Pathways from the ADN to the BSN
To increase the overall number of BSNs in the workforce, RNs with an ADN or diploma need to be able to access educational pathways. Existing options for ADNs in Washington State include:
Community College-University Articulation Agreements. All community colleges in Washington State have at least one formal articulation agreement with an existing State-approved, university-based RN-BSN program.27
1+2+1 Model. UW Bothell and Everett Community College are planning to offer a 1+2+1 program, which allows students to complete one year of pre-requisites at UW Bothell, complete a two-year pre-licensure RN program at Everett Community Col-lege, and return to UW Bothell to complete the BSN degree.
Community Colleges Offering BSNs. As of April 2013, one approved community college-based program exists in Washing-ton State as a joint creation of the UW Tacoma and Olympic College.29 Programs at Bellevue and Wenatchee Valley Colleges
are under development, and additional community colleges have expressed interest in creating programs at other locations.
Dual Admission/Enrollment. Dual admission/enrollment in ADN and BSN programs allows for a seamless transition from the ADN to the BSN. Students are admitted to the ADN program and complete and take the NCLEX-RN (National Council Licensure Examination for Registered Nurses) exam. They simultaneously have admission to the BSN program so they can move directly into it.13
LPN to BSN programs. Pacific Lutheran University in Tacoma is the only educational institution in the state, thus far, to offer an LPN to BSN program, but these programs are not uncommon in other states.13
• Expand BSN programs offered at the workplace. Offering BSN-level nursing programs or classes on site can reduce the barrier of distance to nursing programs. Evidence suggests that providing classes in hospitals supports working adults in their ability to participate: for example, they can take classes and continue to work part-time.2 Programs in Washington State, Arizona, and Minnesota illustrate this strategy:
In Washington State, univer-sity RN-BSN programs are offered at employment and Community College campus sites. For example, Seattle Pacific University offers such a program at Group Health Cooperative and Valley Medical Center in Renton. UW Bothell offers a program at Skagit Valley College and Everett Community College. UW Tacoma offers a program at Providence St. Peter Hospital in Olympia. And Washington State University offers one at Yakima Valley College and Walla Walla Community College, in addition to programs at WSU campuses in Spokane, the Tri-Cities, and Vancouver.
Carondolet Health Network in Tucson offers an onsite BSN program that subsidizes students in exchange for a two-year work commitment. The Network anticipated an initial enrollment of 20
students and instead admitted 104.2
Project Advancing Nurses’ Wisdom is a partnership between a university, hospital, and nurses association in Minnesota to offer an on-site baccalaureate completion program for RN employees. The program offers classes during weekday evenings on site. The majority of program costs are kept low through cost sharing by the university and the hospital, a collective bargaining unit-negotiated tuition reimbursement
program, and hospital-offered interest-free loans.26
• Collaborate across educational settings. Community colleges play an important role in offering educational opportunities to students who may not have access to traditional university baccalaureate programs. They are the predominant educational institutions in rural and medically underserved areas.2 The IOM suggests that community colleges can help ensure pathways to the BSN degree in three key ways: 1) join collaboratives across educational settings, 2) develop innovative and easily accessible programs that link students to schools offering a BSN degree, and 3) develop their own BSN programs.2 • Provide incentives for
nurses to become faculty.
In order to expand faculty pools for teaching and turning out more BSNs, nurses with credentials to teach need incentives to do so. Salaries for advanced nurses in clinical settings far exceed their counterparts in teaching positions. Hence, the IOM suggests offering a monetary incentive to educate and become educated appropriately in order to teach.2 An example is the congressionally directed grant awarded to UW Bothell that funded scholarships to 30 Master of Nursing students who were teaching at least part-time in partner community and technical college programs.
Conclusion
BSN-prepared nurses can offer a significant contribution in knowledge and leadership to our rapidly evolving health system. Achieving a BSN also can benefit nurses themselves, in that the degree offers increased competencies, employment and career opportunities, and can position nurses for any new licensure changes that may develop. Barriers to achieving a BSN, though numerous, are amenable to change. Creative ideas are already reducing their size and extent. And the small but intriguing evidence base suggests that expanding the pool and reach of BSN-support strategies could catalyze real growth in BSN-prepared nurses.
n June 2013, stakeholders interested in the future of baccalaureate-level education for practicing nurses in Washington State participated in a Safe Table Forum offered on two successive days: first in Eastern Washington (Spokane, June 12), and again in Western Washington (Tukwila, June 13). These forums provided an opportunity for participants to engage in cross-sector learning, conversation, and thoughtful problem solving on the topic of BSN education in the nursing profession. The forums were sponsored by the Washington Center for Nursing through funding from the Robert Wood Johnson Foundation’s Academic Progression in Nursing
Initiative (APIN). Both forums were cohosted by the University of Washington’s Center for Health Workforce Studies and Health Policy Center.
