Baccalaureate Nursing Degree as Minimum Education Requirement for Entry to Registered Nursing Practice in Alberta

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1 Baccalaureate Nursing Degree as Minimum Education Requirement for Entry to Registered Nursing Practice in Alberta A Proposal Submitted to the Health Professions Advisory Board By Alberta Association of Registered Nurses August, 2003

2 TABLE OF CONTENTS TABLE OF CONTENTS...2 EXECUTIVE SUMMARY INTRODUCTION KEY MILESTONES FOR REGISTERED NURSE EDUCATION IN ALBERTA RATIONALE OF PROPOSED REQUEST FACTORS INFLUENCING THE DEMAND FOR THE INCREASE IN ENTRY-TO-PRACTICE REQUIREMENTS EDUCATIONAL/TRAINING IMPLICATIONS EFFECT OF CHANGE ON PROFESSION EFFECT OF PROPOSED CHANGE ON THE HEALTH CARE SYSTEM EFFECT OF NOT RECEIVING APPROVAL FOR REQUESTED CHANGE ADDITIONAL FACTORS THE BOARD SHOULD CONSIDER...42 REFERENCES...45 APPENDIX A: HISTORICAL OVERVIEW OF NURSING EDUCATION IN ALBERTA...48 APPENDIX B: PRACTICE STATEMENT FOR REGISTERED NURSES IN THE HEALTH PROFESSIONS ACT...54 APPENDIX C: PRACTICE STATEMENT FOR REGISTERED NURSES IN THE NURSING PROFESSION ACT...55 APPENDIX D: THE REGISTERED NURSES EXAMINATION COMPETENCIES...56 APPENDIX E: STAKEHOLDERS INCLUDED IN CONSULTATION WITH AARN ON BETP...67 August

3 EXECUTIVE SUMMARY This document was prepared in August 2003 for the Health Professions Advisory Board, and presents the Alberta Association of Registered Nurses (AARN) rationale, evidence, and consultation processes undertaken to support the AARN s policy decision to require a baccalaureate degree as the minimum educational requirement for initial entry-to-practice as a registered nurse (RN) in Alberta, as of January 1, The AARN is the professional and regulatory body for the 26,000 registered nurses in Alberta. The Health Professions Act (HPA) states a college must govern its regulated members in a manner that protects and serves the public interest. This responsibility includes, but is not limited to, ensuring that new registered nurses have received the education required to practice competently. Alberta is poised to make significant and positive changes in its health care system, particularly in its movement toward primary health care models of care delivery. In June 2003, stakeholders including nurse educators, nurse administrators from regional health authorities and federal health services, nurse practitioners, representatives of provincial nursing interest groups and nursing unions, senior policy officials from Alberta Health and Wellness, and AARN representatives discussed their vision for primary health care and expressed their conviction that registered nurses should take a strong leadership role in a primary health care focused system. Stakeholders agreed that registered nurses have a unique contribution to make through their holistic perspective and approach in working with individuals, families, and communities; understanding the needs of clients using a client-centred approach, and working and communicating with clients to share decision-making and priority setting, considering the determinants of health and overall family and community context in which clients live. Since 1979, the AARN has endorsed the baccalaureate degree as minimum education for entry to registered nursing practice in Alberta. This decision followed the 1975 Alberta Government Task Force on Nursing Education recommendation that by 1990 the educational preparation for registered nurses be a baccalaureate degree. The primary factor influencing the need to increase the entry-to-practice requirement for Alberta s registered nurses is the change in competencies required to meet client and health system needs. Registered nurse competence is defined as all of the knowledge, skills, attitudes, and judgment required to meet client needs in an evolving health care system. Education of new graduates must constantly evolve in response to growth in the knowledge base and changes in the health system and the needs of its clients. General competency differences between students at the end of degree versus diploma completion are best described by the degree or depth of attainment, rather than as present/absent. Evidence-based practice and research skills are strengthened and consolidated within baccalaureate nursing programs. These are needed along with strong clinical skills to meet the professional demands of diverse and changing health care environments, the increased complexity and acuity of the patient/client, and collaboration within the interdisciplinary team. August

