Perspectives on Education Strategies to Increase BSN- Prepared Workforce: BSN in 10 Community Colleges Awarding Baccalaureate Degrees Seamless Academic Progression Prepared for: June 15, 2014
I. Introduction The landmark Institute of Medicine (IOM) report The Future of Nursing: Leading Change, Advancing Health recommends increasing the proportion of nurses to 80 percent by 2020. While the IOM report does not stipulate specific legislative strategies, leaders from the Future of Nursing: Campaign for Action commissioned an examination of related key stakeholders perspectives regarding state legislative strategies being considered or pursued. This report provides the Campaign for Action team with a synthesis of the perspectives of key stakeholder groups Action Coalitions, education workgroup members and APIN grantees related to mandates and legislative strategies being considered or pursued to advance the IOM recommendation across the U.S. At this point in time, and in its current form, the contents of the report are intended for internal use by the Campaign for Action. The following strategies were explored: BSN in 10, which would require all nurses to achieve a minimum of a BSN within 10 years of initial licensure or within 10 years of legislative implementation in the state. State legislation allowing community colleges to award a baccalaureate degree. State legislation mandating state colleges and universities work with community colleges to ensure no redundancy in required prerequisites for transfer students to advance seamless academic progression. II. Methodology Telephone interviews were conducted with key stakeholders between December 3, 2013 and January 22, 2014. Stakeholders interviewees and interview questions were agreed upon in consultation with the Campaign for Action team. E-mails were sent to stakeholder groups comprised of Action Coalition leads, Action Coalition education workgroup members, and APIN grantees describing the purpose of the interview and requesting their participation. A second follow-up e-mail was sent to all non-respondents. Table 1 details the respondent information for the project. Seventy-eight percent of stakeholders participated in a 30-minute interview. Twenty-three states were represented (Table 2). Major Interview Areas Viability of three selected educational strategies for advancing IOM recommendation. Advantages and issues associated with pursuing the strategies. Additional strategies being pursued.
Table 1: Interview Response Information (n) (%) Initial Contacts 62 100% Interviews Deferred to Others 3 5% Interviewees 59 Completed 46 78% Not able to Schedule 13 22% Table 2: State Distribution by Category of Respondents Action Coalitions AC Education Workgroups APIN Grantees California 1 2 Colorado 1 Florida 1 2 Hawaii 1 Idaho 1 Indiana 1 Illinois 2 2 Louisiana 1 Massachusetts 1 Minnesota 1 2 Mississippi 1 1 New Mexico 1 New York 1 North Carolina 1 North Dakota 2 Ohio 2 Oklahoma 1 2 Rhode Island 1 Texas 1 1 Washington 1 2 1 West Virginia 1 Wisconsin 1 4 Wyoming 1 1 2
III. Findings A. Overall Perspectives on Legislative Strategies to Increase BSN Prepared Nurses Stakeholders provided ratings and perspectives on the climate and progress being made on key strategies to increase the proportion of BSN-prepared nurses (Exhibit 1). 1 Without exception, there is agreement that a significant push needs to happen in all states in order to approach or reach the 80/20 IOM goal. There is a call from nurse leaders to be more inclusive rather than exclusive in considering the viability of various strategies to address the IOM recommendation. The current momentum is strong and needs to be accelerated if not now, when? Exhibit 1: Ra.ngs on Climate and Progress on Educa.onal Strategies Climate for "BSN in 10" * 1.9 Climate for BSN at Community College * 2.4 Progress Toward Seamless Progression ** 4.2 0 1 2 3 4 5 * 1=not at all supportive; 5=extremely supportive ** 1=initially stages; 5=very advanced stages Support for BSN in 10 is not at the level required to successfully enact legislation. The nursing community remains divided on the issue and without nursing as the driving force behind a BSN in 10 movement, it would be all but impossible to bring other requisite stakeholder groups to the table. The climate for allowing community colleges to award the BSN currently is mixed. In most states, granting of BSNs by community colleges has garnered serious discussion and debate and remains a controversial strategy for increasing the pool of BSN-prepared nurses. States where community colleges already are awarding the BSN support expansion and recommend that other states give the strategy serious consideration. Mandate/legislative approaches are not being pursued actively to advance any of the three educational strategies discussed in this report. Employing this type of approach at this point is viewed overwhelmingly as divisive and could derail the progress that has been made to date. Seamless academic progression strategies have been embraced widely and already are reaping intended outcomes. It is viewed as the cornerstone for building a BSN-prepared workforce. Therefore, it is not surprising that states currently are entrenched in developing, refining, and implementing models to support progression from associate to baccalaureate degree programs. 1 Information and perspectives presented in this report are based solely on stakeholder interviews. 3