Forum participants represented an array of perspectives and organizations, including nursing students; educators from
Washington State universities and community and technical colleges; employers from Washington hospitals, health systems, and community health centers; government health-related agencies; community-based organizations; and practicing nurses representing Washington hospitals, health
I
June 12 & 13, 2013
Safe Table Forum Findings
systems, and labor unions. The proportion of participant types varied between the two forums. For example, the Spokane forum had more students and fewer nurse employers, while the Tukwila forum had fewer students and more employers. The Tukwila forum also had representatives from nursing organized labor, which was not represented in Spokane. The forums offered three ways for participants to share information and ideas: expert presentations that included time for questions and answers, small group discussion, and large group report-out and discussion. The goal was to offer participants a variety of opportunities to share knowledge and ideas across varied backgrounds and perspectives, and to begin to build collective wisdom on the future of nursing baccalaureate-level education in Washington State.Each forum began with two presentations that provided context for the issue, the first from a national perspective and the second from a Washington State perspective (see box on page 10). After engaging in question and answer dialogue with the speakers, participants worked in pre-assigned small groups. Each group comprised
Forum Speakers Pat Farmer, DNP, FNP, RN Nurse Expert, Center to Champion Nursing in America Campaign Academic Progression in Nursing: An Overview from the National Per-spectives
Peg Currie, MS, BSN (Spokane)
Vice President
and Chief Nursing Officer, Providence Sacred Heart Medical Center, Spokane
Academic Progression from RN to BSN: An East-ern Washington Regional Perspective
Kim Williams MS, RN (Tukwila)
Chief Nursing Officer and Interim COO,
Providence Regional Medical Center Everett
Academic Progression from RN to BSN: A West-ern Washington Regional Perspective
one of three types of participant: nurse educator, nurse employer, and practicing and student nurses. Within their groups, participants considered and responded to four discussion questions. Each question asked for the same information across all three types of participant, but was tailored to each of the perspectives they represented. The themes of the questions were:
For practicing nurses, nursing students, and nurse employers: 1. What are the benefits gained
from nurses acquiring a BSN degree?
2. What are the disincentives to nurses acquiring a BSN degree?
3. What is needed from employers and academic programs to support nurses in enrolling in and completing a BSN program?
4. What kind of community support do nurses need to enroll in and complete a BSN program?
Page 16 offers a table listing the specific questions for each type of participant.
As they worked in their small groups, participants recorded their ideas on flip charts. They understood that they could choose what to record from their conversation and what they would not record: that is, the parts of the conversation
that would essentially remain in the room. The forum speakers circulated among the groups to offer their thoughts and answer questions. At the close of the small-group session, participants and speakers came together in the full group to share what they had discussed. The forum hosts took notes during this large-group discussion; participants could see the notes on a large overhead screen and could request that their comments not be recorded.
Forum Conversations:
Common Themes
Regarding Benefits,
Disincentives, and
Supports
Several common themes emerged from small-group and large-group participant conversations across both forums. These themes are summarized below and presented in Tables 1-4.
Common Themes Regarding Benefits
A BSN degree can offer enhanced high-level skills in three areas: leadership, working with interdisciplinary teams, and systems thinking. The academic work involved in acquiring a BSN also offers nurses an increased level of professionalism and credibility, and enhances nurses’ confidence and self-esteem. Higher education also offers
nurses increased employment opportunities and career mobility.
Common Themes Regarding Disincentives
Disincentives for individual nurses include the financial burden of returning to or beginning school (for example, tuition expenses, loss of time status, loss of full-time employee benefits); the inaccessibility of available programs due to location or competitive admissions; and lack of a clear understanding of how a nurse will benefit by earning a BSN degree – especially when the nurse already is highly experienced. Disincentives noted in both forums specifically by practicing and student nurses included the lack of easily accessible information on available programs, an inability to assess the differences and similarities across programs, and challenges in navigating financial aid resources. They also noted that some practicing nurses feel threatened with loss of employment because they do not have a BSN; these nurses can feel devalued and as a consequence, can be more resistant to wanting to return to school.
