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

Transcription

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

21 The three questions posed during the survey, and the public response received were: 1. What is the minimum level of education you believe nurses are currently required to have to practice in Alberta? university degree - 50 % of respondents post-graduate degree - 12 % college diploma - 31 % high school - 4 % don t know - 4 % 2. In most other Canadian provinces, new nurses entering the profession are either presently or soon will be required to have a minimum of a bachelor s degree in nursing. In Alberta, nurses are required to have a minimum of a college diploma to practice. Would you support or oppose changing education requirements for new nurses entering the profession in Alberta to have a minimum of a bachelor s degree in nursing? Would that be strongly or somewhat? strongly support - 36 % somewhat support - 32 % somewhat oppose - 20 % strongly oppose - 9 % don t know - 3 % 3. Given your level of knowledge about the AARN, what would you recommend that the AARN do to improve the quality of nursing in Alberta? In this open-ended question, 23% (the largest single answer group) said more education/make sure they have a degree/continuing education. In summary, the results of this survey provided evidence of significant support for degree preparation from the public of Alberta, with 62% of Albertans assuming that registered nurses already had university preparation, and 68% believing that they should. Registered Nurses of Alberta Alberta s registered nurses have been consulted in numerous ways since the issue of degree preparation as the minimum entry-to-practice qualification first began receiving attention during the 1970s. In a formal sense, the perspective of AARN members is represented by the elected members of AARN provincial council and the decisions that they have made on this issue. However, in order to give individuals an opportunity to have more direct input, an AARN member survey in 2000 asked registered nurses to rate their level of support for the baccalaureate entry-to-practice initiative and to indicate their reasons for support or lack thereof. Of the 750 registered nurses who responded to these questions, 61% indicated that they were supportive or very/completely supportive while 38% indicated that they were not supportive. Of August

22 the 61% who were supportive, more than half (54%) stated that they were very or completely supportive of baccalaureate as entry-to-practice. Members were asked to provide reasons for their support or non-support of the change in requirements. In order of response frequency, the reasons most often given for lack of support were: degree nurses lack hands-on experience; degree nurses are no more qualified than diploma nurses; will worsen the nurse shortage; diploma nurses are practical/degree nurses are administrative; degree is too expensive; degree is too time-consuming; nurse salary does not justify cost of degree. The most frequently stated reasons for supporting baccalaureate entry-topractice were: degree provides a wide range of education; degree lends respect to the profession; degree is needed for increased role of registered nurses; diploma is not sufficient; degree ensures high quality nurses; degree provides nurses more opportunities. In further breakdowns of the member response data, it was revealed that diploma-prepared respondents were less likely (17%) to be strongly in support of the proposed educational requirement than were respondents with baccalaureate degrees (58%) or masters/doctoral degrees (97%). It was also noted that respondents with less than seven years of nursing experience, and those with fifteen or more years, were more likely to be strongly supportive of baccalaureate preparation than were respondents with seven to fifteen years experience as a registered nurse. Alberta s Health Authorities and Other Health System Stakeholders In May 2002, the AARN engaged the services of a consultant to conduct two rounds of focus groups to attempt to achieve a shared framework of understanding about Alberta s health system, the required roles of registered nurses within it, and the role of baccalaureate entry-to-practice within this framework. Groups that were represented in the consultation include Alberta Health and Wellness, regional health authorities, provincial professional associations and colleges, senior nursing leaders, nursing education, organized labour in nursing, AARN members, nursing students, private health care providers, third party payers, associated partners, and health consumers. A total of eight focus group discussions were conducted between August and October (For a complete list of stakeholders included in consultation process with the AARN, see Appendix E). The results included consensus on several emerging themes within the health system: Patient/Client Care: The complexity of the client s health profile and the resultant health care needs was highlighted as a key feature of patient/client care. Participants identified increased acuity, aging population, and social factors as the evidence of the many facets of patient care that need to be considered in the health system today and when compared historically, the participants concluded that there is a trend to increasing complexity. August

23 Health System Change: Participants identified the various aspects of health reform in Alberta contributing to the current culture in transition. They suggested the concept of primary health care was the overall tie-in, including multidisciplinary/interdisciplinary and inter-sectoral teamwork, resulting in an integrated health system. Workplace Profile: Participants consistently expressed concern that the health system today is significantly challenged by professional recruitment and retention. Staff shortages and the demographics of the registered nurses currently working in the health system emerged as the focus groups primary indicators and sources of concern. Support of external recruitment efforts affecting the number of registered nurses available in the recruitment pool was also very important to stakeholders. Regionalization, the application of business (effectiveness and efficiency) principles to health services, and the rurality of the province were also identified as key features of the health workplace. Utilizing Information and Knowledge: Participants asserted that advances in technology have resulted in more information being available to the registered nurse as well as increased accountability for evidence-based practice. Telehealth was the most common example given of the registered nurse as a knowledge worker and caregiver. Respondents expressed concern that the profession understand the implications related to the skills and knowledge requirements of the registered nurse, as well as implications regarding privacy and confidentiality for clients/patients. The six principal roles of registered nurses in the system were identified by stakeholders as: critical assessor/thinker/interpreter coordinator of care/planner/quality assurance decision-maker/problem solver clinical care giver/health promoter advocate/leader case manager While there was no clear consensus of support about the role of the baccalaureate entry requirement within the framework, stakeholders did comment on how the AARN should go forward, indicating the following areas as critical: The need for the AARN to give clear rationale for baccalaureate entry with respect to the roles of the registered nurse and link to competencies. Implementation issues timelines and human resource requirements. The cost of baccalaureate education to the system and to the individual. Interdisciplinary/multidisciplinary educational opportunities. The need for registered nurse role clarity in relation to the range of nursing services, while not emphasizing a sole practitioner or superiority. Concern regarding capacity for nursing student placements. August

24 In December 2002, the AARN received a document from the Health Authorities Health Professions Act Review Committee, highlighting its concerns with the proposed move to the baccalaureate requirement, which was at that time planned for a January 1, 2005 implementation. The concerns expressed seemed to fit within a few key themes including: The cohort of around 150 diploma graduates that would be missing from the workforce during the transition year, and the effect of magnifying an existing registered nurse shortage. Implications for direct patient care, assuming that degree-prepared nurses will not be employed in direct patient care. Lack of clear distinction between diploma and degree graduates, in terms of competencies. Possible cost impacts for the system, since there is a small wage differential for degree nurses. Several meetings and teleconferences followed over the next few weeks, with an AARN discussion paper developed in February and circulated to stakeholders by Alberta Health and Wellness as part of the registered nurse policy consultation for HPA. The consultation feedback to government from the Health Authorities HPA Review Committee indicated some outstanding issues with the policy on baccalaureate entry-to-practice, in addition to some comments in support of the policy. The health authorities issues, and responses subsequently communicated to the health authorities by the AARN, were as follows: HA HPA Review Committee Comments The AARN is encouraged to explore the potential for a more gradual transition to a degree-prepared RN. The number of applicants to the degree programs is increasing, and the educational system must increase its capacity accordingly. The anticipated loss of at least 150 new diploma graduates per year from Alberta educational institutions, as well as an unknown number of diploma graduates from other provinces and countries, and AARN Written Responses to HA HPA Review Committee As AARN indicated in the discussion document circulated in February, we have been actively exploring various transition strategies, working with RN educational program leaders and other stakeholders. A more gradual transition was agreed upon as a necessary strategy to allow for educational programs to wind down their programs, as well as to address the valid short-term concerns of health authorities about the impact of losing a cohort of diploma graduates in As a result, the AARN Provincial Council passed a motion in March 2003 that specifies revised timing for implementation. This new timeline will see admissions to diploma-exit RN programs continue up to September 1, Because of the 4 to 5 year completion time typically granted to students, the final transition to baccalaureate as the requirement for entry-to-practice will take place in 2007 or As indicated in the discussion paper, anyone previously licensed with an RN diploma would continue to be eligible for licensure in Alberta; this includes foreign RNs and RNs returning from leaves. It is only initial registration that will have the baccalaureate requirement by 2007 or 2008 August

25 HA HPA Review Committee Comments those returning from leaves and long-term absences from the workplace (for example, maternity leaves). This is seen as having a high potential to exacerbate the already significant provincewide shortage of RNs, and impact upon future wage settlements. The potential loss of these new diploma graduates will be most keenly felt in rural and remote areas, as our experience suggests that Baccalaureate-prepared RNs are most often attracted to urban centers. The potential negative impact of BETP upon rural training programs, as the greatest supply at present is from diploma programs. "These nurses tend to be people with attachments to our communities (because the practical experience is most often offered locally.) The nurses from the urban programs cannot operate in the multi-skilled environment of rural health care without additional training and may or may not have roots in the rural communities. None of the urban baccalaureate programs have their candidates trained to do practicums in the rural localities. The perception that over time, the "problem" which may be precipitating the need for BETP will address itself, without the need for a formal mandate. That is, somewhat more entry-level nurses are choosing the BETP route over time and this trend will continue in the future. AARN Written Responses to HA HPA Review Committee Impact on the current shortage of RNs is being addressed through the gradual implementation plan described above, and by strategies underway with universities and Alberta Learning. One such strategy is to increase the number of seats in the after-other-degree baccalaureate programs (which bring new RNs into the workforce within a two year time period). Currently, the seats allocated to these twoyear programs are a small fraction of the number of applications received. The possible impact on future wage settlements is something that employers have the mandate to address through labour relations strategies over the next several years. AARN policy on baccalaureate as entry-topractice is silent on the topic of salary level or differential. We recognize that graduates of nursing programs often feel more comfortable seeking employment in settings that they have experienced through their clinical placements as students. AARN is currently working with nursing leaders and with Alberta Learning to address several issues related to clinical placements of nursing students in Alberta, including reducing barriers to student clinical placement in rural areas by developing a centralized clinical placement process for all nursing programs and all Regional Health Authorities (RHAs). Currently, 80% of Alberta s new RNs have graduated from degree programs, with only 20% choosing the diploma route. It is true that, if present trends continue, there will be a dwindling of applicants to diploma-exit streams to the point where these programs will no longer be viable to operate. It is partly for this reason that nursing program directors have recently requested from the AARN some clear direction and timelines, to provide them with much- August