Continued collaboration and development of partnerships among key stakeholders, including nursing educators, health care administrators, academic leaders, accrediting bodies and nurses themselves, are core to success in driving any meaningful change in the educational composition of the nursing workforce. 1. Perspectives on Mandating BSN in 10 Mandating BSN in 10 as a way to increase the proportion of BSN-prepared nursing elicited a wide-range of viewpoints. While BSN in 10 has not gained significant traction, discussions have occurred and raised both favorable and unfavorable points regarding its viability. Favorable BSN in 10 Perspectives: BSN in 10 holds the most significant promise for driving an increase in BSN-prepared nurses. Without such legislation, the profession will fall short of the 80/20 goal not only in 2020 but on into the future. Others went a step further and said that without making the BSN the entry point for the profession, we will never be able to move the needle for BSN-prepared nurses in any meaningful way. Some posed the question, should BSN in 10 be legislated at the federal rather state level? While this approach is not something that would take hold now given opposition that currently exists within individual states for BSN in 10, it should be introduced for discussion at forums where education advancement is on the agenda, at least to periodically take the pulse key stakeholder and keep the issue on the radar screen. Strong evidence documenting the link between a BSN-prepared workforce and better patient outcomes already exists. BSN in 10 would be a significant step in ensuring that that an adequate supply of BSN-prepared nurses are available to ensure quality patient outcomes. Passage of BSN-10 legislation would strengthen the credibility of nursing as a profession, while still recognizing the importance of the ADN as a critical entry point for a diverse group of individuals. Master s degrees and even doctorates are entry level educational requirements for many other health care professions (i.e., pharmacy and physical therapy). Significant numbers of ADN nurses continue to flow into the nursing workforce. However, the proportion of ADN nurses that independently continue on to the BSN remains low. As an example, only about 20 percent of associate degree-prepared nurses in New York go on for the BSN. Additionally, retirement of the baby boomer cohorts, where the larger percentages of baccalaureate and higher level degree prepared nurses exist, will further challenge the ability to reach the BSN goals solely with the approaches now being undertaken. 2 2 Interview with Barbara Zittel on January 3, 2014. 4
Employer hiring practices, particularly in urban areas and those on the Magnet journey, continue to trend toward exclusive or preferential hiring of BSNs or hiring ADNs with the stipulation that they obtain the BSN within a specific time period. BSN in 10 legislation would create the impetus for ADN nurses to obtain their BSNs in order to successfully compete for positions, particularly in acute care facilities. Current educational capacity limitations and faculty shortages call into question the ability to produce BSN nurses at the levels recommended by the IOM. Only with mandates/legislation will nursing be able to make the case for the need to expand BSN educational capacity and expand the pool of qualified faculty. Opposing BSN in 10 Perspectives: There is continued skepticism among some ADN nurses, community college nursing educators and health care agencies of the existing evidence base that demonstrates that a richer mix of BSN nurses results in better patient outcomes. The current educational infrastructure cannot accommodate the influx in the number of individuals that will be pursuing BSNs. Collective effort by all levels of nursing education to prepare for and sustain this requirement will be needed to ensure seamless educational models, appropriate clinical education models, and the increased availability and reliability of technology. The potential impact on small, rural hospitals ability to retain BSN nurses needs to be carefully considered. With a BSN, nurses will have the opportunity to seek job opportunities with larger employers in urban areas, where the potential for career advancement may be greater. Technology to support on-line/distance learning options is not consistently available in rural areas, where ADNs make up a large proportion of the RN workforce. The availability of reliable distance learning options will be critical for ADNs living and working in rural areas to pursue advanced education. Not all health care providers, particularly those outside of acute care, foster an environment that supports continuing education. Tuition reimbursement is not a given and many organizations are not providing a salary differential for BSN-prepared nurses. The current ADN workforce and those individuals entering community colleges to obtain the ADN tend to be older and they may be less willing to pursue the BSN. Additionally, employers may be less eager to provide incentives to encourage their more mature workers to return for the BSN. 5