4 Evidence-based practice skills enhance the registered nurse s critical thinking, clinical decisionmaking, and leadership in situations of increased complexity and acuity of the patient/client within the health system. Nursing care is increasingly being provided in homes and other community settings rather than in hospitals. The focus of degree programs on nursing knowledge at the group and community level, as well as at the level of individuals and families, provides for enhanced competencies in areas such as health promotion, health protection, and disease prevention. It also enables the registered nurse working in an acute care setting to better coordinate the client s transition into the community following an episode of acute illness. Evidence in the literature points convincingly to the strengthening of registered nurses practice as a result of degree preparation, by increasing the ability of registered nurses to function autonomously, by enhancing their abilities to plan and deliver interventions in more innovative and efficient ways, and by improving the quality of patient care and effectiveness of care outcomes. A commonly held perception is that baccalaureate education is intended to prepare nurses specifically to fill roles in management, teaching, and research, and that this will then leave fewer registered nurses to provide frontline clinical care. This is not the case. According to AARN statistics for the 2002 membership year, of registered nurses who entered practice with a baccalaureate degree, 4.9% are currently employed in management positions, compared to 7.1% of those who entered with a diploma. In Alberta, 80% of registered nurses who originally entered practice with a baccalaureate degree are currently employed at the staff nurse or community health nurse level. Findings in a report released in January 2000, the Labour Market Integration of Graduates in Nursing in Canada illustrated the significance of education as a retention strategy, showing that nursing graduates of diploma programs were more likely than their universityeducated counterparts to leave the country (34% versus 19% respectively). The aging of the nurse population will be the single most influential factor in future registered nurse shortages. Replacement of these experienced leaders of nursing practice and innovation will depend on recently graduated registered nurses who have learned to think broadly, creatively, independently, and critically through their educational preparation and much shorter nursing experience. A baccalaureate entry standard can form an important component of a comprehensive plan to deal with projected shortages, because it is known to be the more attractive option for younger recruits who have long career spans. Baccalaureate as entry-to-practice for registered nurses should be seen as an investment in the health system and its future sustainability, not as a cost. A more well-prepared nursing workforce will be able to better manage patient care and service delivery issues, using a more global system perspective, for improved cost-effectiveness. As a profession, registered nurses have been preparing for the transition to baccalaureate entry-to-practice for almost thirty years, including the innovation of collaborative education programs. The time has come to ensure that new nursing graduates are adequately prepared to meet the challenges and the opportunities they will face in the realities of today s nursing practice environments. August

5 1.0 INTRODUCTION The purpose of this proposal is to document for the Health Professions Advisory Board the rationale, evidence, and consultation processes undertaken in support of the AARN s policy decision to require, as of January 1, 2010, a baccalaureate degree as the minimum educational requirement for initial entry-to-practice as a registered nurse in Alberta. It is the understanding of the AARN that this policy change will require approval by the Minister of Health and Wellness prior to becoming part of the Registered Nurse Regulation under the Health Professions Act (HPA). The AARN is the professional and regulatory body for the 26,000 registered nurses in Alberta. The Health Professions Act states a college must govern its regulated members in a manner that protects and serves the public interest. This responsibility includes, but is not limited to, ensuring that new registered nurses have received the education required to practice competently. Under the Nursing Profession Act (NPA) of 1983, the Universities Coordinating Council was given authority to prescribe minimum standards for approved schools of nursing and to make rules respecting any matters that are required to secure an effective program of study in nursing. Through a May 1999 Letter of Agreement for Delegation of Authority under the Universities Act, the AARN assumed these and related responsibilities from the Universities Coordinating Council. Upon coming into force of the Health Professions Act for registered nurses, the statement on the role of the College will apply, including Section 3(1)(f) which states that the College may approve programs of study and education courses for the purposes of registration requirements. It is within our legislated mandate under both current (NPA) and upcoming (HPA) legislation that the AARN now seeks to establish a nursing baccalaureate degree as the minimum educational requirement for entry-to-practice as a registered nurse in this province. 2.0 KEY MILESTONES FOR REGISTERED NURSE EDUCATION IN ALBERTA (for a more complete historical overview of nursing education in Alberta, see Appendix A) to 1930 Nursing programs were developed across the province, beginning with Medicine Hat General Hospital in Nursing education was an apprenticeship system where the students were labourers and service to the hospital took precedence (Field, p. 15, 16). In Alberta, the University of Alberta did not offer a post-rn diploma in teaching until 1940, although a five-year degree had been offered since 1924 this included one year of arts and science, three years in a diploma nursing program, and a professional year at university. August

6 Until 1937, students had to travel to the University of British Columbia to complete the final year of university courses (Field, p. 26; Ross-Kerr, p. 160). The 1930s The Weir Report: Survey of Nursing Education In Canada (Canadian Nurses Association, 1932) recommended that nursing education become an integral part of the general education system and be funded by government, that schools of nursing be independent of hospitals, and that minimum entrance requirement be senior matriculation (Sherwood & Henderson, p. 10, Oct. 1990). The 1940s In 1941, the Registered Nurses Act of 1916 was amended to include a grade twelve educational requirement to enter a school of nursing in Alberta (Sherwood & Henderson, p. 24, Nov. 1990). The 1960s In 1966, the new four-year integrated baccalaureate program commenced at the University of Alberta. Prior to this date, students enrolled in a five-year program during which the threeyear diploma nursing component was received in the University of Alberta Hospitals (Sherwood & Henderson, p. 16, Feb. 1991). In 1966, the University of Calgary gained independence from the University of Alberta and a second integrated degree program began accepting students in 1970 (Ross-Kerr, p. 186). In 1967, the first two-year college nursing program commenced at Mount Royal College in Calgary, followed by Red Deer (1968), and Lethbridge (1969). The 1970s By 1975, there were two basic baccalaureate programs in nursing, five two-year college programs and six hospital schools all preparing registered nurses. Programs leading to a registered nurse were two, three, or four years in length (Field, p. 41). The Alberta Task Force on Nursing Education was commissioned in January 1975 by the Government of Alberta to prepare a framework for the planning and coordination of the education of nursing personnel in Alberta. The task force report, released in February 1976, recommended that by 1985 there be two routes of professional nursing preparation: a university based baccalaureate program, and an articulated baccalaureate program between a university and non-university setting. The task force report also recommended that by 1990 the minimum educational preparation for professional nursing be the baccalaureate degree (Chapman, p. 15, Jul.-Aug. 1991). In November 1977, the Government of Alberta produced another document, Position Paper on Nursing Education: Principles and Issues, noting that baccalaureate education was desirable, but not agreeing that it should be the minimum entry requirement (Chapman, p. 15). In 1979, the AARN released its position statement The Alberta Association of Registered Nurses supports the goal of the baccalaureate degree (basic or post-rn) as the minimum August