26 HA HPA Review Committee Comments Both baccalaureate and diploma graduate nurses write the same registration examination: "It has not been demonstrated that the competencies of the baccalaureateprepared nurse are superior to a diploma graduate... we do not believe that the AARN has addressed this issue." AARN Written Responses to HA HPA Review Committee needed planning parameters. We are increasingly concerned about the ongoing ability of diploma graduates to perform well on the Canadian Registered Nurse Examination (CRNE). Over the past few years, with several provinces already requiring baccalaureate education, this exam has shifted toward reflecting competencies gained in degree programs. This trend is expected to increase significantly after 2005, when two large provinces (Ontario and BC) will have moved to baccalaureate education as entry-to-practice. It is the intent of CNA to significantly change the CRNE to reflect the BN competencies. Implementation of these changes is scheduled for Consultation with Alberta s health authorities on this policy has continued, including further meetings and written communication in June and July On August 13, 2003, a teleconference was held between the Health Authorities HPA Review Committee and senior AARN officials to work toward resolution of any concerns that still exist on the part of health authorities. A draft of the AARN s proposal to the Health Professions Advisory Board was circulated to committee members in preparation for this teleconference. Nursing Education Programs There have been several consultations in recent months between the AARN and Alberta s nursing education program leaders concerning the baccalaureate entry policy, the timing of the transition, and related issues such as coordination of student clinical placements and possible internship programs for new registered nurses. In an April 2003 letter from the AARN president to the deans and directors of all Alberta nursing programs, a transition plan was proposed that would see final implementation of the new registration requirement by 2007 or Respondents indicated general support of the policy, as well as appreciation of the AARN s effort to provide them with some transition planning parameters. Some also indicated that, due to calendar publication schedules, they would need to continue admitting students to diploma exit streams into the fall of 2004, and that their policies provided for a maximum of five years to complete a diploma program. In response to these concerns, the AARN provincial council made a policy decision in May 2003 that December 31, 2009 will be the last date on which a new graduate of a diploma nursing program will be eligible for registration in Alberta. A final consultation with twelve representatives of Alberta s nursing education programs was held in July 2003 for the purpose of further delineating the competencies expected of students at the end of the diploma program as compared with the degree program. These individuals also August

27 provided the AARN with some information regarding comparative costs and other program parameters. Alberta Learning During Alberta Health and Wellness stakeholder consultation on the registered nurse policy statements under HPA in February-March 2003, the following comments were submitted by Alberta Learning. A meeting was held in April between senior staff from AARN and from Alberta Learning and the accompanying responses were discussed at that time. Alberta Learning Comments The new AACRN is proposing that the entry-topractice requirement for RNs be changed from diploma to baccalaureate. We do not support this proposal. We have not been provided with the evidence or competency-based analyses to justify the degree as the appropriate academic standard. A higher entry-level requirement will necessitate the development of new nursing degree programs at Alberta public post-secondary institutions and/or a significant expansion of seats in existing nursing degree programs at Alberta Universities. Either option will present significant cost implications to both Alberta Learning and the Alberta public postsecondary system. Extending the basic entry requirement to a degree, thereby lengthening the training program, may not be viewed favourable by employers, particularly given the RN shortage. It will also reduce overall access. At the national level, there is movement underway to establish a working group to develop a common template for use by all jurisdictions to assess requests for higher entry-to-practice level credentials in health disciplines. Alberta Learning supports this initiative and would like to be updated on the status of a proposed moratorium on approving new proposals of the nature. We are aware that several jurisdictions that have legislated a degree entry are reconsidering the merits of this decision (i.e. Ontario) or have temporarily gone back to the diploma entry (i.e., Manitoba). AARN Comments in Response The expansion of seats required is not extensive, given that 80% of nursing students are already choosing the degree route within the collaborative programs. The need to accommodate in the degree-completion the approximately 150 students per year who currently choose diploma exit is offset to some extent by removing the need for colleges to continue offering the diploma-exit term of study We acknowledge the significant concerns of employers about the possible effect on the preexisting nursing shortage, and are working on transition strategies to address these. We have also become aware of this national work, but have informally been assured that the purpose of this task group is to address issues concerning some allied health (technical) occupations, and will not focus on nursing. In discussion with our colleagues at the College of Nurses of Ontario, they indicate that there is no reconsideration of BETP 2005; further that their government remains fully supportive. Manitoba did temporarily revert to diploma as the August

28 Alberta Learning Comments Grant MacEwan College and Lethbridge Community College have advised us that they want to maintain the diploma program. This reflects very strong employer support in these regions for diploma nurses. Changes at the entry-level may also necessitate changes in the existing refresher program at Grant MacEwan College. Again, this will present cost implications for Alberta Learning. The department would request from the AACRN a list of Alberta employers supportive of the degree entry. This list should be made available to other interested parties as well. AARN Comments in Response entry requirement, but work is underway to reinstitute a baccalaureate requirement. We are not aware of such concerns at GMC or LCC. Indeed, the nursing program leaders there have been supportive, and have raised concerns only about timelines for transition, student notification in calendars, etc. There should be no impact on nursing refresher programs. The AARN has been asked by the health authorities to work officially through their HPA Review Committee on this and other HPA issues. Alberta Health and Wellness Over the past several months, formal discussions were held between the AARN and senior government officials, including the Minister and Deputy Minister of Health and Wellness and the Premier. While the Minister and the Premier did not raise specific issues regarding this proposed change in requirements, the Deputy Minister expressed some concern about anticipated resistance on the part of health authorities regarding the potential for increased costs. The AARN has been unable to directly determine the views of Alberta Health and Wellness regarding baccalaureate entry-to-practice for registered nurses. 3.2 Educational/Training Implications Describe the education/training changes required if there were a regulatory change and outline the differences between the current and proposed program. What is the cost of implementing changes in the educational program? (Identify costs associated with the proposed change such as additional resource material or equipment etc.) It has been somewhat difficult to ascertain actual average cost differences for the diploma versus degree programs across the province, given variables such as differences between funded amounts per FTE student and actual costs incurred by programs, etc. Further, although the nursing education providers in the province have been highly successful in collaborating and integrating their programs, the various educational institutions still maintain separate budgets and budgeting systems, therefore making estimation of entire program costs problematic and incompatible for comparison purposes. It would be expected, though, that requiring degree completion by the approximately 20% of nursing graduates per year (150 graduates) who now choose diploma exit would imply some additional cost for the educational system. August

29 What must not be overlooked, however, is the issue of cost-effectiveness and viability of diploma exit programs when so few nursing students are choosing to pursue that option. The following facts supplied by Grande Prairie Regional College provide an example for illustrative purposes. Over the past five years there have been very few nursing students at Grande Prairie Regional College who choose the diploma exit option. The last time courses for the diploma exit option were offered at GPRC was in That year there were only four students. These four had to have their own instructor. Thus, the small student-teacher ratio drove up the actual education cost per student. Subsequently, a decision was made that GPRC could not offer the diploma exit courses unless a minimum of six students enrolled. Since 2000, GPRC has only had one or two students a year request the diploma exit stream. They have had to incur the added cost of relocating to Edmonton or Red Deer to complete their program. In recent published statements nursing students at Grant MacEwan College indicated their strong preference for degree preparation versus nursing diploma. A diploma in nursing is fine, but a degree offers more opportunities. Most specialities, such as home care, require nursing degrees. (Edmonton Journal, August 16, 2003, p. B2). What effect will the proposed change have on current students? Will the students have to take additional courses or do extra clinical placements? Please explain. Current students and students who are admitted up to and including the fall of 2004 will not be affected, since they can still choose the diploma or degree option (see implementation schedule in Section 4.0). However, after that time, students will have the option of degree completion only. This does involve both additional coursework and additional clinical time, as compared to the diploma exit option. This would be expected to impact on those approximately 150 students per year who currently take the diploma exit option. If your profession has clinical placements, describe the anticipated impact on future clinical placements (e.g. type, location or duration and availability of the placement). There would be an impact on clinical placements, as these are required by students in the final year for degree completion. These placements are in a variety of hospital and community settings. There are several issues in the province at this time concerning availability and coordination of clinical placements for students in nursing and other health programs. The AARN is currently working with nursing leaders and with Alberta Learning to address several of these clinical placement issues in Alberta, including reducing barriers to student clinical placement in rural areas by coordinating clinical placement processes for all nursing programs and all RHAs. August

30 Will current practitioners need upgrading or will there be provisions for grand-fathering? If upgrading is necessary, describe how this will be done and the financial and human resource implications. What are the cost implications? How will this affect the practitioner re-entering the profession? There will be a grand-parenting provision associated with the proposed change, which means that all registered nurses who entered practice before the January 1, 2010 date will continue to be eligible for licensure in Alberta, and will continue to be able to practice to full scope as registered nurses. There will be no mandatory upgrading of registered nurses who are already licensed to practice. In spite of the grand-parenting provision, some stakeholders have expressed concern that diploma-prepared registered nurses might feel devalued in some way, or possibly leave the system when the new requirement is implemented. However, implementing baccalaureate entryto-practice does not in any way imply a lesser value on the contribution of diploma-prepared registered nurses already working within the health system. These experienced diplomaprepared registered nurses have acquired considerable knowledge and skills as a result of their basic education, augmented with years of experience and a commitment to continuing education. They will continue to play a vital role in Alberta's health system. It is important to note that diploma-educated nurses have not left the health care system in jurisdictions that have already implemented this change. It is also relevant to note that experienced diploma-prepared registered nurses who are practicing in other jurisdictions will continue to be eligible to obtain a license to practice in Alberta, provided the diploma was obtained prior to December For those receiving nursing diplomas after that date, Alberta s new health professions legislation provides an alternative route for licensing through a substantially equivalent competency provision. This will be done through Prior Learning Assessment and Recognition (PLAR), which will assess the applicant s competencies. In terms of registered nurses re-entering the system after a lapse in employment and/or licensure, this change will not directly affect them. The new requirement applies only to initial entry-topractice as a registered nurse in this province after Even though upgrading to a degree will not be necessary for registered nurses who are already practicing, there is likely to be an increased interest among these practicing nurses to obtain a baccalaureate through one of the post-rn routes. This is increasingly an option that many diploma-prepared registered nurses in the system already choose to pursue. Of the current AARN membership, 62% have diploma as their highest level of preparation, while 38% have a baccalaureate degree or higher. The availability of distance learning post-rn programs makes this a very viable option for Alberta s nurses, regardless of location, and allows for part-time study which can allow the nurse to continue employment and minimize the financial impact. August