BSN in 10 mandates could discourage entrants from coming into the field. Some states are currently experiencing nursing shortages and worry that increasing educational requirements could only worsen the situation. Enforcement would prove challenging. Mechanisms for keeping accurate records of where individuals are in the process and what legally can be done if a licensed RN does not obtain the BSN within the mandated time frame need to be carefully considered and a transparent process needs to be established to avoid issues for the nurse, employer and state licensing boards. Pursuing a BSN can be a significant financial investment both for the nurse and the employer. While many employers offer financial incentives for nurses to obtain the BSN, requiring the BSN within 10 years will significantly increase the financial impact on employers. States with Most Supportive Climate for BSN in 10 New York, Rhode Island, North Dakota and Colorado reported the highest level of support for BSN in 10 and shared their perspectives on the current climate in their states (Exhibit 2). Exhibit 2: "BSN in 10" 5 4.5 4 3.5 3 NY RI 2.5 ND CO 2 1.5 1 IN WV WY FL MN LA IL WA WI TX MS OH NC CA OK ID MA * 1=not at all supportive; 5=extremely supportive New York: Under the leadership of the New York Organization of Nurse Executives and Leaders (NYONEL) and with the support of more than 51 state and national nursing and health care organizations, New York s BSN in 10 is positioned for success. With a new state Senate Republican sponsor, a Democratic Assemblyman sponsor, and the recently announced support of the Healthcare Association of New York State (HANYS), the bill has a higher potential for enactment than ever before. While no timeline for moving forward 6
has been finalized, nothing is planned until after the budget passage, which typically happens after April. Rhode Island: In 2008, a state Senate Committee on Nursing explored the issue and felt support existed to move forward. The driving force at the time was the Rhode Island Nurses Association, but for a variety of reasons, including priorities in other legislative areas, the decision was made not to proceed and, as time has passed, it has not regained momentum in the state. North Dakota: The climate within the nursing community is improving with regard to the BSN in 10 initiative. However, there is still a good bit of distrust lingering from the 2003 repeal of the 1987 mandate requiring the baccalaureate degree as the educational credential for those wishing to take the RN licensure exam. Hospitals, health systems and long term care facilities continue their strong opposition to any legislation related to the BSN. Nurse leaders in the state are keeping a watchful eye on what is happening in other states and are not likely to pursue BSN in 10 until a good number of other states take the lead. Colorado: In June 2014, the state convened a panel of leaders in service and academics to discuss progression to the 80/20 goal and key steps to achieve this goal. The panel decided to explore the viability of pursuing BSN in 10 legislation and sought consultation from New York. However, the lack of legislative sponsorship and a divided nursing community were cited as the major obstacles impacting the decision not to move forward at this point. 2. Perspective on Community Colleges Awarding BSN Degrees As efforts by the nursing profession to create a more highly educated workforce intensify, there continues to be interest in and controversy surrounding the awarding of baccalaureate degrees by community colleges. Exhibit 3 provides ratings on the current level of support for community colleges awarding the BSN in respondent states. Exhibit 3: Community Colleges Awarding Baccalaureate Degree 5 FL TX NM 4.5 4 ND WA 3.5 3 2.5 HI 2 1.5 MN CO WI RI CA OH NC ID 1 IN WV WY LA IL NY MS OK MA. * 1=not at all supportive; 5=extremely supportive 7
Favorable Perspectives on Community Colleges Awarding BSN Degrees: Improves access to the BSN: BSNs offered by community colleges increase educational opportunities for individuals, particularly in rural areas where there is limited or no access to four-year institutions. Creates greater affordability: Tuition at upper division courses at community colleges is typically lower than at four-year institutions. Expands educational capacity: Capacity constraints already exist in many states and new avenues for creating capacity need to be available in order to move the BSNprepared nurse needle upward in any significant way. Maintains/expands the diversity of the nursing workforce. Opposing Perspectives on Community Colleges Awarding BSN Degrees: Awarding of BSN by community colleges has not been widely embraced nationwide. Main areas leading to this unfavorable stance include: Quality of the education: The quality issue is at the forefront for those opposed to this strategy. Not all community colleges are accredited and there is little or no regulation of existing or emerging programs, particularly proprietary/for-profit programs. There also is concern that nursing leadership at community colleges currently is unstable and salaries already are under-resourced. These institutions want to start BSN programs that require doctoral-prepared faculty, a group who remain a challenge to recruit. Strong university support for being the appropriate venue for granting of a baccalaureate degree: There is an existing point of view within the university community that the ADN environment is distinctively different from that of the BSN. This raises the issues of availability of faculty with doctorates, the level/rigor of research being pursued, and availability of sponsored programs outside the university setting. Viewed as a deviation from the historic mission of community colleges: Public funding is already stretched and taxpayers typically bear the burden of supporting these institutions. Higher costs may be associated with providing baccalaureate degrees and calls into question how these added costs would be covered without adversely affecting the affordability that makes community colleges