Disincentives noted specifically by employers included staffing challenges, including shift coverage and tension between
staff with different education levels; costs associated with tuition and benefit coverage; and the risk of losing nurses once they’ve earned their degree. Themes Regarding Employer, Community, and Colleague Support for the BSN
Working nurses who enroll in and complete a BSN degree program need flexible scheduling, both in their workplaces and in the educational program’s instructional offerings. These nurses also need to maintain full-time employee benefits. Conversely, employers have their own support needs. They need help in developing enhanced partnerships with academia, and in finding ways within the community, government, and the nursing profession to increase scholarship and financial aid to support their nurse staff students. They also need to hold larger conversations with executive-level leadership, other health care providers (including doctors), and academia to enhance everyone’s mutual understanding of the importance of higher education among nursing staff.
A statewide central,
comprehensive, and neutral repository for information on educational pathways, programs, and fiscal resources would address Washington
State’s lack of clarity in, and information about, the variety of nursing degree programs available and their delivery methods. Nursing BSN students also need financial aid and scholarships, tutoring and mentorship programs, childcare support, and technical assistance. The nursing profession could offer more positive messaging regarding the BSN degree. In addition, the case for a BSN degree needs to be targeted not just to nurses but to other health professionals as well – and even to family members.
Summary Tables
The two forums generated themes in common, as summarized above, as well as some ideas and points of discussion unique to a particular small group – nurse educator, nurse employer, and practicing and student nurses – in one or both of the forums. The conversations in both forums repeatedly highlighted the need for collaboration, open communication, and generation of collective knowledge across all stakeholders in order to most effectively address the issues regarding baccalaureate-level educational pathways for practicing nurses.The following tables offer a full summary of themes that emerged, by discussion question, in each forum.
“A BSN Education enhances nurses’ skills
and abilities beyond providing basic patient care; fosters
skills in leadership, systems-thinking,
health policy, problem-solving, and moving patients along
A BSN education:
• Increases the leadership pool and positions more nurses for progression to advanced levels of education (such as MSN, nurse educators, etc.)
• Enhances nurses’ skills and abilities beyond providing basic patient care; fosters skills in leadership, systems-thinking, health policy, problem solving, moving patients along the continuum of care
• Provides a bigger picture or larger scope of understanding of nursing as a discipline • Provides better communication and teamwork skills
• Provides nurses with more credibility, more respect from interdisciplinary teams, and increased professionalism
• Allows for increased career mobility, employment opportunities, and possibilities for advancement • Can lead to increased self-confidence, self-esteem, and personal satisfaction
• Offers more opportunity to be part of leadership conversations, and an increased ability to change the culture of the institution and be a part of practice improvement
A BSN education:
• Supports navigation of increasingly complex patients • Encourages a culture of life-long learning
A BSN education:
• Generates better patient outcomes (Spokane & Tukwila)
• Helps facilities achieve Magnet Status and awards in the American Nurses Credentialing Center’s Pathways to Excellence program (Tukwila)
• Increases nurses’ ability to work in and understand the value of interdisciplinary teams (Tukwila) • Increases understanding and application of evidenced-based practice and research (Tukwila) • Benefits facilities that host student projects for BSN or MSN programs (Tukwila)
• Reduces health care costs when there’s a BSN-prepared workforce (Tukwila) • Offers financial gains for nurses with BSN (Tukwila)
A BSN education:
• Exposes students to a variety of practice settings and more opportunities to gain from the experiences of others (Spokane)
• Increases nurses’ ability to work in and understand the value of interdisciplinary teams (Tukwila) • Allows students to explore their interests in nursing within a broader academic environment (Tukwila) A four-year BSN program:
• Offers a pathway to the BSN with fewer pre-requisite barriers (Spokane) A BSN education:
• Increases understanding and application of evidenced-based practice and research (Tukwila)
Table 1
Benefits of a BSN-Level Education
THEMES HELD IN
COMMON
Across groups
and locations
NURSE EMPLOYER
THEMES
In each location
PRACTICING &
STUDENT NURSE
THEMES
In each location
NURSE EDUCATOR
THEMES
In each locatio
n
THEMES HELD IN