31 The Alberta Registered Nurse Educational Trust also provides financial assistance for nurses who choose to further their education. 3.3 Effect of Change on Profession Please describe what effect the proposed change will have on your profession s scope of practice. How do the competencies of the current minimum entry-to-practice requirement differ from the proposed entry-to-practice requirement? Will the proposed change: increase, decrease or have no effect on your profession s key role and functions? affect your profession s core competencies? During AARN consultations about the emerging roles that registered nurses are expected to fill in Alberta s health system, health stakeholders identified these roles as including: critical thinker, case manager, caregiver in all settings, problem solver, educator, leader/change agent, coordinator, and health promoter. More recently, in the registered nurse policy consultation for HPA, the health authorities commented that the BETP proposal recognizes the increased complexity and acuity of the patient care population, and the need for registered nurses to assume more of a leadership role. Baccalaureate preparation provides the beginning registered nurse with a broad base for the full development of nursing competencies and for fulfilling the important advocacy roles that the public has a right to expect from registered nurses who are the providers in closest and constant proximity to clients in every clinical setting throughout the system. Registered nurses address the health needs of people throughout the life span. These clients may be individuals, families, groups, or communities in any and all of the various environments and settings in which they live and work. These practice locations include, but are not limited to: outpost nursing stations in remote areas, palliative home care, continuing care facilities, street nursing of disadvantaged inner city populations, operating room, nursing as a member of a primary health care team in an after hours clinic, nurse practitioner in an adolescent health clinic, triage/provision of health information/way-finding through a telephone nursing service, air ambulance emergency transport, cardiac transplant unit, paediatric intensive care, acute medical care unit, obstetrical delivery/post partum care, occupational health in industrial settings, and public health immunization clinics. The scope of practice of registered nurses is determined by the needs and health goals of their clients and is limited only by the specific competencies of the individual registered nurse to perform the activities necessary for the client population with whom that nurse works. Registered nurses are uniquely prepared and located to provide leadership and serve as change agents in facilitating and strengthening health services. Collectively, we must ensure that August

32 registered nurses enter practice with a solid foundation of knowledge with which to realize their full scope of practice in meeting health needs of Albertans. 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. This indicates that, even with baccalaureate degrees, the vast majority of registered nurses will continue to be employed in the provision of direct nursing care in facilities or in the community. This fact notwithstanding, a baccalaureate degree will provide a very solid foundation for registered nurses to later move into leadership positions as needed within Alberta s health system, as well as preparing them for emerging roles such as that of nurse practitioner. It should also be pointed out that nursing leadership is broader than formal management. It also means clinical leadership among staff nurses, particularly in long-term care settings and rural areas, where it is possible that an individual staff nurse could be the only registered nurse on a unit or on a shift. The concept of clinical leadership and why a baccalaureate degree best prepares a nurse for this role is perhaps best illustrated by quoting an excerpt from a letter published in the AARN Newsletter in July/August The letter was written by Jackie McDonald, a registered nurse practicing in Alberta and completing a post-rn degree program. She was reacting to a question others often asked her about what good jobs she was hoping to line up by completing a degree. Her letter stated: This question implies that jobs on a staff nurse level are not good jobs. Furthermore, it refers to the days when a degree was a ticket away from the bedside and shift work. Times have changed, and well-educated nurses are being purged from hospitals. One has to seriously consider what one s aspirations are. My education has reinforced the notion that the bedside is precisely where advanced nursing skills are needed the most. It is on the individual level that principles of illness prevention and health promotion really mean something. It is also the place in which I feel the most at home. There is a place for a BScN there, but it requires that I seek out opportunities to expand my role. I see myself initiating patient care projects, using theoretical and research principles. I see myself becoming more skilled as a resource person, providing direction and knowledge to new staff and students. I see myself as an instigator of policy change, helping to represent my care area in the greater hospital. My answer to this question will now be: I already have a good job. I intend to push back the boundaries of a conventional staff nurse. I will try to use my knowledge to make a difference to the patients I care for and to the nurses with whom I work. August

33 Will the proposed change affect your profession s mobility between jurisdictions? Canadian nursing jurisdictions have developed the Mutual Recognition Agreement of the Regulatory Bodies for Registered Nurses, in consideration of the terms of Chapter 7 of the Agreement on Internal Trade. The purpose is to set out commonly held national registration/licensure principles to facilitate mobility of registered nurses across the country. Because there is some variability in the legislation within provincial jurisdictions, the legislation supersedes the agreement. However, if jurisdictions have baccalaureate as their entry-to-practice requirement, it would be as an exception that they would recognize a new diploma prepared nurse from another jurisdiction. While the regulatory bodies are working towards communality, the majority will greatly influence the accepted standard for mutual recognition. Therefore, future mobility of Alberta s registered nurses could be negatively impacted if baccalaureate does not become the standard entry requirement in this province. Will the proposed change affect the supply of practitioners? Will the supply increase, decrease or remain the same? With the proposed transition to baccalaureate entry-to-practice, concern has been expressed about possible consequences of the absence of the cohort of diploma-prepared registered nurses for the nursing workforce. While this concern is legitimate, it is important to consider the loss of cohort issue in light of the actual size of the diploma-exit cohort. The following table portrays the current nursing education picture in Alberta, using AARN statistics based on persons taking the registered nurse exam over the past three years: Year Total Number of Graduates Diploma Graduates Degree Graduates % Diploma Graduates It is clear that in recent years between 78 and 84% of nurses graduating in Alberta and writing the registered nurse exam have completed a degree program, indicating that there is already a very strong preference for baccalaureate preparation among individuals entering the profession. This percentage would be even higher, if not for a known ceiling effect due to insufficient numbers of funded educational seats to accommodate all nursing students who wished to proceed to baccalaureate after completing the first two years of their program. Still, the temporary loss of approximately 150 diploma graduates during the twelve to eighteen month period of transition was an important issue and had been addressed through further consultation and an adjustment of the implementation timeline to January 1, Other discussions with directors of Alberta s nursing schools and with the Minister of Learning identified two steps that could eliminate any dip in the total number of registered nurse August

34 graduates during the transition period. The first step would be to obtain additional funding from the Minister of Learning for after degree programs to address shortages now and help address the elimination of a diploma-prepared nursing cohort. These programs are intended for people who already hold an undergraduate degree in arts or sciences and are admitted for two years of intensive nursing content leading to a degree in nursing. There is considerable demand for these programs. For example, the University of Alberta program had 334 qualified applicants for its after degree nursing program last year, but had funding for only 70 first year seats. The second step was the scaling down of diploma-exit graduates over a longer period of time, rather than an abrupt end to the cohort existing as of January 1, The new timeline addresses this. These strategies, in conjunction with the effects of increased nursing seats over the past years, would support the increased numbers of nursing graduates required to accommodate health system needs. On a more general note, there is currently a worldwide shortage of nurses, regardless of the educational requirements for entry-to-practice. One factor contributing to workforce retention issues is the adequacy of the individual s preparation to meet the demands of the workplace. Registered nurses across many practice settings, and particularly in rural or remote areas, are now expected to function in a much more autonomous way, often without formal supports such as frontline managers and clinical educators. In this increasingly complex and demanding environment, registered nurses with baccalaureate degrees will be better prepared to meet the challenge, thus potentially aiding in job satisfaction and long-term retention. There is a responsibility on the part of all stakeholders to ensure that registered nurses entering the workplace are as well prepared as possible to fulfill the diverse roles expected of them. The aging of the nurse population will be the single most influential factor in future registered nurse shortages. 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. Diploma preparation, on the other hand, is a characteristic more often associated with an aging nursing workforce, many of whom will be expected to retire during the next 10 to 15 years. As noted in current AARN statistics, the average current age of registered nurses who entered practice with a diploma is 46 years, compared to 35 years for those who entered with a baccalaureate degree. A report released in January 2000, the Labour Market Integration of Graduates in Nursing in Canada , prepared by the Canadian Council on Social Development, illustrated the significance of education as a retention strategy. Findings showed that, as a proportion of total migration, nursing graduates of diploma programs were more likely than their universityeducated counterparts to leave the country (34% versus 19% respectively). A reduction of 15% in the turnover of nurses could result in significant cost savings to employers even if calculated only on the easily identifiable recruitment and orientation costs per turnover, without including the more subtle costs of lost productivity and stress to other staff members. If one were to calculate an average orientation cost for a registered nurse on the basis of four weeks (about 150 August

35 hours) at an hourly salary of $25.00 ($ ), plus at least one week (37.5 hours) of the time of the more experienced nurse ($29.00 per hour) to provide the orientation ($ ), the conservative cost per hire would total almost $ With the addition of minimal recruitment costs of $ per hire, the cost to an organization each time a registered nurse leaves would be at least $6,000. Nurse graduates of college diploma programs also were more likely to be underemployed, unemployed, or unable to find work in nursing. As a result, they showed an increased prevalence in part-time work and lower pay as compared to university prepared nurses (Canadian Nurses Association, 2000). On a final note about nursing supply and shortage issues, it has been well documented across the country that there is no current shortage of applicants to nursing education programs. For this reason, future nursing supply is increasingly dependent on educational funding decisions by governments, more so than on other factors. If a change in supply is expected please explain. What actions have the profession taken or propose to take to address those changes? A change in supply is not expected as a direct result of this policy change. How will the change in supply affect the service to the public? A change in supply is not expected as a direct result of this policy change. How will the change affect the status of current practitioners (e.g. professional standing, prestige, public recognition)? It is widely acknowledged that the status of a professional discipline is closely tied to the length and rigour of the education required for entry into practice. Individual pride in obtaining a registered nurse designation through a rigorous qualifying program cannot be underestimated. Nor should we forget that the credential to practice is awarded to an individual in recognition of a primary obligation to the recipient of service, as opposed to any employer, funding body, or other stakeholder. Alberta s health authorities said, during HPA policy consultation: Attainment of a baccalaureate degree provides registered nurses with increased credibility in relating to other regulated health professionals in a team environment. A lack of support for baccalaureate entry from health authorities will send a negative message to future nurses regarding the status of the profession and career choices. This lack of support could also disadvantage Alberta. August

36 It is worth emphasizing that the anticipated improvements in professional status, prestige, and credibility do not constitute primary or sufficient reason for seeking this change in entry-topractice requirements. However, together such factors do represent important means to achieving the ends of enhanced professional accountability and public safety, as further described in Section 3.4. How will the change affect the status of current practitioners who do not possess the additional qualifications? This change should not affect the status of diploma-prepared registered nurses who are already licensed to practice. These experienced registered nurses have acquired considerable knowledge and skills as a result of their basic education, augmented with years of experience and a commitment to continuing education. They will continue to play a vital role in Alberta's health system and will continue to maintain access to registration. It is also worth noting that registered nurses generally identify themselves as RN rather than with any degree or diploma designation. This, coupled with the evidence that the majority of the public already assumes nurses are degree-prepared, means that there should be no visible change in status or designation. 3.4 Effect of Proposed Change on the Health Care System Please describe how the changes in entry-to-practice requirements have the potential to affect the health system as a whole. Please describe the information or evidence that you have used to form the basis of the answers to the questions. What impact will the proposed entry-to-practice requirements have on the health system? How will the proposed change affect health determinants, health promotion or disease/injury prevention? Will there be improvements in service delivery? If yes, how? Health service delivery will be positively impacted through a registered nursing workforce that can provide better communication and coordination across the continuum of care, enhanced interdisciplinary collaboration, and a greater focus on evidence-based practice in all care settings. These improvements in communication and coordination of client care across today s complex health system are also expected to improve patient safety, since it has been recognized that many system errors occur at the points of hand-off of care between different providers and different sectors within the system. A nursing workforce better prepared to work within a primary health care model will, over time, make significant contributions to population health through their enhanced knowledge and skill in addressing the determinants of health, health promotion, and disease prevention. August