7 educational preparation for professional nursing and further, that by the year 2000, the baccalaureate degree in nursing be the minimum requirement for entry into the nursing profession in the province of Alberta (Chapman, p. 15). The 1980s Work began on the development of collaborative nursing education programs, whereby existing nursing programs were integrated through a common curriculum and students could choose to complete with a baccalaureate degree or exit with a diploma. Within these collaborative programs, the diploma exit stream was instituted as an interim step until the full implementation of the baccalaureate degree as entry-to-practice. The 1990s The University of Alberta and Red Deer College collaborative program began in September The Edmonton Collaborative Program began in September 1991 and the Calgary Conjoint Program began in In May 1999, a letter of agreement between the Universities Coordinating Council (UCC) and the AARN was signed transferring the UCC functions under Sections 54 and 55 of the Nursing Profession Act to the AARN. AARN Provincial Council subsequently established the Nursing Education Program Approval Board (NEPAB) by bylaw effective April 1, 1999 and delegated the UCC function to this arms length board. The Current Situation Currently in Alberta, there are eleven approved schools of nursing offering nursing education programs leading to entry-to-practice as a registered nurse: Athabasca University Grande Prairie Regional College Grant MacEwan College Keyano College Lethbridge Community College Medicine Hat College Mount Royal College Red Deer College University of Alberta University of Calgary University of Lethbridge These schools offer a variety of nursing education programs with various routes and scheduling options leading to entry-to-practice as a registered nurse, including: Baccalaureate programs (3.5 to 4 academic years) Diploma programs [ranging from19/20 months (for students with advance credits from previously completed courses) to 3 academic years] August

8 After degree baccalaureate programs (for those with a first degree) Licensed practical nurse (LPN) bridging programs (allowing LPNs to obtain a baccalaureate or diploma) Registered psychiatric nurse (RPN) bridging program (allowing RPNs to obtain a baccalaureate) Collaborative programs continue to be offered, including: University of Alberta, Grande Prairie Regional College, Grant MacEwan College, Keyano College, and Red Deer College University of Lethbridge and Lethbridge Community College University of Calgary and Medicine Hat College Athabasca University and Mount Royal College 3.0 RATIONALE OF PROPOSED REQUEST The primary consideration will be a demonstrated and evidence-based change in the core competencies required to practice the profession. Please describe which issues are creating the need for the proposed change. Which factors are influencing the demand for the increase in entry-to-practice requirements? What is/are the source(s) of influencing factors (e.g. regulatory body, professional association, labour, health sector, education sector, clients, public etc.)? What other sources are influencing the demand for the increase (e.g. supply and demand, national influences, changing roles of other professions, new knowledge and/or technology)? Will the proposed change impact other professions in the system? How will the change fit within existing professions/regulations? Since 1979, the AARN has endorsed the baccalaureate degree as minimum education for entry to registered nursing practice in Alberta. Alberta already has a higher proportion of baccalaureateprepared registered nurses than the national average, and a large majority of nursing students are choosing the degree route over the nursing diploma. In fact, since 1997 the number of new Alberta-educated registered nurses entering practice with a baccalaureate degree in nursing has been four times greater than the number entering practice with a nursing diploma. The primary rationale for the AARN s proposed change to a baccalaureate degree as minimum entry-to-practice is the increased breadth and depth of competency required of entry-level registered nurses to meet the rapidly changing demands of Alberta s health care system. This factor, along with other related issues and impacts, are discussed in detail in Sections 3.1 through 3.5 of this proposal. The following brief overview of the national and international situation is included to describe the larger context within which this change in entry-to-practice is proposed. Baccalaureate as entry-to-practice was approved by the Canadian Nurses Association in 1982, and all provincial nursing associations have endorsed this position. In fact, Alberta was the August