COMMON
Across groups in
Spokane
Table 2
Disincentives for BSN-Level Education
• Differentials in education level among staff or management-level nurses may lead to tensions, hostility, or negativity on the team
• Serious financial considerations for nurses going back to school or entering BSN-level programs, including costs of tuition, lack of financial assistance, reductions in FTE leading to fewer overall earnings and reduced benefit coverage, no clear understanding of financial benefit with BSN-degree
• Challenges with meeting program pre-requisite requirements (especially statistics), an inability to transfer credits, and an inability to earn credit for work experience
• Lack of available support systems, such as: meeting childcare needs, flexible scheduling from employers, and tutoring
• Inaccessibility of programs – entry into programs is competitive and overall is not as available in rural locations
• Creates staffing issues; with more nurses in school now, they become less available to work the hours needing coverage
• Creates financial impact for institution: costs of reimbursing for tuition, bringing programs on-site; cost of benefits for nurses working less than full time; meeting expectations for higher pay once BSN is earned • Risk of losing employees to another institution or within the organization once BSN is earned – no pay-off for
investment at facilities
• Creates legal issues if nurses fail to comply with retention agreements for receiving education support (Tukwila)
• Impact on quality of work for nurses enrolled in school; may be doing school work at work (Tukwila) • Limited resources available to offer staff (Tukwila)
• With increased numbers of new graduates through preferential hiring, facilities may lose inherent and institutional knowledge of experienced nurses (Tukwila)
• A BSN-degree is not required for employment during times of inadequate nursing supply (Spokane) • Age of nurse can dissuade desire to go back to school; a feeling of isolation in one’s cohort due to age and
experience (Tukwila)
• Lack of access to clinical placements and technology (Tukwila)
• Lack of diversity in higher degree programs; educators may need more training in cultural competency and inclusion (Tukwila)
• Stress of going back to school; impacts on family-life-work balance
• Lack of easily available information to navigate program options or features, funding sources, or resources for educational planning
• Threats of losing job increases resistance; experienced, practicing nurses who are faced with losing their job because of the lack of a BSN degree feel devalued, and thus resistant to wanting to pursue a higher degree • BSN degree recruitment and admissions tactics feel like “used cars salesmen” – high-pressure “sales” of
programs cause fear of exploitation (Spokane)
• Will the BSN actually provide nurses with more credibility in the workplace? (Tukwila)
THEMES HELD IN
COMMON
Across groups
and locations
NURSE EMPLOYER
THEMES
In each location
NURSE EDUCATOR
THEMES
In each locatio
n
PRACTICING &
STUDENT NURSE
THEMES
In each location
• Flexibility in programs, times, locations, delivery methods (online vs. in person) provide non-traditional approaches for non-traditional students
• Positive messaging around earning a BSN – returning students need to feel valued, not depreciated • Need real differential in pay scales and defined practice roles between BSNs and non-BSNs
• A centralized system to access comprehensive information on BSN programs in Washington State: for example, approved program options, outlined similarities and differences between programs, funding sources, how to navigate application process. Have this system maintained by a neutral party.
• Provide more financial aid and academic advising, mentorship, counseling, and tutoring (statistics, writing, technology, etc.)
• Standardize nursing school requirements
• Create more robust competency measures and outcome assessments for nursing students, more evaluation/ research on how practice changes from pre- to post-BSN education
• Financial support: more federal funds; increased grant opportunities to fund education and practice programs; make funds available through health care reform; increase subsidies for nursing care (Medicare); create creative internal opportunities to fund nursing education, e.g., secure funds through board
organizations or hospital foundations, or allow donation of paid time off to be converted to education funds • Enhanced partnerships: with academic intuitions and other employers to enhance academic programs, e.g.,
provide
more classes on-site, host faculty office hours, streamline program requirements/needs with employer requirements/needs
• Help with educating staff on value of BSN: education at organizations is needed to bring a shared understanding of why BSN-degree is desirable. Groups needing such education include: C-suite staff (executive leadership), other employers and community leaders, employees, nurses and other health care professionals (doctors, etc.). Academic partnerships could assist in this effort.