37 What impact will the proposed entry-to-practice requirements have on clients/patients? Will there be improvements in public safety and/or health outcomes? If yes, how? Because the knowledge required for competent practice as a registered nurse is expanding at such a rapid rate, it is unrealistic to think that the discipline can be sufficiently mastered within the period of study currently required for a nursing diploma. As such, nursing as a profession must consider seriously the ethics of depriving the public of the full measure of nursing knowledge that should be available to assist and protect them, as well as the ethics of leading students to believe that a two- to three-year program constitutes an adequate introduction to the discipline (Christman, 1991; Jacobs et al, 1998). On the issue of public protection through the actions of registered nurses, the Code of Ethics for Registered Nurses (Canadian Nurses Association, 2002), which is endorsed by AARN, requires nurses to, among other things: put forward, and advocate for, the interests of all persons in their care... promote appropriate and ethical care at the organizational/agency and community levels by participating in the development, implementation and ongoing review of policies and procedures designed to provide the best care for persons with the best use of available resources given current knowledge and research. There are two high profile Canadian examples of registered nurses in specific clinical settings who have identified high-risk situations and attempted to advocate for appropriate action at the institutional level. The most recent is the SARS situation in Ontario, in which nurses working at the site of the second cluster in May 2003 had raised concerns that patients at that site might be infected with the SARS virus. In a June 9 letter asking Premier Eves to begin a full public inquiry, the Registered Nurses Association of Ontario described the circumstances contributing to the second cluster of SARS, and those that aggravated its spread, including the lack of response to early warnings raised by nurses (RNAO Media Release, June 9, 2003). The second well-documented case is that of the pediatric cardiac surgery deaths at Winnipeg Health Sciences Centre. During 1994, twelve children died while undergoing, or shortly after having undergone, cardiac surgery at that hospital. What followed was a suspension of the program and a subsequent inquest, which found that nurses had raised a number of concerns over the time period that these deaths were occurring, but that these concerns had not received appropriate and timely attention within the organization. The specific findings of the inquest report included: Throughout 1994, the experiences and observations of the nursing staff involved in this program led them to voice serious and legitimate concerns. The nurses, however, were never treated as full and equal members of the surgical program, despite the fact that this was the stated intent of the administrative changes that the program underwent in June Intensive care unit nurses, for example, were never properly involved in the August

38 review team that assessed the program during 1994, and nurses were not properly involved in the Williams and Roy Review. The concerns expressed by some of the cardiac surgical nurses were dismissed as stemming from an inability to deal emotionally with the deaths of some of the patients. As well, any concerns over medical issues that the nurses expressed were rejected as not having any proper basis, clearly stemming from the view that the nurses did not have the proper training and experience to hold or express such a view. In addition, while HSC doctors had a representative on the hospital's board of directors, nurses did not. The concerns expressed by the PICU and the NICU nurses over the types of procedures that were to be carried out in the intensive care units were not addressed in a timely manner. In a number of cases it appears that the concerns of the operating room nurses over the nature of the deaths that occurred and with the mortality rate were interpreted as an inability to cope with the unfortunate, unavoidable death of a child. There was an implication that the nurses lacked a vision of the larger picture. Historically, the role of nurses has been subordinate to that of doctors in our health-care system. While they are no longer explicitly told to see and be silent, it is clear that legitimate warnings and concerns raised by nurses were not always treated with the same respect or seriousness as those raised by doctors. There are many reasons for this, but the attempted silencing of members of the nursing profession, and the failure to accept the legitimacy of their concerns, meant that serious problems in the pediatric cardiac surgery program were not recognized or addressed in a timely manner. As a result, patient care was compromised. (Sinclair, 2001, Ch. 10). While it is not possible to establish a direct link between the educational preparation of the nursing workforce and the negative outcomes that occurred in these two examples, there are two potential factors that may have contributed to the lack of attention given to patient advocacy efforts of registered nurses. One is a lack of system know-how among nurses in terms of how to best pursue change and achieve action within a complex organization. The other relates to nurses credibility with other members of the health care team, as persons who are educated, knowledgeable, and therefore qualified to speak out on issues of patient safety. One can certainly question whether a more educated, confident, and credible nursing workforce might have had greater success in preventing negative outcomes for patients in these or similar unfortunate situations. What impact will the proposed requirements have on other health care professionals? Will there be an effect on other professions (e.g., educational requirements, employment opportunities, scope of practice, job assignments, status, etc.)? How will this impact employer needs and demands and other professions? There is no anticipated negative impact on other health professionals. One positive result will be the benefits to be derived from working in an interdisciplinary environment with registered nurse colleagues who have an increased breadth and depth of knowledge. Within the nursing team, this proposed change could have a positive impact on the clarity of roles and functions between August

39 registered nurses and licensed practical nurses, potentially removing some of the current confusion about these respective roles on the part of employers, clients, the public, and the professionals themselves. By increasing the entry-level education of the largest proportion of Alberta s health workforce, there is an opportunity to effect the kinds of large scale system changes that may have positive spin-off effects in terms of expanded roles and opportunities of other health disciplines. What effect will the proposed change have on human resources? Health human resource planning should take into account the fundamental requirement that registered nurses be appropriately educated to meet the complex and changing health needs of the public. For the purposes of long-term recruitment, registered nursing as a profession must continue to have appeal for the brightest and the best of our young people, who have so many different career choices available to them. In their submission to Alberta Health and Wellness this spring, Alberta s health authorities stated that: Employers such as health authorities need to take a long-term view from the perspectives of recruitment and retention, and health workforce planning. The health system is becoming more complex, and there will be an increasing need over time for Registered Nurses with strong clinical and critical thinking skills, who are able to function far more autonomously. One overall benefit to health human resources of more degree-prepared nurses is that it will expand the availability and flexibility of the workforce to fulfill roles across a wider variety of hospital, community, and public health settings. The area of nursing leadership into the future is another important human resource consideration, in addition to the issues of entry-level supply of nurses. Sufficient numbers of nurse educators, clinical nurse specialists, nurse educators, and nurse researchers must be educated to support nurses in direct care, as well as to address shortages within educational institutions and health agencies. Baccalaureate preparation provides the foundation for nurses to move into these leadership positions in the future. What effect will the proposed change have on duties of current practitioners? What effect will the proposed change have on current job assignments? Please see previous sections. What effect will the proposed change have on worker flexibility as it relates to the scope of practice, service settings or accountability? The registered nurse with baccalaureate preparation has the flexibility to work across many settings and care teams, which can optimize the use of health system resources. As regional health authorities amalgamate and redefine their health service needs and priorities, there will be August

40 a distinct advantage to having a registered nurse workforce capable of being deployed across the service continuum, from prevention and promotion to community, tertiary, and continuing care. Implementation of primary health care reform, in particular, will be critically dependent on the availability of registered nurses whose education has prepared them well to take on these new roles. What effect will the proposed change have on supply of practitioners? During the recent consultation on the registered nurse HPA policies, which included a change to baccalaureate entry-to-practice by 2005, some have identified this as having a high potential to exacerbate the already significant province-wide shortage of registered nurses. This concern has been addressed through a more gradual transition and a January 1, 2010 implementation date, and by strategies underway with universities and Alberta Learning. One such strategy is to increase the number of seats in the after-other-degree baccalaureate programs (which bring new registered nurses into the workforce within a two year time period). There has been an increase in the numbers of such seats for the Fall 2003 term. Throughout the world we are seeing a shift to baccalaureate preparation for registered nurses. Long-term nursing supply, and the attractiveness of Alberta as a place of employment, will be positively influenced by a registered nurse educational requirement that parallels the world standard. What effect will the proposed change have on retention or turnover rate of practitioners? Please describe how this will affect employers, practitioners and patients. Ultimately, retention may be improved by having beginning nurses who are more prepared to face the challenges of practice within the ever more complex health care environment. Magnet hospitals research conducted in the 1980s in the United States and recently reconfirmed by Aiken, Havens, and Sloane (2000), indicates that in hospitals which possess magnet qualities, including the retention of nurses, the percentage of registered nurses with baccalaureate preparation is significantly higher (over 50%) than that of hospitals nation-wide (USA), which is about 34%. Of the current AARN membership, 62% have diploma as their highest level of preparation while 38% have a baccalaureate degree or higher. At the time of entry-to-practice, though, only 23% were prepared at the baccalaureate level. This illustrates that a significant number of Alberta nurses will interrupt their employment to obtain a degree, and that avoidance of such interruptions may improve retention. AARN membership data for the 789 diploma graduates who received their initial registration within the past five years (1998 through 2002) indicates that 93 (12%) of these new registered nurses have already completed a post-rn baccalaureate program or are currently studying within August

41 one. This demonstrates that, for a significant number of new graduates, there is an early recognition of the need to pursue further education to support their nursing practice. What effect will the proposed change have on labour contracts? Currently, the labour contract between the United Nurses of Alberta and the primary employers (Alberta s health authorities) specifies a wage differential of $1.25 per hour for baccalaureate preparation. This differential is being paid to more than one third of the registered nurse workforce, including the group of new registered nurse graduates, 80% of whom enter practice with a degree. Any possible impact on future wage settlements is something that employers and unions have the mandate to address through labour relations discussions over the next several years. AARN policy on baccalaureate as entry-to-practice is silent on the topic of salary level or differential. Please comment on any changes in cost of the proposed change taking into consideration capital costs, human resources and patient outcomes. How do you intend to address negative impacts? This change 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 costeffectiveness. A stronger nursing focus on determinants of health, health promotion, and disease prevention will also have a long-term impact on the health of Albertans, reducing future health service costs and enhancing sustainability. Any consideration of financial impacts must also take into account the potential cost savings due to risk avoidance and error management that can result from having professional staff members who are well prepared to take on the responsibilities expected of them in various care settings. The current emphasis on patient safety issues raises the importance of examining the preparation of clinical staff to provide and advocate for safe, competent care in a system with higher client acuity and fewer administrative supports available. It is worthwhile noting that some American jurisdictions considering baccalaureate entry to nursing practice are doing so based on a higher quality care ultimately costs less approach. 3.5 Effect of Not Receiving Approval for Requested Change Describe the effect on the public of not receiving approval for this request. The public of Alberta could certainly have reason to question why registered nurses in this province have a lower educational standard than those in the rest of Canada and beyond. In terms of possible effects on the health of the Alberta public, the issues of nursing advocacy and patient safety are salient concerns. In addition, the public will continue to lack the full benefit of primary health care reform and its expected positive results on the health of Albertans, since the August