9 jurisdiction that brought the baccalaureate position to the Canadian Nurses Association by resolution in This change to entry requirements has been fully implemented in six provinces and territories; Ontario and British Columbia will implement the requirement in The Current Transition to Baccalaureate Entry to Registered Nurse Practice In Canada, the Atlantic provinces led the way, having completed their transition to baccalaureate entry-to-practice by In Manitoba, the transition was to be completed by 2000; however, in April 2000, the Manitoba government announced support to open a new 23-month diploma program. The College of Registered Nurses of Manitoba has since set, as one of its goals, to have the baccalaureate degree as the educational requirement by The Saskatchewan Registered Nurses Association made its announcement in March of 2000 and has completed the transition. The Government of Ontario changed its legislation in 1999 to enable baccalaureate entry and anticipates completing the transition by the end of British Columbia Registered Nurses Association made its announcement in 2002 and anticipates completing its transition in The Northwest Territories Registered Nurses Association holds the position that the baccalaureate should be required for entry-to-practice. Both nursing education programs in this territory offer baccalaureate programs, and students are not widely utilizing the existing diploma exit. The Yukon, which has no entry-level educational programs, has the highest percentage of baccalaureate graduates in the country (CNA, Fact Sheet: Entry to Practise). The Canadian picture reflects a growing international trend toward degree preparation for entrylevel registered nurses. Several countries, including New Zealand, Australia, Finland, Sweden, Iceland, and some Latin American nations, have degree-level initial education for registered nurses. The United Kingdom is in the process of moving toward a degree requirement. Even Ethiopia, one of the most disadvantaged countries in the world, is in the process of expanding its bachelor of nursing programs to a total of four from the current one, in recognition of the need to prepare registered nurses for their diverse roles and responsibilities within the health system. One exception to this progress internationally is the United States, where implementation to date has been limited to a few states, in spite of the fact that American nurses were the first (in 1965) to officially support degree preparation as the minimum requirement. There is considerable American literature on this topic, citing numerous reasons for the slow progress, including the fragmentation of nursing education between universities, colleges, and hospitals, all with a vested economic interest in maintaining their programs. Indeed, some nursing leaders in the United States lament the fact that their country has not moved to the Canadian style of collaborative models of nursing education, which could facilitate a more cooperative approach to resolving this issue. Because of the documented trend toward baccalaureate as entry-to-practice, implementing this requirement is an important aspect of ensuring that the quality of nursing services in Alberta is keeping step with standards set across the country and beyond. In addition, it has been observed that, as more jurisdictions have adopted baccalaureate entry requirements, the national registered August

10 nurse exam is increasingly reflecting competencies gained within baccalaureate programs. This trend will pose a future disadvantage to the supply of registered nurses within Alberta, since diploma-prepared candidates may have increased difficulty passing the licensing exam. The trends in implementation of the baccalaureate requirement across the country may also disadvantage the mobility of Alberta s registered nurses if they are prepared at a different level than other Canadian nurses. Have alternative solutions to address the issues been considered? If so, those alternative solutions should be described. The AARN has been working for more than twenty years toward this change in entry-to-practice requirements for registered nurses. At the time this effort was begun, nursing degree programs were very different from diploma programs, in terms of the content covered within the program. In the absence of formal support from government of this change in the entry-to-practice standard, the profession and the nursing education sector have attempted to respond to the expanded knowledge and scope required of registered nurses. We have done so over these past twenty-four years by attempting to cover, at least at an introductory level, most content relevant to registered nursing practice in the current environment. For example, concepts such as population health, health determinants, evidence and research, and health teaching were previously taught only in degree programs, but now are part of all nursing program curricula. The effort to provide some exposure to all subject areas means less time available for a thorough depth of knowledge and less time for supervised clinical practice. These alternative solutions were facilitated by the collaborative programs which were started, in part, to ease the transition to baccalaureate registered nurse preparation. The point is long past, however, when the significant breadth and depth of content required for competent nursing practice can be adequately addressed within a two to three year program of study. 3.1 Factors Influencing the Demand for the Increase in Entry-to-practice Requirements What is the evidence to support a change in core competencies required for entry-to-practice? Describe and include supporting documentation. The primary factor influencing the need to increase the entry-to-practice requirement for Alberta s registered nurses is the change in competencies required to meet client and health system needs. The education of new graduates must constantly evolve in response to growth in the knowledge base and changes in the health system and the needs of its clients. There is much current talk about health reform, including a necessary shift to primary health care models of service delivery across all sectors. What is often not recognized within these discussions is that Alberta has a workforce of 26,000 registered nurses who are ideally positioned to help achieve these reforms, if they are adequately prepared to do so. August