• Hold recognition ceremony/celebrations for BSN-earners (Spokane)
• Support for ESL and non-native students, students of diversity and first-generation college students (Spokane) • Increase competency-based learning and the ability for returning students in BSN programs to receive credit
for prior experience (Tukwila)
• Align incentives with practice and education (Tukwila)
• Match students who are working within a specialty area to mentor each other; match students working within a facility with mentors in that facility (Tukwila)
• Have new, larger, regional conversation about mutual benefits of BSN-level nursing (Tukwila)
• Bring the nurses into the problem-solving conversation regarding school and employment – what can we do together? What can we do for you? What can you do for us? (Spokane)
• For nurses who choose not to advance their education, find meaningful ways to keep them involved and feeling valued (Spokane)
• Guarantee a return to full-time position on completion of BSN degree (Spokane)
• Increase competency-based learning and receiving credit for prior experience for returning students in BSN programs (Tukwila)
Table 3
Support Needed for Students to Enroll in and Complete BSN Degree
THEMES HELD IN
COMMON
Across groups
and locations
NURSE EMPLOYER
THEMES
In each location
NURSE EDUCATOR
THEMES
In each locatio
n
PRACTICING &
STUDENT NURSE
THEMES
In each location
• Employers need to provide incentives for nurses including: maintaining full-time benefits if they are working part-time and going to school, childcare support, flexible schedules, tuition assistance or reimbursement, and increased pay rates for BSN attainment
• Increased nursing scholarship programs, loan forgiveness, and affordable interest rates on student loans • Improved positive communication regarding the need for and benefits of a BSN degree, especially among
ADNs, but also in the larger community
• Hosted “family nights” to inform families about the benefits of returning to school, what to expect when your family member is in school, ways to support the student, and available resources for students and families (i.e., childcare)
• Academia and employers need to help identify, make available, and connect students to needed academic-related resources, e.g., computer labs, study spaces, tutors, peer-support groups, mentor programs • Shift culture among nursing staffs and at health care facilities as a whole to support nurses returning to
school. Facilities should encourage, celebrate, and recognize nurses publicly for academic achievements, yet acknowledge the differing yet valuable skills and experience of non-BSN level nurses
• Make ADN to BSN programs more “seamless”; provide more opportunity to transfer credits; limit the need to repeat classes; and enhance opportunities to earn credit for experience
• Create new and enhance existing community, facility, and academic partnerships to expand resources for nursing students
• Prepare hospital/preceptor site staff to effectively host students and to identify potential student projects (Tukwila)
• Address the lack of diversity in nurse workforce and in higher education – create effective strategies to increase diversity (Tukwila)
• Increase capacity of BSN programs, provide more varied applications for learning (distance learning and online programs)
• Demonstrate importance of nursing education by increasing nursing faculty salary or providing faculty stipends (Tukwila)
• Address the lack of diversity in nurse workforce and in higher education – create effective strategies to increase diversity (Tukwila)
• As ADNs are graduating now, if they can’t find a job, create programs to help them grow skills and transition to BSN programs (Tukwila)
• Bring nursing unions to the table in the discussion of differentiated practice and salary differentials between BSN-level and non-BSN nurses; employers will likely not make decisions without knowing how the union will respond (Spokane)
• Prepare hospital and preceptor site staff to effectively host students and to identify potential student projects (Tukwila)
Table 4
Support Needed from the “Community” to Enroll in and Complete BSN Degree
THEMES HELD IN
COMMON
Across groups
and locations
NURSE EMPLOYER
THEMES
In each location
NURSE EDUCATOR
THEMES
In each locatio
n
PRACTICING &
STUDENT NURSE
THEMES
In each location
Question 1: Benefits gained Question 2: Disincentives Question 3: Employer & academic support Question 4: Community support
What do employers gain by having BSN-educated nurses in their employ?
What do nursing students gain by
enrolling in a BSN program? What do nurses gain for themselves by having a BSN?
What are the disincentives for employers to having nurses on their staff enrolled in BSN programs?
What are the disincentives nursing students face either as new or returning students to enrolling in a BSN program?
What are the disincentives for nurses entering a BSN program, either as new or returning students?
What do employers need in order to support their nurses on staff in enrolling in a BSN-level academic program?
