A Preliminary Analysis of Facilitators and Barriers to Meeting the IOM 80/20 Goal: Are AAs the answer? Patricia Pittman

A Preliminary Analysis of Facilitators and Barriers to Meeting the IOM 80/20 Goal: Are AAs the answer? Patricia Pittman

System Changes Require Education Changes 1. Broadening RN skills 2. Expanding supply

Despite the need (and 50 year debate) its not happening Source: Fulcher and Mullin 2011 Adapted from HRSA 2010

Fragmentation of Nursing Education Diploma ADN BSN MSN DNP BA MA Ph.D. (nursing) Licensure Ph.D. Residency +200 certificates

Compare to MDs and PTs BA OD MD Residency Fellowship/ Specialty Training Licensure BA DPT Licensure Residency/ Fellowship

Does Fragmentation Matter? Breakage in flow means curriculum and credits uncoordinated = students and universities struggle in the transition. Inefficient use of faculty and clinical resources across settings.

Innovations to Increase Efficiency 1. RN to BSN Articulation Agreements (AAs) target key barriers: credits, costs and location. 2. BSNs within CCs 25 such programs in 10 states as of October, 2010 (Russell). Florida as leader. Removes credit and cost barriers but opposed by state schools. 3. Stand alone online ADN BSN degree programs (For profits) numerous, but little established reputation and often expensive. 4. ADN MSN (reducing BSN level attrition) (reduces cost opportunity of BSN but expensive) 5. Accelerated BA to BSNs 6. DEIs higher efficiency of all programs

7 mandate credits ( 40-72), only FL require acceptance 18 voluntary. ADN-BSN Agreements

Critical Components Vary Whether student acceptance is guaranteed and minimum GPA required Number of CC credits recognized (time to complete) Curriculum coordination: ie whether any courses have to be repeated Cost of completion credits Sharing of faculty and clinical resources Inclusion of other innovations, e.g. Dedicated Education Units (DEUs) or ADN to MSNs, are part of AAs.

How Effective Are AAs? Oregon reports: Doubled student/teacher ratio Higher than average licensure passage rates (95-100% vs. 88%) 23-32 % completion rate compared to 9% nationwide BUT cost and lack of employment incentives continued barriers) (Tanner)

Prospects for Expansion: University Perspectives YES Public schools may have a legal or political obligation to form partnerships. Second tier private, public and for profit see lower costs in ADNs. Bulk deals. More graduates in less time, helps increase school visibility. For some it can be a strategy for increasing diversity and demonstrating community engagement. NO With capacity shortage, little financial incentive to increase the number of applicants. CC partnerships increase administrative burden Time to develop agreements Junior and senior years differ ( post ADN is not clinical) Schedules may vary (night classes) credit transfer and equivalence, career counseling, For high prestige, intensive, expensive private research universities, little interest. ADNs difficulty in affording tuition. Seek students interested in research.

Community College Perspectives Many nursing deans convinced market is changing in urban areas due to Magnet and are keen to establish AAs to ensure graduates can get jobs. Community College presidents suspicious that AAs are the beginning of the end of cash cow. BSN as entry level requirement Rural CCs without AAs could dry up. Tend to oppose BSN in CCs which would require warfare with state universities.

Student Perspectives Starting point: ADN students includes high percent of working mothers (many single) for whom affordability is key. Career advancement incentives growing But opportunity costs still high even in Oregon Typical in-state cost of a BSN at a public school $28k vs. $6k for an ADN at a CC (Fulcher et al), ie as much as $14K additional costs to complete BSN. Average earnings < $6k between ADN and BSN grads (HRSA) Location as a barrier if faculty don t come to CC.

Will AAs Continue to Spread? Facilitators 1. Magnet is driving employers to choose BSNs, at least during the recession and among large urban employers. 2. CC deans, more committed than ever to making the change. 3. Some universities benefit financially or in diversity Barriers 1. Demand in rural areas low 2. CC Presidents 3. Research universities 4. Still unaffordable for many ADN students (70%)

What should we track? 1. Context: is the marketplace trend towards BSNs real/permanent? 2. Intervention: which components are essential To engage CCs and Universities To expand admission To incent completion 3. Unintended consequences: will AAs exacerbate rural disparities? Will demand for LPNs replace ADNs? Will higher career attrition among BSNs increase leakage? 4. Outcomes : What percent completion do we need to achieve 80/20 by 2020? (Joanne.)