11 Contrasts between the practice statement for registered nurses in the Health Professions Act (Schedule 24, Section 3) (Appendix B) and the previous description of the practice of nursing in the Nursing Profession Act (Section 2) (Appendix C), clearly show the evolution of both public expectations and the increased autonomy of registered nurse practice. For example, the HPA practice statement identifies the broad application of nursing knowledge to families, groups and communities, an increased focus on wellness and health promotion, and the inclusion of diagnosis, treatment and referral. In 2002, Alberta s health system stakeholders told us that the six principle roles of registered nurses in today s complex health system are: 1. critical assessor/thinker/interpreter 2. coordinator of care/planner/quality assurance 3. decision-maker/problem solver 4. clinical care giver/health promoter 5. advocate/leader 6. case manager Registered nurses simply must receive sufficient basic education to acquire the knowledge base to enable them to competently fulfill these roles. Knowledge about health, health care, and nursing is growing exponentially. In fact, it has been estimated that the current volume of scientific information will increase more than 32 times within ten years. Registered nurses must have expertise in many areas in order to provide safe care and leadership in today s complex health care system. They must be prepared to be knowledge workers, to competently lead the nursing team and provide consultation to other team members, as well as to provide direct nursing care when client acuity and complexity are high. The scope of registered nursing practice encompasses much more than a set of activities or tasks that various workers may be trained to perform. Indeed, the definition of registered nurse competence includes all of the knowledge, skills, attitudes and judgment required to meet client needs in an evolving health care system (Canadian Nurses Association, 1998). It is important to remain aware of this broad definition of registered nurse competence, because it is quite common for persons outside the discipline of nursing to view the roles of different nursing personnel in terms of the observable psychomotor tasks that they are able to perform. This view (which, to some extent, has been perpetuated by the restricted activities focus within HPA) ignores or downplays the vital significance of nursing knowledge and judgment, which are often much more important than the specific task performance, but are not directly observable. The view also leads some stakeholders to believe, for example, that LPNs can safely replace registered nurses in many workplaces, because their scope of practice allows them to do many of the same tasks, or that there is no perceived advantage in having baccalaureate-prepared nursing graduates because the tasks they perform appear to be no different from those performed by diploma nursing graduates. August

12 It has been said that registered nurses have one foot high on the crystal tower of knowledge and theory and one foot in the dust and grit of human need (Shalala, 1992). In the academic setting of a degree program, nursing is taught and learned within a liberal arts and science context, and with a greater emphasis on research and evidence. A liberal education serves to broaden students view of the world and helps them to see where their professional discipline and their clients needs fit within that world. This ability is increasingly important as nurses practice across a wider variety of hospital and community settings than they did in the past, and take on more responsibility in assisting clients to find their way though the continuum of health services. Evidence-based practice and research skills are strengthened and consolidated within the baccalaureate program. These are needed, along with strong clinical skills, to meet the professional demands of diverse and changing health care environments, the increased complexity and acuity of the patient/client, and collaboration within the interdisciplinary team. The evidence-based practice skills enhance the registered nurse s critical thinking, clinical decision-making, and leadership in situations of increased complexity and acuity of the patient/client within the health system. Broad education in the social sciences, as well as education related to population health, supplies the diverse knowledge and enhanced evidence-based decision-making skills necessary for effective practice across the continuum of care, and particularly in community settings. Nursing care is increasingly being provided in homes and other community settings rather than in hospitals and this is likely to expand given the support for primary health care as a model for delivering care. The degree program s focus on nursing knowledge at the group and community level, as well as at the level of individuals and families, provides for enhanced competencies in areas such as health promotion, health protection, and disease prevention. It also enables the registered nurse working in an acute care setting to better coordinate the client s transition into the community following an episode of acute illness and vice versa. This broad understanding of the health care system and evidence-based decision-making are critical contributions of the degree-prepared registered nurse in facilitating continuity of care for the movement of patients between various services and settings, as well as in using resources effectively and efficiently. Extended preparation and exposure in an academic environment provides the background needed by registered nurses for effective participation in interdisciplinary teams, in particular, in decision-making about matching types of health care services to patient needs, to result in the best patient outcomes. This background includes enhanced verbal and written communication skills, as well as knowledge of planning and evaluation. In terms of why a stronger and more diverse set of registered nurse competencies are required in today s evolving health system, the 1996 position statement of the American Association of Colleges of Nursing provides a succinct rationale: Rapidly expanding clinical knowledge and mounting complexities in health care mandate that professional nurses possess educational preparation commensurate with the diversified responsibilities required of them. As health care shifts from hospital-centered, August