What do new and returning nursing students need to support them in enrolling and completing a BSN-level academic program?
What do new and returning nursing students need to support them in enrolling and completing a BSN-level academic program? What kind of support do nurses
need from their communities – for example employers, colleagues, family – to enroll in and complete a BSN program?
What kind of support do nurses need from their communities – for example employers, colleagues, family – to enroll in and complete a BSN program?
What kind of support do nurses need from their communities – for example employers, colleagues, family – to enroll in and complete a BSN program?
Employers
Safe Table Forum Discussion Questions
by Participant Group Type
References for material cited in this briefing paper
1. Nelson MA. Education for Professional Nursing Practice: Looking Backward into the Future. Online J Issues Nurs. 2002 May; 7(2): [no pages].
2. Institute of Medicine [Internet]. Washington (DC): The National Academies Press; c2011. The Future of Nursing: Leading Change, Advanc-ing Health; 2011 Oct 05 [cited 2013 May 21]. Available from: http://www.iom.edu/Reports/2010/The-Future-of-NursAdvanc-ing-LeadAdvanc-ing-Change- http://www.iom.edu/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health.aspx
3. American Association of Colleges of Nursing [Internet]. Washington (DC): American Association of Colleges of Nursing; c2013. The Impact of Education on Nursing Practice Fact Sheet; 2012 Oct 24 [cited 2013 May 31]. Available from: http://www.aacn.nche.edu/media-rela-tions/fact-sheets/impact-of-education
4. U.S. Department of Health and Human Services Health Resources and Services Administration [Internet]. Washington (DC): US Govern-ment; c2013 Feb. The Registered Nurse Population: Findings from the 2008 National Sample Survey of Registered Nurses; 2010 Sept [cited 2013 June 6]. Available from: http://bhpr.hrsa.gov/healthworkforce/rnsurveys/rnsurveyinitial2008.pdf
5. National League for Nursing (NLN) [Internet]. New York (NY): NLN; c2011. Baccalaureate Programs as a Percentage of All Basic RN Pro-grams and Baccalaureate Graduations as a Percentage of All Basic RN Graduations: 1988-89 to 1994-95 and 2002-03 to 2007-08; 2008 [cited 2013 June 6]. Available from: http://dev.nln.org/research/slides/pdf/AS0708_F12.pdf
6. American Association of Colleges of Nursing (AACN) [Internet].. Washington (DC): AACN; c2013. The Essentials of Baccalaureate Educa-tion for Professional Nursing Practice: Faculty Tool Kit; 2009 Feb 19 [cited 2013 Sept 25]. Available from: http://www.aacn.nche.edu/ education-resources/BacEssToolkit.pdf
7. American Organization of Nurse Executives (AONE) [Internet]. Chicago (IL): AONE; c2012. The AONE Nurse Executive Competencies; 2011 [cited 2013 Sept 25]. Available from: http://www.aone.org/resources/leadership%20tools/nursecomp.shtml
8. Benner P, Sutphen M, Leonard V, Day L, Shulman LS. Educating Nurses: A Call for Radical Transformation. San Francisco: Jossey-Bass; 2009.
9. American Association of Colleges of Nursing (AACN) [Internet]. Washington (DC): AACN; c2013, Interprofessional Education Collaborative Expert Panel: Core competencies for interprofessional collaborative practice: Report of an expert panel; 2011 [cited 2013 Sept 25]. Avail-able from: http://www.aacn.nche.edu/education-resources/ipecreport.pdf
10. Quad Council of Public Health Nursing Organizations (QCPHNO) [Internet]. No city of publication: QCPHNO; c2011, Quad Council Compe-tencies for Public Health Nursing; 2011 [cited 2013 Sept 25]. Available from: http://www.achne.org/files/Quad%20Council/QuadCouncil-CompetenciesforPublicHealthNurses.pdf
11. Weinberg DB, Cooney-Miner D, Perloff JN, Bourgoin M. The gap between education preferences and hiring practices. Nurs Manage. 2011 Sep; 42(9): 23-28.
12. Rambur B, McIntosh B, Palumbo, MV, Reinier K. Education as a determinant of career retention and job satisfaction among Registered Nurses. J Nurs Scholarsh. 2005; 37(2): 185-192.