42 registered nursing workforce would not be optimally prepared to participate in such system change. Describe the effect on the health care system. As above. Describe the effect on the members of the profession. Our members might legitimately view this in terms of a disconnect between this province s active leadership in many areas of health reform and the lack of endorsement of an educational requirement that will position registered nurses to help move reform forward. It could also be interpreted as a lack of respect for the credibility of nurses expertise and mandate in determining what preparation is required for competent nursing practice in today s system. Registered nurses might view it as an example, on a very large scale, of our profession s concerns being unheard, unrecognized, and not acted upon. 4.0 ADDITIONAL FACTORS THE BOARD SHOULD CONSIDER Please describe any other information the Board should consider in its deliberations. Are there any unique requirements in Alberta, which support this change? There are certain unique features of Alberta, relative to other jurisdictions, that place this province in a better position than others to realize the full benefit of a degree-prepared registered nurse workforce. The province s commitment and its progress to date in moving to a primary health care focused system is one such feature, as evidenced by Alberta s fully integrated regional system of health service delivery and by new programs such as alternative payment plans for physicians. This means that, more so than most other provinces, Alberta is poised to begin real health reform related to promotion/prevention, determinants of health, and chronic disease management. The vital contributions of a broadly educated and experienced workforce of 26,000 registered nurses will provide added impetus to such reform across the full range of service settings, and will multiply the ultimate benefits for Albertans. This province is also distinguished by the extent to which collaborative nursing education programs have become the norm, and by the well-developed distance learning options that are available in nursing, both for completing an initial degree in nursing and for later upgrading to a degree. These features not only provide many options for education regardless of where a student lives, but also will make the transition to degree entry-to-practice less challenging than it has been in provinces without existing collaborative nursing education programs. Of note is the fact that Ontario is using Alberta s model of collaborative nursing education in preparation for transition to baccalaureate entry-to-practice by August

43 Does implementation of the proposal require any legislative changes? If so, what changes are needed? No need for legislative change is anticipated. This new educational requirement for entry-topractice, and its January 1, 2010 implementation date, will come into force as part of the Registered Nurse Regulation under Alberta s Health Professions Act. What does the proposed implementation schedule look like? The final implementation date has been modified from January 1, 2005 to January 1, The reasons for this change were two-fold: 1. To address the health authorities expressed need for a more gradual transition to the new entry-to-practice standard, in order to avoid any possible short-term exacerbation of the nursing shortage problems during the transition year. 2. To address the reality that nursing education programs are already preparing calendars for the fall 2004 term, and some of these calendars continue to advertise a diploma-exit program option. The policy within these programs is to allow for a five-year maximum time frame for completion, in recognition of possible extenuating circumstances students may face. The modified implementation schedule will allow nursing students who begin studies in a diploma-exit program in the fall of 2004 the ability to write the Canadian Registered Nurse Examination up to October 2009, and to apply for licensing after program completion. The implications of this timing are that: Nursing education programs will have the flexibility to initiate their own transition plans for completing planned diploma programs and implementing curriculum changes for the baccalaureate stream. December 31, 2009 will be the last date on which graduates of Alberta s diploma-exit nursing programs will be considered to have met the educational requirements for eligibility for licensure as a registered nurse in Alberta. Any new diploma nursing graduate who fails to pass the licensing exam in October 2009 will be treated as a special exception to the above, in consideration of the AARN s policy to allow a maximum of three writings of the exam. Experienced diploma-prepared registered nurses who are practicing in other jurisdictions will continue to be eligible to obtain a license to practice in Alberta, provided the diploma was obtained prior to December For those receiving nursing diplomas after that date, Alberta s new health professions legislation provides an alternative route for licensing through a substantially equivalent competency provision. This will be done through Prior Learning Assessment and Recognition (PLAR), which will assess the applicant s competencies. The same process will be applied after 2009 for applicants from other countries. August

44 Describe the effects the proposed change might have on other jurisdictions. Canadian nursing jurisdictions have developed the Mutual Recognition Agreement of the Regulatory Bodies for Registered Nurses, in consideration of the terms of Chapter 7 of the Agreement on Internal Trade. The purpose is to set out commonly held national registration/licensure principles to facilitate mobility of registered nurses across the country. Because there is some variability in the legislation within provincial jurisdictions, the legislation supersedes the agreement. However, if jurisdictions have baccalaureate as their entry-to-practice requirement, it would be as an exception that they would recognize a new diploma prepared nurse from another jurisdiction. While the regulatory bodies are working towards commonality, the majority will greatly influence the accepted standard for mutual recognition. Describe any jurisdictional comparisons where a similar change has been made or considered. Please see Section 3.0. Is the request consistent with other current health, education and labour policy decisions? Describe. There is no identified inconsistency with such decisions; indeed, this change is very supportive of many of the Alberta government s health reform priorities. However, the Ministry of Learning and the educational institutions currently offering a nursing diploma-exit stream will, over the next few years, need to address this transition through resource reallocation and related strategies. The proposed change in the registered nurse entry-to-practice requirement is also entirely consistent with national and international trends and decisions concerning nursing education and regulation. August

45 REFERENCES Aiken, L.H., Havens, D.S., & Sloane, D.M. (2000). The magnet nursing services recognition program: A comparison of two groups of magnet hospitals. American Journal of Nursing, 100(3), Alberta Association of Registered Nurses. (2000). Entry-to-Practice Competencies. Edmonton, AB: Author. American Association of Colleges of Nursing. (1996). The baccalaureate degree in nursing as minimal preparation for professional practice. In Journal of Professional Nursing, 17(5), Canadian Council on Health Services Accreditation. (2003). Indicators (2 nd Ed.). Ottawa, ON: Author. Canadian Council on Social Development (2000). Labour Market Integration of Graduates in Nursing in Canada Ottawa, ON: Author. Canadian Nurses Association. (1932). Weir Report: Survey of Nursing Education In Canada. Ottawa, ON: Author. Canadian Nurses Association. (1998). Educational Support for Competent Nursing Practice. Ottawa, ON: Author. Canadian Nurses Association. (1999). Blueprint for the Canadian Registered Nurse Examination. Ottawa, ON: Author. Canadian Nurses Association. (2000). Labour Market Integration of Graduates in Nursing in Canada, Ottawa, ON: Author. Canadian Nurses Association. (2002). Code of Ethics for Registered Nurses. Ottawa, ON: Author. Canadian Nurses Association. (2003). Final edited Nursing in Canada fact sheet: Entry to practise. Ottawa, ON. Chapman, Y. (1991). Our history A proud heritage: AARN Newsletter, 47(7), Christman, L. (1991). Knowledge growth: A challenge to administrators. Journal of Nursing Administration, 21(5), Coulson, I., Keane, A., Davediuk, K., & Himsl, S. (2003). A call for innovative models for continuing care centres that humanize care and promote quality of life. Stride, May-June, 4-8. August

46 Doran, D.I., Sidani, S., Keatings, M., & Doidge, D. (2002). Issues and innovations in nursing practice: An empirical test of the nursing role effectiveness model. Journal of Advanced Nursing, 38(1), Ferguson-Pare, M.L. (1996). Registered nurses perception of their autonomy and the factors that influence their autonomy in rehabilitation and long-term care settings. Canadian Journal of Nursing Administration, 9(2), Field, P.A. (1978). An analysis of the course of change in nursing education in Alberta, Unpublished project submitted in partial fulfillment of course EDCI 601, University of Alberta, Edmonton, AB. Harrington, C., Kovner, C., Mezey, M., Kayser-Jones, J., Burger, S., Mohler, M., Burke, R., & Zimmerman, D. (2000). Experts recommend minimum nurse staffing standards for nursing facilities in the United States. The Gerontologist, 40(1), Health Professions Act, R.S.A. 2000, c. H-7. Jacobs, L.A., DiMattio, M.J.K., Bishop, T.L., & Fields, S.D. (1998). The baccalaureate degree in nursing as an entry-level requirement for professional nursing practice. Journal of Professional Practice, 14(4), Johnstrude, L. (2003, August 16). Colleges want power to grant degrees: Students like environment but want credentials too. Edmonton Journal, B2. Kovner, C.T., & Schore, J. (1998). Differentiated levels of nursing work force demand. Journal of Professional Nursing, 14(4), Kramer, M. & Schmalenberg, C. (1988a). Magnet hospitals: Institutions for excellence, Part I. JONA, 18(1), Kramer, M. & Schmalenberg, C. (1988b). Magnet hospitals: Institutions for excellence, Part II. JONA, 18(2), Kramer, M. & Schmalenberg, C. (1991). Job satisfaction and retention: Insights for the 90s. Nursing 91, (Mar.), Manuel, P., & Sorensen, L. (1995). Changing trends in healthcare: Implications for baccalaureate education, practice and employment. Journal of Nursing Education. 34(6), McDonald, J. (1994). That s a good question : One RN s thoughts on earning a BScN. Alberta RN, 50(7), 32. Nursing Effectiveness, Utilization and Outcomes Research Unit, McMaster University, University of Toronto. (1999). What does research say about baccalaureate entry to practice? Hamilton, ON: Author. Nursing Profession Act, S.A. 1983, c. N O Brien-Pallas, L.L., Doran, D.I., Murray, M., Cockerill, R., Sidani, S., Laurie-Shaw, B., & Lochhaas-Gerlach, J. (2001). Evaluation of a client care delivery model, part 1: August