13 inpatient care to more primary and preventive care throughout the community, the health system requires registered nurses who not only can practice across multiple settings - - both within and beyond hospitals - - but can function with more independence in clinical decision-making, case management, provision of direct bedside care, supervision of unlicensed aides and other support personnel, guiding patients through the maze of health care resources, and educating patients on treatment regimens and adoption of healthy lifestyles. In particular, preparation of the entry-level professional nurse requires a greater orientation to community-based primary health care, and an emphasis on health promotion, maintenance, and cost-effective coordinated care. Accordingly, the American Association of Colleges of Nursing recognizes the Bachelor of Science degree in nursing as the minimum educational requirement for professional nursing practice. (AACN, 1996). Over the past few years, all Canadian nursing jurisdictions updated and revised their nursing competencies through extensive consultation with practicing nurses, nurse managers, educators, and others. In 2000, the AARN released its position paper, Entry-to-Practice Competencies (AARN, 2000). Because this document and other nursing competency publications are intended to describe the competencies required of all registered nurses, regardless of educational program, they do not contain specific distinctions between the competencies expected at the end of a diploma program and those expected of degree graduates. During a recent consultation session with twelve senior nursing education leaders representing both diploma and degree programs, the AARN sought to validate the general and specific competencies that were different, either in type or in degree, between graduates of the two types of registered nurse program. The group identified the following general differences between students at the end of degree versus diploma completion, and there was consensus that in most cases the competency differences are best described by the degree or depth of attainment, rather than as present/absent. This is a result of the responsiveness diploma nursing education programs have shown over the years in trying to cover, at least at an introductory level, content relevant to entering registered nursing practice in today s environment. This differs from the past, when the diploma and degree programs were very different in content. General differences identified for graduates of degree programs were: The degree completion program enhances knowledge of the health system and how it operates, issues management, leadership, group work, political awareness, problem solving, data collection, and analysis. Diploma education focuses on the individual within the family; degree provides knowledge of and exposure to the client and family within the larger community; degree graduates are better able to identify required client services within the larger system. The degree provides better health assessment skills, due to increased content and more opportunity for supervised practice. Added confidence and overall competence comes from a lengthened program, through the experiences gained during that program. August

14 Generally speaking, degree programs provide 200 or more additional hours of classroom instruction and 350 to 500 additional laboratory and/or clinical practice hours, than do diploma programs. These numbers reflect recent information submitted by nursing education program providers throughout the province. For the identification of specific competency differences, the nursing educators used as a framework the AARN position paper on Entry-to-Practice Competencies (AARN, 2000). The following table lists these competencies under four categories, with some identified specific areas of difference highlighted in the second column. AARN s Entry-to-Practice Competencies Identified Differences in Competency Level with Degree Preparation 1. Professional Responsibility The registered nurse is personally responsible and accountable for ensuring that her/his nursing practice and conduct meet the standards of the profession and legislative requirements. 1.1 Accepts accountability for own actions and decisions. 1.2 Practices in a manner consistent with: a) AARN Nursing Practice Standards; b) CNA Code of Ethics for Registered Nurses; c) legislated scope of practice; and d) provincial and federal legislation. 1.3 Takes action on questionable orders, decisions, or interventions of other health team members. 1.4 Uses standards of practice to continually assess own competence and learning needs. 1.5 Recognizes limitations of own competence, seeking assistance when necessary. 1.6 Follows quality and risk management processes to enhance nursing practice. 1.7 Describes professional self-regulation including the role of the AARN. 2. Knowledge-Based Practice The registered nurse continually strives to acquire knowledge and skills to provide competent, evidencebased nursing practice. 2.1 Uses various data collection approaches to complete client assessment. 2.2 Collaborates with client and other health team members to develop a plan of care. 1.3, 1.6: At the end of the baccalaureate program, a student demonstrates greater ability and likelihood to question and enhance existing nursing practice. This reflects more course content in leadership and risk management, more challenging course assignments in these areas, and more opportunities to observe and practice in clinical settings. 2.1: The degree graduate will be aware of more sources of data and approaches to assessment. 2.3: Exposure of the degree student to a wider August

15 AARN s Entry-to-Practice Competencies 2.3 Anticipates potential health problems or issues and their resultant consequences for clients. 2.4 Provides rationale for proposed client care. 2.5 Applies critical thinking skills in all practice activities. 2.6 Selects and implements nursing interventions (See ICNP ) that support the plan of care mutually established with the client and other health team members. 2.7 After evaluation, modifies plan of care in collaboration with client and other health team members. 2.8 Uses information and other technology to support nursing practice. 2.9 Maintains clear, concise, accurate, and timely records of client's care Uses effective time management strategies to organize workload Provides direction and delegates to Licensed Practical Nurses (LPNs) and Unregulated Care Providers (UCPs), and evaluates clients' responses to care provided by LPNs and UCPs Applies principles of primary health care to nursing practice. 3. Ethical Practice The registered nurse complies with the Canadian Nurses Association s Code of Ethics for Registered Nurses (1997). 3.1 Identifies own values and assumptions. 3.2 Demonstrates sensitivity to client diversity in nursing practice. 3.3 Shares appropriate information with team members while respecting confidentiality and legal requirements. 3.4 Advocates for clients or the client's designate or empowers these to advocate for themselves. 3.5 Follows established processes to address ethical dilemmas. 3.6 Practices within professional boundaries Identified Differences in Competency Level with Degree Preparation variety of clinical settings enhances this competency. 2.4, 2.5, 2.8: More advanced content in research and evidence leads to enhanced competency of the degree graduate in these areas. 2.12: Degree students have more exposure in settings where promotion and prevention are emphasized (i.e., community health settings), as well as broader content in epidemiology, social sciences, etc., resulting in much higher competency levels related to principles of primary health care. 3.1, 3.2: The degree addresses how my values and assumptions make a difference to my practice, and how do clients values influence this. 3.3: The degree has more interdisciplinary focus, and where the team framework fits into the global picture of the organization. The degree program focuses more on building capacity within the client, i.e., doing with rather than doing for. 3.5, 3.7: The degree graduate is more i d h dil d i August