13. Washington Center for Nursing [Internet]. Seattle (WA): Washington Center for Nursing; c2013. Master Plan for Nursing Education, 2008 March 31 [cited 2013 May 22]. Available from: http://www.wacenterfornursing.org/nursing-education/master-plan-for-nursing-education/ 14. National Council of State Boards of Nursing (NCSBN) [Internet]. Chicago (IL): NCSBN; c2013. 2012 Environmental Scan: Annual
Re-view of Emerging Issues and Trends that Impact Nursing Regulation; 2012 [cited 2013 June 5]. Available from: https://www.ncsbn. org/2012environment_scan_final.pdf
15. Kendall-Gallagher D, Aiken LH, Sloane DM, Cimiotti JP. Nurse Specialty Certification, Inpatient Mortality and Failure to Rescue. J Nurse Scholarsh. 2011 June: 43(2): 188-194
16. Aiken LH, Cimmiotti JP, Sloane DM, Smith HL, Flynn L, Neff DF. The Effects of Nurse Staffing and Nurse Education on Patient Deaths in Hos-pitals with Different Nurse Work Environments. Med Care. 2012 Dec: 49(2): 1047-1053
17. Blegen MA, Goode CJ, Park SH, Vaughn T, Spetz J. Baccalaureate education in nursing and patient outcomes. J Nurs Adm. 2013 Feb; 43(2):89-94.
18. American Nurses Association [Internet]. Silver Spring (MD): American Nurses Association; c2013. Fact Sheet: Registered Nurses in the U.S. Nursing by the Numbers; 2011 May [cited 2013 May 31]. Available from: http://nursingworld.org/NursingbytheNumbersFactSheet.aspx 19. Altman TK. Registered Nurses Returning to School for a Bachelors Degree in Nursing: Issues Emerging from a Meta-Analysis of the
Re-search. Contemp Nurse. 2011 October; 39(2): 256-272.
20. Graf CM. ADN to BSN: Lessons from Human Capitol Theory. Nurs Econ. 2006 May/Jun; 24(3): 135-142.
21. Morgenthaler M. Too Old for School? Barriers Nurses Can Overcome When Returning to School. AORN J. 2009 Feb; 89(2): 335-345. 22. Association of PeriOperative Registered Nurses (AORN) [Internet]. Denver (CO): AORN; c2013. New York and New Jersey Consider BSN
Requirement; 2008 Feb 01 [cited 2013 May 31]. Available from: http://www.aorn.org/News.aspx?id=22262
23. Sizemore MH, Robbins LK, Hoke MM, Billings DM. Outcomes of ADN-BSN Partnerships to Increase Baccalaureate Prepared Nurses. Int J Nurs Educ Scholarsh. 2007; 4(1): Article25.
24. Washington State University (WSU) [Internet]. Pullman (WA): WSU, c2013. College of Nursing RN-Bachelor of Science in Nursing, [date unknown] [cited 2013 June 10]. Available from: http://nursing.wsu.edu/Academic-Programs/RN-BSN/
25. Western Governors University (WGU) [Internet]. Salt Lake City (UT): WGU; c2013. WGU, BS Nursing. 2013 [cited 2013 August 16]. Avail-able from: http://www.wgu.edu/online_health_professions_degrees/bachelor_science_nursing
26. Eckhardt, JA, Froehlich. An Education-Service Partnership: Helping RNs Obtain Baccalaureate Degrees in Nursing at their Practice Sites. J Nurs Educ. 2004 Dec; 43(12): 558-561.
27. American Association of Colleges of Nursing (AACN) [Internet]. Washington (DC): AACN; c2013, Articulation Agreements Among Nursing Education Programs; 2013 May 7 [cited 2013 Sept 25]. Available from: http://www.aacn.nche.edu/media-relations/fact-sheets/articula-tion-agreements
28. Delaney C, Piscopo B. RN-BSN Programs: Associate Degree and Diploma Nurses’ Perceptions of the Benefits and Barriers of Returning to School. J Nurse Staff Dev. 2004; 20(4): 157-161.
29. Washington State Department of Health (WA DOH) [Internet]. Olympia (WA): WA DOH; c2013. Washington State Department of Health, DOH 669-080: Approved Nursing Programs in the State of Washington, 2013 April [cited 2013 June 10]. Available from: http://www.doh. wa.gov/portals/1/Documents/Pubs/669080.pdf
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