47 Variability in nursing utilization in community home nursing. Nursing Economics, 19(6), O Brien-Pallas, L.L., Doran, D.I., Murray, M., Cockerill, R., Sidani, S., Laurie-Shaw, B., & Lochhaas-Gerlach, J. (2002). Evaluation of a client care delivery model, part 2: Variability in client outcomes in community home nursing. Nursing Economics, 20(1), Registered Nurses Association of Ontario. (2003, June 9). RNAO calling on Premier Ernie Eves to conduct full public inquiry into SARS outbreak. [Media Release]. Rich Vivone & Associates. (2003). Health: Allegations of mistreatment. Insight into Government, 17(40), 4-5. Ross-Kerr, J.C. (1998). Nurses and nursing in Alberta prepared to care. Edmonton, AB: University of Alberta Press. Shalala, D.E. (1992). Nursing and society -- the unfinished agenda for the 21 st century. In Perspectives in nursing New York: National League for Nursing. Sherwood, J. & Henderson E. (1990). Our history A proud heritage: The 1930 s dirty and depressing. AARN Newsletter, 46(9), 10 & 31. Sherwood, J. & Henderson E. (1990). Our history A proud heritage: The war years and beyond AARN Newsletter, 46(10), Sherwood, J. & Henderson E. (1991). Our history A proud heritage: AARN Newsletter, 47(2), Sinclair, C.M. (2001). The Report of the Manitoba Pediatric Cardiac Surgery Inquest: An Inquiry Into Twelve Deaths at the Winnipeg Health Sciences Centre in Winnipeg, MN: Provincial Court of Manitoba. August

48 APPENDIX A: HISTORICAL OVERVIEW OF NURSING EDUCATION IN ALBERTA Historical Overview of Nursing Education In Alberta (references available on request) 1894 to 1930 As the railroad reached Alberta and new immigrants rapidly arrived, so came the need for hospitals. With the establishment of hospitals, came the need for nurses. The early nurses were lay nurses that came from England, the United States, and other parts of Canada. The first nursing program began at the Medicine Hat General Hospital in 1894; the first nurses graduated from this program in The second nursing program began at the Calgary General Hospital School of Nursing in Nursing training was an apprenticeship system where the students were labourers and service took precedent over everything else. The doctors undertook what formal lectures there were. The doctors prepared the examinations and a certificate was presented by the hospital providing the training. Each hospital determined the length of the program. Work of the students was not confined to the hospitals; they were also hired to do private nursing in private homes, but the hospitals generally kept the fees. All the schools of nursing in Alberta (except St. Michael s, Lethbridge, and Foothills) opened between 1895 and Three schools (at Banff, High River, and Camrose) were short lived, but the remaining schools continued in operation as service units for hospitals until the mid-sixties. In 1907, a private duty registry was established in Calgary. The nurse in charge ensured that all individuals registering had a diploma from a training program. This related to the concern that many people working as nurses were untrained lay workers. In 1918, the first registration examinations were held in Calgary; they included both written and oral examinations. The first degree in nursing to provide community health nurses and educators was offered in 1926, but until 1937 students had to attend the University of British Columbia for classes in their final year. In Alberta, the University of Alberta did not offer a post-rn diploma in teaching until 1940, although a sandwich-type 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

49 The 1930s No other event in the history of nursing affected the profession as profoundly as the Weir Report: Survey of Nursing Education In Canada published by CNA in The Weir Report was an extensive survey and some of the recommendations contained in the report were: nursing education must become a integral part of the general education system and be funded by government, the minimum size for any hospital continuing with a nursing program must be seventyfive beds, greater consistency among programs, both in the program content and in reporting on the programs, nurses to instruct nurses, better prepared nursing instructors, minimum entrance to be a senior matriculation. Weir also recommended that schools of nursing should be independent of hospitals. During this decade, schools of nursing were well established in large urban centers and some small towns (e.g., Camrose and High River). The 1940s In 1941, the Registered Nurses Act of 1916 was amended to include a grade 12 educational requirement to enter a school of nursing in Alberta. The 1950s The 1950s saw the formation of a Student Nurses Association (SNA). There was concern regarding the amount of time students spent providing care to patients vs. the quality of their educational programs. Under legislation, the General Faculties Council (University of Alberta) was responsible for the inspection of schools of nursing. The Post-AARN Meeting/Convention notes of May 1958 record appreciation to the University of Alberta for appointing a full-time advisor to schools of nursing. The 1960s In 1963, the Alberta Department of Health clearly stated that the hospital schools of nursing would continue to provide diploma programs as a two-year college program would be too expensive. This was because the hospitals would have to hire nurses to replace the third year students. The government s position was emphasized by the approval of the Foothills Hospital School of Nursing, which opened in In 1966, there were still no purely independent schools of nursing in Alberta. The last half of the 1960s saw the introduction of the college nursing programs. August

50 On September 19, 1966, twenty-nine students enrolled in a new four-year integrated baccalaureate program at the University of Alberta. Prior to this date, students enrolled in a five-year program during which the three-year clinical experience was received in the University of Alberta Hospitals. In 1967, the new two-year diploma nursing program commenced at Mount Royal College in Calgary. The first students were admitted to the Red Deer College Program in September The Lethbridge Community College Program commenced one year later in September In 1966, the University of Calgary gained independence from the University of Alberta. The school of nursing was established in 1969 and accepted its first students in The 1970s The Edmonton General Hospital gave up its school of nursing in the early 1970s at the onset of the Grant MacEwan Nursing Program. St. Michaels in Lethbridge was phased out, a new school was established at Lethbridge Community College, and the Medicine Hat hospital program also transferred to the community college. Thus in a little over five years, five new college programs and one new university program were developed. By 1975 there were two basic baccalaureate programs in nursing, five two-year college programmes, and six hospital schools all preparing registered nurses. Programs leading to a registered nurse were two, three, and four years in length. The Alberta Task Force on Nursing Education was commissioned on January 24, 1975 (following the creation of the Department of Advanced Education 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 completed in September 1975 and released in February 1976 recommended that by 1985 that 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. It further recommended that by 1990 the minimum educational preparation for professional nursing be the baccalaureate degree. In August 1975, government released a draft of legislation entitled The Adult Education Act. It attempted to combine all legislation regarding advanced education under one act. This omnibus concept was not well received by various institutions and professional associations. The concerns regarding this legislation were that it gave the Minister of Advanced Education very broad powers to control institutions including fees, services, faculties, programs of study, budget. In addition, the Act would give cabinet (on the recommendation of the Minister) very broad powers with respect to academic qualifications and standards for entrance into professional associations. The Adult Education Act was withdrawn in January In November 1977, the government provided another framework for the planning and coordination of education of nursing personnel presented in the document Position Paper on August

51 Nursing Education: Principles and Issues. This paper noted that baccalaureate education was desirable, but did not agree that it should be the minimum entry requirement. The AARN further refined its position and in 1979 released a position statement that supported the goal of the baccalaureate degree (basic or post-rn) as the minimum educational preparation for professional nursing. It further stated 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. The 1980s In 1983, the funding and administration for hospital schools of nursing were transferred from the Department of Hospitals to the Department of Advanced Education. The University of Lethbridge School of Nursing opened in During the 1980s, nursing education became united with the goal of baccalaureate entry-topractice by the year Work began on the development of collaborative programs as a strategy to accomplish baccalaureate entry-to-practice by the year The 1990s The University of Alberta and Red Deer College collaborative program began in September The Edmonton Collaborative Program began in September The Calgary Conjoint program began in The Medicine Hat and Lethbridge Community College and University of Lethbridge collaboration 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 Section 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. Development of Collaborative Nursing Programs Edmonton Planning started in 1985 for the Edmonton program. Several objectives have spurred the collaborative activities: the need for more accessibility to baccalaureate preparation for nurses, the need to equip grads with skills for continued learning, the need to prepare grads with critical thinking and clinical decision-making capabilities. In 1991, the Minister of Advanced Education announced the approval and implementation in September 1991 of the Edmonton area collaborative nursing education model. August

52 Six nursing education programs (Red Deer College, University of Alberta Faculty of Nursing, University of Alberta Hospitals School of Nursing, Royal Alexandra Hospital School of Nursing, Misericordia Hospital School of Nursing, and Grant MacEwan Community College) collaborated to deliver a single nursing curriculum, the first of its kind in Canada. Grande Prairie Regional College and Keyano College joined in 1994/1995. This program involved the first two years at the non-university sites and then years three and four at the University of Alberta Faculty of Nursing. The University of Alberta did not admit to years one and two, in order to increase the numbers in years three and four. Students choosing the diploma exit could take a twenty-four week term following year two, for a two and a half year diploma. The programs changed to a context-based approach in Calgary In 1987, Mount Royal College, Foothills Hospital, and the University of Calgary Faculty of Nursing began developing a conjoint program for nursing education. A proposal was submitted to Advanced Education in April Students were admitted in September 1993: one curriculum at three sites, first year at Foothills Hospital site, second year students to choose either Foothills Hospital or Mount Royal College site, final two years students to choose Mount Royal College or University of Calgary site, diploma exit only after year three at Mount Royal College. Foothills Hospital School of Nursing closed in The Calgary Conjoint Program stopped admitting students in September Closure of Hospital Based Schools of Nursing (Edmonton) Since the onset of collaborative programs: there was duplication of services, hospital based schools remained out of the general structure of advanced education in the province, downsizing and restructuring of the health care system has limited the employment opportunities for grads. Discussions about voluntary closure of the three hospital schools of nursing in Edmonton, who were producing three year diploma graduates, were underway when the Department of Advanced Education and Career Development made the decision to close the hospital based schools and consolidate pre-licensure nursing education in Edmonton at Grant MacEwan Community College and the University of Alberta. August

53 Hospital Based Schools of Nursing in Alberta Royal Alexandra Hospital School of Nursing University of Alberta Hospitals School of Nursing: Strathcona Municipal University Nursing Program Misericordia Hospital School of Nursing Edmonton General Hospital School of Nursing Foothills Hospital School of Nursing St. Michael s General Hospital School of Nursing, Lethbridge, St. Mary s Hospital School of Nursing, Camrose, Provincial Mental Hospital Ponoka School of Nursing St. Joseph s General Hospital School of Nursing, Vegreville, Archer Memorial Hospital School of Nursing, Lamont, High River Hospital School of Nursing Calgary General Hospital School of Nursing Brett Hospital School of Nursing, Banff, Galt Hospital School of Nursing, Lethbridge, Holy Cross Hospital School of Nursing Medicine Hat General Hospital School of Nursing August

54 APPENDIX B: PRACTICE STATEMENT FOR REGISTERED NURSES IN THE HEALTH PROFESSIONS ACT Health Professions Act, RSA 2000 Chapter H-7 Schedule 24: Profession of Registered Nurses 3 In their practice, registered nurses do one or more of the following: (a) based on an ethic of caring and the goals and circumstances of those receiving nursing services, registered nurses apply nursing knowledge, skills and judgment to (i) assist individuals, families, groups and communities to achieve their optimal physical, emotional, mental and spiritual health and well-being, (ii) assess, diagnose and provide treatment and interventions and make referrals, (iii) prevent or treat injury and illness, (iv) teach, counsel and advocate to enhance health and well-being, (v) co-ordinate, supervise, monitor and evaluate the provision of health services, (vi) teach nursing theory and practice, (vii) manage, administer and allocate resources related to health services, and (viii) engage in research related to health and the practice of nursing, and (b) provide restricted activities authorized by the regulations. August