16 AARN s Entry-to-Practice Competencies identified by AARN. 3.7 Recognizes and reports situations which are potentially unsafe for clients or health team members (e.g.: abusive clients or caregivers, faulty equipment, inappropriate staff/patient ratios or skill mix). 4. Provision of Service to the Public The registered nurse provides nursing service in collaboration with the client, significant others, and other health professionals. 4.1 Collaborates as a member of an interdisciplinary health team to achieve client health outcomes. 4.2 Employs communication skills appropriate to various clients, health team members, and situations. 4.3 Exercises accountability for decisions which are delegated to others. 4.4 Communicates with health team members to ensure continuity of health services for clients. 4.5 Describes the overall organization of health care. Identified Differences in Competency Level with Degree Preparation equipped to see the dilemmas and tensions; knows better how to work within the system to resolve issues. 3.6: The diploma graduate has a basic knowledge, but limited application/ integration; the degree program provides for consolidation of learning about professional practice. 4.1: The degree graduate is more able to articulate ideas with confidence and work collaboratively with others. 4.2: Additional supervised practice consolidates communications skills; opportunity to practice these skills with more diverse communities. 4.4, 4.5: In diploma programs, focus has been on the client within a family; the degree graduate has a larger view of community and system of health services. In summary, this comparison of expected competencies between diploma and degree graduates highlights some key differences in all of the categories of entry-level competencies. The nature of the differences described in the item-by-item comparisons also confirms what the educators had stated in general terms, i.e., that the degree program consolidates, integrates, and strengthens the student s knowledge and competencies gained within the diploma nursing program. Competencies Assessed by Canadian Registered Nurse Examination During recent consultations on the subject of baccalaureate entry-to-practice, some stakeholders questioned the need for this change, based on the observation that both diploma and degree graduates write the same licensing examination. The assumption then follows that the two groups must have equivalent entry-level competence if they can pass the same exam. Figure 1 situates the competencies that form the basis of the registered nurse exam within the full complement of Competencies for Practice as a Registered Nurse. The square figure represents all the competencies that are expected of registered nurses. The large circle inside the square constitutes the competencies that registered nurses must possess on entry-to-practice. These are August

17 the competencies that nursing students are expected to have acquired when they graduate from a nursing program. The smaller circle within the circle of Entry-to-Practice Competencies delineates the Competencies Assessed by the RN Exam. The registered nurse exam focuses on the competencies related to safe and effective practice that can be measured on a multiple-choice examination. While this list of competencies is quite extensive (and is provided in Appendix D, for information), there are many more untested areas of competence that are important for the student to acquire in order to feel confident and competent to begin her professional practice. Nursing educators report that during the diploma exit term there is a need to focus on those competencies that will be assessed by the registered nurse exam, in order to prepare students adequately to meet these tested requirements. The final year of study taken by degree students allows time to progress further into the full domain of entry-to-practice competencies. Figure 1: Competencies Assessed by the Registered Nurse Exam All Competencies for Practice as a Registered Nurse Entry-to-Practice Competencies Competencies Assessed by the RN Exam Of note is that current discussions at the national nursing association level have acknowledged an expectation that in 2005, when the two large provinces of British Columbia and Ontario implement baccalaureate entry, there will be a noticeable shift to include in the registered nurse national exam more competencies that are gained primarily within degree programs. Ethics, professional boundaries, communication, advocacy, assessment, and documentation are topics that are expected to have increased testing in the new examination format. What evidence is available to support the position that an increase in entry-to-practice requirements will have a beneficial effect on the following? Please provide a description of how these areas will improve due to the proposed increase in entry-to-practice requirements. August

18 Professional/provider: Competence/knowledge? Skills? Practice? Please see previous section. What evidence is available to support the position that an increase in entry-to-practice requirements will have a beneficial effect on the following? Please provide a description of how these areas will improve due to the proposed increase in entry-to-practice requirements. Patient care? Health outcomes? Health System? While there have been surprisingly few rigorous empirical studies of the specific differences in patient care or health outcomes associated with baccalaureate-prepared nurses, the literature does contain some evidence in this regard. For example: A University of Toronto study recently found that home care clients cared for by baccalaureate-prepared nurses had significantly greater improvement in knowledge and behaviour scores than did clients of nurses who had other educational preparation (O Brien Pallas et al, 2002). Knowledge and behaviour scores were based on the change from admission to discharge of clients understanding of their specific health related problems and their application of knowledge and skills to deal with those problems, such as making life style changes. The authors suggest that, given the variability and unstructured nature of the home care environment, degree preparation may give the nurse an advantage in structuring appropriate client interventions. O Brien Pallas et al (2001) also found that home care delivery by degree-prepared registered nurses was associated with fewer client visits and that these registered nurses had greater satisfaction with the perceived adequacy of care. These findings suggest the potential for a more cost-effective service for both treatment and preventative interventions when degreeprepared registered nurses deliver client care. In another Ontario study of the effects of several nurse and client variables on role performance by nurses in hospitals, Doran et al (2002) found that greater educational preparation of nurses had a positive effect on their communication patterns and care coordination. Based on this finding, these authors suggest that nursing care quality is higher on units where nurses have higher levels of educational preparation and that this, in turn, may have a beneficial impact on the outcomes for patients. Research has shown that baccalaureate education contributes to a sense of professional autonomy (defined as independence within one s own practice), whereas diploma education was associated with lower autonomy (Ferguson-Pare, 1996). Greater autonomy is evidenced by the increased ability of nurses to make decisions independently based on nursing August

19 assessment and diagnosis and resulting in mutual problem-solving with clients, appropriate connections with resources and referrals as needed. This greater autonomy could enhance client care and advocacy in a variety of clinical settings. In a 1995 study, employers reported that baccalaureate-prepared nurses are promoted and assigned to leadership positions more often, but were not necessarily given more complex patient assignments than other registered nurses. They emphasized the importance of clinical skills of all registered nurses and placed value on baccalaureate nurses for their ability to problem solve and to see the broader picture of patient care. A bachelor s degree enhances the skills of an individual to look at the continuum of care requirements and challenge the rote ways of practicing. (Manuel & Sorenson, 1995) research through the American Academy of Nursing (AAN) identified magnet hospitals which were successful in attracting and retaining nurses, were good places to work, and delivered quality nursing care (Kramer & Schmalenberg, 1988a, 1998b). In the early 1990s, the American Nurses Association established a program to recognize excellence in nursing services, the Magnet Nursing Services Recognition Program, providing an American Nurses Credentialling Centre (ANCC) designation for those hospitals that met magnet criteria from the nursing perspective. In a more recent study Aiken, Havens, and Sloane (2000), revisited the AAN and ANCC designations to assess their continuing relevance in identifying centres of exemplary nursing care. Aiken et al point out that over 50% of registered nurses in currently identified magnet hospitals hold baccalaureate degrees, as compared to only 34% of nurses in all of United States hospitals together. This evidence points convincingly to the strengthening of registered nurses practice through degree preparation, by increasing the ability of registered nurses to function autonomously, by enhancing their abilities to plan and deliver interventions in more innovative and efficient ways, and by improving the quality of patient care and effectiveness of care outcomes. The evidence to support an impact on the overall health system is seen in the movement toward primary health care models, and the relationship between this shift and the need for a welleducated registered nurse workforce. In June 2003, the AARN held a visioning day, bringing together provincial nursing leaders to discuss their vision for the role of registered nurses in a primary health care focused system and identify strategies for achieving that vision. Participants included nurse educators, nurse administrators from regional health authorities and federal health services, nurse practitioners, representatives of provincial nursing interest groups and nursing unions, senior policy officials from Alberta Health and Wellness, and AARN. Some of the things participants told us were: Registered nurses have a unique contribution to make to a primary health care focused system in Alberta through their holistic perspective and approach in working with individuals, families, and communities; understanding the needs of clients using a clientcentred approach, and working and communicating with clients to share decision-making and August

20 priority setting, considering the determinants of health and overall family and community context in which clients live. The impact of the work done by registered nurses in primary health care will be seen in improved population health and individual health status and functionality, including increased support for client self-care management. Increased health system capacity, costeffectiveness, and efficiency will also result from the appropriate utilization of nurses and the earlier identification of chronic and systemic issues. The impact on the nursing profession will be a call for greater skill and competency in health promotion and disease prevention, and greater understanding of primary health care. Nurses within a primary health care system will increasingly work to the full scope of their knowledge and skill. Given these directions for change, growing complexity in the health care system, and the expectations of registered nurses practicing within that system, it is essential that registered nurses receive the education they will require to function to their full scope of practice. Contrasts of previous scope of practice statements for registered nurses in Alberta and the statement recently developed by AARN for use under the Health Professions Act readily identify these increasing expectations for autonomous and creative nursing practice. Without that preparation, we would disadvantage both registered nurses and our province in achieving the goal of moving toward a primary health care focused system. A high percentage of the current nursing workforce, including many of our nursing leaders, are predicted to retire over the next ten years. Replacement of these experienced leaders of nursing practice and innovation will depend on recently graduated registered nurses who have learned to think broadly, creatively, independently, and critically through their educational preparation and much shorter nursing experience. Identify all of the stakeholders potentially affected by the proposed changes including the public, employers, government, educational institutes and professions. What consultation has been carried out with stakeholders? Describe the consultation process, including responses received during the consultation. Public of Alberta In August 2000, the AARN commissioned the Angus Reid Group to conduct a public survey of Albertans concerning a number of nursing issues, including the level of public support for degree education for registered nurses. A total of 648 telephone interviews were conducted with randomly selected Albertans aged 18 or older, excluding anyone working within the health system. The results were considered accurate within 3.9% (+ or-) 19 times of 20. August

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