55 APPENDIX C: PRACTICE STATEMENT FOR REGISTERED NURSES IN THE NURSING PROFESSION ACT Nursing Profession Act, SA 1983 Chapter N-14.5 with amendments in force as of August 1, 1996 Part 1: Practice of Nursing 2 A registered nurse and a certified graduate nurse are entitled to apply professional nursing knowledge for the purpose of (a) (b) (c) (d) (e) (f) (g) (h) promoting, maintaining or restoring health; preventing illness, injury or disability; caring for the injured, disabled or incapacitated; assisting in childbirth; teaching nursing theory or practice; caring for the dying; co-ordinating health care; engaging in the administration, education, teaching or research required to implement or complement exclusive nursing practice or all or any of the matters referred to in clauses (a) to (g). 3 (1) Subject to the provisions of this or any other Act entitling a person to practise a science, therapy or system of practice, a person is guilty of an offence who, not being a registered nurse or permit holders, engages in exclusive nursing practice. (2) Nothing in this Act authorizes or allows the holder of a temporary or special permit to engage in exclusive nursing practice contrary to the limitations, conditions or restrictions applicable to the permit or to the permit holder. (3) Nothing in this Act prevents (a) a student enrolled in an approved school of nursing from engaging in exclusive nursing practice in the course of the student s education program, or (b) a student enrolled in an approved school of nursing from engaging in exclusive nursing practice in the course of her employment if the student is directly supervised by a registered nurse. August

56 APPENDIX D: THE REGISTERED NURSES EXAMINATION COMPETENCIES [Excerpt from Appendix C of Assessment Strategies Inc. for Canadian Nurses Association, Blueprint for the Canadian Registered Nurse Examination. (1999), Ottawa, ON: Author. Reprinted with permission from the Canadian Nurses Association.] A. Nurse-Client Relationship The nurse-client relationship is a relationship that is therapeutic and is established to meet the health needs of clients. The relationship is based on trust, respect, and knowledge, and involves interactions that are purposeful and focused on working with clients to maximize clientidentified health status outcomes. The nurse: 1. establishes a professional relationship with the client (e.g., interprets the nursing role with respect to availability, accessibility, responsibility, and limitations; responds to client s concerns; identifies self by name and role). 2. uses therapeutic communication techniques with the client (e.g., identification of communication barriers; use of other approaches to communicate when barriers exist; use of appropriate means to communicate with an unconscious client). 3. identifies effects of own values and assumptions on interactions with clients. 4. applies the principles of a helping relationship (e.g., openness non-judgmental attitude, active listening). 5. demonstrates consideration for client diversity (e.g., sexual orientation, child birth practices, dietary differences, gender, beliefs, values, spirituality). 6. provides culturally-sensitive care when working with the client (e.g., openness, sensitivity, recognizing the culturally-based health practices and values). 7. discerns when client s health practices can be accommodated or modified (e.g., methods of child discipline, alcohol and drug use). 8. collaborates with the client in planning and evaluating care (e.g., validates data with clients; reviews and measures health care outcomes; determines the client s satisfaction with process and outcome of care). 9. facilitates the client s participation in all aspects of care (i.e., fosters an environment that encourages questioning, exchange of information, and a creative approach to care). 10. selects interventions that are consistent with the client s identified concerns and priorities. 11. supports the informed choice of the client to make decisions regarding care. August

57 12. considers the client s existing resources throughout the plan of care (e.g., financial restrictions, transportation, social network, physical ability). 13. obtains client s consent prior to involving others in care. 14. applies principles of effective group processes. 15. maintains a caring environment that assists the client in achieving health outcomes. B. Health Promotion Health promotion is a focus of care motivated by the desire to enable clients to increase control over and improve their well-being, thereby actualizing client health potential. It includes encouraging healthy lifestyles, creating supportive environments for health, strengthening community action, reorienting health services, and building healthy public policy. The nurse: 1. identifies determinants of health that are pertinent to the client and the situation (e.g., income, social status, education, employment, work conditions). 2. collaborates with the client to develop and establish health promotion priorities. 3. assists the client in understanding the link between health promotion strategies and health outcomes (e.g., possible risk and benefits). 4. supports the client s choice to use alternate therapies (e.g., aromatherapy, acupressure, therapeutic touch, nutritional supplements, diets). 5. incorporates cultural practices in health promotion activities. 6. encourages the client to seek out groups for mutual aid, support, and community action. 7. coordinates activities with client and others to facilitate continuity of care (e.g., nutrition program for pregnant women, seniors walking group). 8. develops learning plans in collaboration with the client. 9. identifies areas for health promotion (e.g., healthy public policy, scent-free environment, latex-free environment). 10. assesses the learning needs of the client (e.g., community assessment). 11. selects appropriate medium and learning strategies to meet client s learning needs and available resources. 12. encourages the client to assume ownership of health promotion plan (e.g., selfmanaged, support groups, self-care activities). 13. incorporates research findings in health promotion activities (e.g., health trends and statistics, population demographics). 14. assists the client in implementing learning plans. 15. verifies client s comprehension of essential information and skills. August

58 16. verifies client s ability to apply essential information and skills. 17. provides evidence-based health-related information to the client. 18. uses principles of teaching/learning in health promotion (e.g., assesses readiness to learn, identifies strategies for change, establishes creative environment conducive to learning). 19. involves key stakeholders in health promotion activities (e.g., community leaders, public and private sector organizations, special interest groups). 20. supports the client through developmental transitions (e.g., puberty, menopause, new community). 21. supports the client in role change (e.g., parenting, retirement, economic issues). 22. teaches about family planning. 23. promotes healthy environment with client (e.g., lobbying, health fairs, anti-smoking campaign, sanitation, ergonomics). 24. promotes health habits related to physical activity/exercise. 25. promotes the use of healthy coping strategies to deal with life events. 26. promotes health habits related to nutrition (e.g., breastfeeding, adherence to the Canada Food Guide). 27. promotes balance between rest/sleep and activity (e.g., good sleep habits, removing stimuli). 28. promotes stress reduction strategies (e.g., relaxation techniques, recreational activities). 29. promotes health practices related to hygiene (e.g., hand washing, waste disposal). 30. promotes healthy sexuality (e.g., gender identity, maturational changes, reducing discrimination). 31. promotes safe sexual practices. C. Illness/Injury Prevention Illness/injury prevention is a focus of care motivated by the desire to enable clients to avoid illness and injury. It includes risk factor reduction, screening and early detection of illness, communicable disease control, and environmental health and safety. The nurse: 1. uses data collection techniques pertinent to the client and the situation (e.g., selected screening tests, risk assessment scales, measuring, and monitoring). 2. identifies actual or potential health problems/risk factors. 3. identifies actual or potential safety risks to the client (e.g., incidents and accidents, environmental pollution, mechanical equipment, domestic violence). 4. incorporates research findings about health risks and risk reduction into plan of August

59 care. 5. collaborates with clients to reduce complex health risks into manageable components. 6. collaborates with client to prioritize needs and develop risk prevention strategies. 7. reduces the risk of disease transmission (e.g., adheres to reporting protocols, uses universal precautions, encourages needle exchange program). 8. minimizes sensory overload (e.g., reducing noise, facilitating continuity of health care delivery, preventing information overload). 9. employs safety measures to prevent client injury (e.g., accessibility of a call bell, supervision, non-violent crisis intervention, suicide prevention). 10. encourages the client s use of safety measures to prevent injury (e.g., seat belts, bicycle helmets, safe grad program, smoke alarms). 11. helps the client to understand preventable health problems or issues and their consequences. 12. implements strategies to prevent communicable diseases (e.g., immunization). 13. implements strategies to prevent domestic violence, abuse, and neglect (e.g., using screening tools, providing information). 14. implements strategies related to the prevention/early detection of prevalent diseases (e.g., cardiovascular, cancer, diabetes, mental illness). 15. implements strategies related to the prevention of addictive behaviours (e.g., smoking, alcohol abuse, illicit drug use). 16. implements strategies to minimize the risk of mental health problems (e.g., stress management, support groups). 17. implements preventive strategies related to the safe use of medication (e.g., overuse of antibiotics, polypharmacy). 18. implements preventive strategies related to environmental safety (e.g., fire safety, smoke detectors, playground safety). 19. implements preventive strategies related to workplace safety (e.g., WHMIS, needle stick injury prevention, back injury prevention). 20. evaluates the effectiveness of preventive measures with the client. 21. employs safety measures to protect self from injury (e.g., latex sensitivity protocols, used needle disposal, needleless systems). 22. employs safety measures to protect self from potentially abusive situations in the work environment. August

60 D. Curative/Supportive Care The focus of curative/supportive care is to help clients deal with responses associated with illness or health issues/problems, along with activities designed to support clients as they resolve their health problems or participate in palliative care. The nurse: 1. uses appropriate techniques for data collection (e.g., observation, auscultation, palpation, percussion, inspection, selected screening tests, interview, consultation, focus group, measuring, and monitoring). 2. collects data about various dimensions of the client (e.g., vital signs, circulatory and respiratory status, lifestyle factors, sensory deficits, level of consciousness, family environment, housing, work milieu, community). 3. collects data from a range of appropriate sources (e.g., the client, previous and current health records/nursing care plans, family members/significant persons/substitute decision maker, census data, and epidemiological data). 4. adapts the assessment to the client s situation (e.g., growth and development stage). 5. validates the data with the client and/or appropriate sources. 6. establishes relationships between and among the various data collected (e.g., determines the relationships between health assessment and laboratory values). 7. interprets data within the context of scientific knowledge and norms (e.g., takes the analysed data and determines that the client s colour, blood gas report and statement of dyspnea are not normal and that a problem exists with the respiratory system). 8. identifies actual and potential health problems. 9. develops the plan of care (e.g., setting priorities, establishing target dates, identifying and prioritizing nursing interventions). 10. documents the plan of care. 11. selects interventions that are consistent with the priority of the health situation. 12. modifies interventions to suit the client s situation by selecting interventions that are consistent with the client s identified concerns and priorities. 13. selects appropriate technology in accordance with available resources and client needs (e.g., blood pressure monitor, infusion pump). 14. supports the client s participation in the implementation of plan of care (e.g., administration of insulin, home IV and TPN programs, self-care groups). 15. helps the client understand the interventions and their relationship to expected outcomes (e.g., possible risk, discomforts, inconveniences, costs). 16. uses principles of teaching and learning with the client receiving curative/supportive care. 17. facilitates appropriate and timely responses of the health team members to client August

61 care needs. 18. coordinates activities with the client and others to promote continuity of care. 19. prepares the client for diagnostic procedures and treatments using appropriate resources (e.g., explanation, information, tests, obtaining specimens from the client). 20. provides client care throughout the perioperative experience (i.e., pre- and postoperative care). 21. promotes optimal ventilation and respiration (e.g., positioning, deep breathing and coughing exercises, oxygen therapy). 22. ensures ventilation and respiration when breathing is impaired (e.g., performs oral or nasal suctioning, performs cardiopulmonary resuscitation). 23. promotes circulation (e.g., active or passive exercises, positioning, mobilization, cast care). 24. monitors fluid balance (e.g., weight, hemodynamic measurement, measuring abdominal girth). 25. promotes adequate fluid intake. 26. relates nutritional needs to physiological conditions (e.g., burns, inflammatory bowel disease). 27. manages nutritional access devices (e.g., TPN, nasogastric tube). 28. promotes urinary elimination in client with compromised system (e.g., irrigating bladder, performing bladder catheterization, pharmacological measures, pushing fluids). 29. promotes bowel elimination in client with compromised system (e.g., enema, rectal tubes, pharmacological and dietary measures). 30. promotes client s correct body alignment (e.g., proper positioning, caring for the client with external immobilizing devices). 31. promotes the tissue integrity of the client (e.g., providing skin and wound care, skin cleansing, wound dressing). 32. promotes comfort by using various measures (e.g., heat and cold application, touch, positioning). 33. promotes sensory stimulation at an appropriate level for the client s health situation (e.g., uses touch with unconscious client, reduces environmental stimuli for the agitated client). 34. intervenes in response to changes observed in the client s condition (i.e., intervenes according to protocols). 35. manages multiple nursing interventions simultaneously (i.e., prioritizes and organizes interventions). 36. communicates to appropriate health team members significant information about the client s condition. August

62 37. modifies plan of care to suit the client s changing situation (i.e., selects interventions that are consistent with the emerging priorities of the health situation and the client s newly identified concerns, priorities, and tolerance). 38. calculates medication dosage correctly. 39. determines medication dosage is safe (i.e., considers food-drug interaction, drugdrug interactions, age, weight). 40. administers medication safely and appropriately (i.e., right person, drug, dose, route, and time). 41. assesses client s response to drugs (e.g., desired effects, adverse effects, interactions). 42. discerns when a PRN medication is indicated (e.g., analgesics, inhalers, antihypertensives, antianginals, bowel medications). 43. takes appropriate actions when desired responses to medication are not attained. 44. assists client to manage pain with non-pharmacological measures (e.g., applying heat and cold, touch, massage, and visual imagery). 45. assists client to manage pain with pharmaceutical agents (e.g., Patient Controlled Analgesia [PCA]). 46. safely administers blood/blood products. 47. manages venous access devices (e.g., implanted devices, peripheral access). 48. manages drainage tubes and collection devices. 49. inserts and removes nasogastric tubes. 50. maintains established peripheral intravenous therapy. 51. maintains central venous intravenous therapy. 52. applies principles of microbiology and communicable disease transmission as demonstrated through the application of universal precautions. 53. intervenes in rapidly changing health situation: myocardial infarction. 54. intervenes in rapidly changing health situation: stroke in evolution. 55. intervenes in rapidly changing health situation: shock (e.g., hemorrhagic, anaphylactic, neurogenic). 56. intervenes in rapidly changing health situation: respiratory distress. 57. intervenes in rapidly changing health situation: labour and delivery. 58. intervenes in rapidly changing health situation: mental health crisis (e.g., psychotic episode). 59. intervenes in rapidly changing health situation: trauma (e.g., burns, fractures). 60. evaluates and responds appropriately to status of clients in relation to anticipated outcomes. 61. evaluates the effectiveness of nursing interventions with the client (e.g., learning needs, comparing actual outcomes to anticipated outcomes). August

63 62. prepares the client for discharge. 63. coordinates continuity of care across care settings (e.g., discharge planning, transfer of care). 64. provides supportive care to clients with chronic illnesses (e.g., chronic pain, COPD). 65. performs palliative nursing interventions to meet spiritual needs (e.g., assesses for spiritual distress, provides time for prayer/meditation). 66. performs palliative nursing interventions to meet physical needs. 67. performs palliative nursing interventions to meet psychosocial needs (e.g., grief work). 68. provides care that is sensitive to clients experiencing loss (e.g., death, amputation, natural disaster). 69. provides supportive care throughout the dying process (e.g., symptoms control, family counselling, advocacy). E. Rehabilitative Care The focus of rehabilitative care is to assist clients with a physical or psychosocial disabling injury or illness to achieve maximum functioning or independence. This includes counseling, support, retraining and education, and environmental modifications. The nurse: 1. facilitates continuity and consistency of care in the approach used by all members of the health care team. 2. individualizes care to accommodate client s deficits in sensory and cognitive functions. 3. begins rehabilitative measures at the earliest opportunity. 4. provides nursing care to prevent the development of complications that can impede recovery (e.g., turning immobile clients q. 2h., early intervention of first and last chest infection detected with CHF/COPD). 5. promotes the client s positive self-concept (e.g., supporting cultural and spiritual preferences, validating client s strengths, and promoting use of effective coping techniques). 6. assists the client in accessing community resources (e.g., self-help groups, geriatric day programs, respite). 7. supports client to draw on own assets and resources in meeting self-care needs. 8. promotes social interaction of client (e.g., encourages and/or creates opportunities for social participation, encourages development of new interests and support systems). 9. assists the client with prosthetic and mobilizing devices (e.g., walker brace). August

64 10. promotes mobility (e.g., active and passive exercises, range of motion exercises, early ambulation, activities of daily living). 11. arranges for adaptations in the environment to facilitate the client s development of independence in activities of daily living (e.g., removal of scatter rugs, keeping essential furniture on one level of the house, raised toilet seat, ordering specialized equipment such as walker, special utensils). 12. promotes elimination (e.g., ostomy care, bowel and bladder retraining, selfcatherization). 13. assesses for psychological and psychosocial adaptation (e.g., recognizes depression and uses resources to assess depression). 14. encourages family and significant others to support the client during the rehabilitation process. 15. assists client with reintegration into family and community networks (e.g., adaptation to role changes, physical mobility, self-help groups). F. Professional Practice Each nurse is accountable to clients for practicing within professional, legal, and ethical standards. This includes applying quality improvement principles, using evidence-based knowledge and critical thinking, establishing collaborative partnerships, coordinating care, monitoring practice, enhancing practice, and recognizing and acting on learning needs. The nurse: 1. practices in a manner consistent with the CNA Code of Ethics for Registered Nurses value: health and well-being. 2. practices in a manner consistent with the CNA Code of Ethics for Registered Nurses value: choice. 3. practices in a manner consistent with the CNA Code of Ethics for Registered Nurses value: dignity. 4. practices in a manner consistent with the CNA Code of Ethics for Registered Nurses value: confidentiality. 5. practices in a manner consistent with the CNA Code of Ethics for Registered Nurses value: fairness. 6. practices in a manner consistent with the CNA Code of Ethics for Registered Nurses value: accountability. 7. practices in a manner consistent with the CNA Code of Ethics for Registered Nurses value: practice environment conducive to safe, competent and ethical care. 8. practices in a manner consistent with the acts governing nursing practice, the regulatory body s standards for nursing and guidelines for the scope of nursing practice. August

65 9. practices in a manner consistent with common law and legislation that directs practice (e.g., criminal code, narcotics control acts). 10. exercises professional judgment when following agency procedures, policies, and position requirements. 11. exercises professional judgment in the absence of agency procedures, protocols, or position statements. 12. practices in a manner consistent with professional values, principles of safety, and obligation to take action (e.g., intervenes when a policy is unsafe or obsolete; challenges questionable orders, actions, or decisions of others). 13. advocates for the client or client s representative, especially when the client is unable to advocate for self (e.g., assists client to gain access to quality health care, facilitates and monitors the quality of care, facilitates appropriate and timely responses by health care team members, and challenges questionable decisions). 14. maintains clear, concise, accurate, and timely records of client care. 15. uses appropriate, cost-effective health care resources to provide effective and efficient care (i.e., human, material, technological, financial). 16. organizes own workload effectively (e.g., time management, prioritizing, setting time frames). 17. identifies an unrealistic workload and seeks assistance as necessary. 18. accepts accountability for own actions and decisions when delegating. 19. uses evidence-based knowledge from nursing, health sciences, and related disciplines in the provision of individualized nursing care (e.g., to plan care, to select nursing interventions). 20. recognizes limitations of own competence and seeks assistance when necessary. 21. delegates health care activities to others consistent with levels of expertise, education, job description/agency policy, and client needs. 22. evaluates the outcomes of delegated health care activities. 23. builds partnerships with nursing and members of the health care team to provide health services. 24. clarifies the nurse s role and responsibilities to other health care team members (e.g., with regulated and unregulated health care providers). 25. demonstrates respect for colleagues (e.g., respect for unique and shared competencies of health care team members). 26. maintains effective communication with the health care team. 27. provides constructive feedback to colleagues (e.g., about client care, peer assessment). 28. uses conflict resolution skills to facilitate health care team interactions. 29. reports unsafe practice of nursing colleagues and other members of the health care team to the appropriate authority. August

66 30. uses established communication protocols within the health care agency, across agencies, health system, and community. 31. participates in planning, implementing, and evaluating changes that affect nursing practice, client care, and the practice environment. August

67 APPENDIX E: STAKEHOLDERS INCLUDED IN CONSULTATION WITH AARN ON BETP Groups represented in the consultation to attempt to achieve a shared framework of understanding about Alberta s health system, the required roles of registered nurses within it, and the role of baccalaureate entry-to-practice within this framework include: Alberta Health and Wellness Regional Health Authorities provincial professional associations and colleges senior nursing leaders nursing education leaders Alberta Nursing Education Administrators Centre for Nursing & Health Studies, Athabasca University Department of Nursing Education, Grande Prairie Regional College Division of Health Studies, Medicine Hat College Faculty of Health & Community Studies, Mount Royal College Faculty of Nursing, University of Alberta Faculty of Nursing, University of Calgary Health & Community Studies Division, Grant MacEwan College Lethbridge Community College Nursing Department, Red Deer College Nursing Diploma Program, Keyano College School of Health Sciences, University of Lethbridge Nursing Education Program Approval Board organized labour in nursing (United Nurses of Alberta) AARN members nursing students private health care providers third party payers associated partners health consumers members of the public. August