an attractive educational alternative for a diverse group of students. RN-BSN programs provide an important revenue stream for universities. If community college BSN options expand in existing states or emerge in new states, universities could face serious competition for students and faculty. Florida is considered the bastion for community colleges awarding BSNs. Texas, North Dakota, New Mexico and Washington State have joined the movement, but to a much lesser degree, currently only operating one program in each state. These states project that increasing numbers of community colleges will enter the market and begin offering the BSN. However, among stakeholders, caution was raised around how these programs will be monitored for quality, particularly as more proprietary, for-profit entities emerge. Colorado nurses fought hard against a 8
proposal that would have terminal baccalaureate degrees conferred in the community college system. The state is going to start in vocationally-oriented programs and nursing educators will follow the issue closely and be prepared take action if the proposal for terminal baccalaureate nursing degrees is raised in the future. 3. Perspectives on Seamless Academic Progression Seamless academic progression is viewed as the cornerstone for building a BSN-prepared workforce (Exhibit 4). Respondents encouraged nurse leaders to be more inclusive rather than exclusive in considering the viability of various strategies to address seamless transition so that ADNs can easily obtain the BSN. Exhibit 4: Seamless Academic Progression 6 5 4 3 2 IN WV ND WY LA MN FL CO IL WA WI NY TX MS RI NC CA OK HI OH ID MA NM 1 0 ** 1=initially stages; 5=very advanced stages Favorable Perspectives on Seamless Academic Progression Strategies Although the original intent was to examine legislative strategies supporting academic progression, respondents shared numerous strategies outlined below. This section provides the overall perspectives on a variety of seamless academic progression strategies being considered or pursued and highlights some general points for consideration. Legislation passed in California in 2009, Assembly Bill 1295, required California State University (CSU) to implement articulated nursing degree pathways between CSU and California community colleges to prevent duplication of courses required for ADN students to complete the BSN. California respondents viewed the legislation as a beneficial stake in the ground and provided the impetus needed nursing educators at community colleges and universities to work in an earnest way to create roadmaps to support seamless transition. There is excitement about the innovative, collaborative models being developed and implemented in many states, with the emphasis on a caution that sight not be lost on the incumbent ADN workforce. While there is an increase in enrollment in RN-BSN programs, research suggests that ADNs are not returning to school at the rate needed to 9
make a significant impact on the number of BSN-prepared nurses. The ability to move increasing numbers of current ADNs into BSN programs will be critical. Implementing strategies that support ease of access to educational programs is only one piece of the puzzle. Employers play a key role in supporting a culture of lifelong learning by supporting practices such as: preferential hiring of BSNs, paying salary differentials for BSN-prepared nurses, providing tuition assistance and creating career advancement opportunities. Universities continue to expand online learning, developing partnerships with employers so that faculty can come on site and establishing satellite campuses in communities. Examples of activities related to development of a shared curriculum include: o New Mexico: The New Mexico Nurse Education Consortium was successful in bringing community colleges and BSN programs together to develop a statewide core curriculum for pre-licensure BSN education. In January the first group of students will be enrolled at the University of New Mexico and Central New Mexico Community College. o West Virginia: A taskforce was created in West Virginia comprised of representatives from the community/technical college system and developed a common curriculum to be sure that there is seamless articulation to a four year university. o Illinois: Stakeholder will bring a standard curriculum to the university deans and community college nursing directors for review in February 2014. o Wyoming: A timeline of 2016 has been set for introduction of a core curriculum. Community colleges continue to provide an important entry point for a diverse group of individuals looking to pursue a nursing career. However, community college deans and directors are sending strong messages to students about the need to obtain the BSN. The ADN is the place to start, not the place to finish. Students can obtain the BSN in four years. Although they may receive the ADN after three years and are eligible to take the NCLEX at that point, students are immersed from the outset in baccalaureate level courses and less likely to opt out without obtaining the BSN. Examples of states developing innovative models to support seamless transition include: o California: California State University of Los Angles (CSULA) has partnered with California community colleges to implement an ADN to BSN collaborative partnership that allows the AD RN to obtain in BSN in a minimum of 12 months after graduating from the community college. Plans are underway to expand the collaborative from 8-10 community colleges. o Minnesota: The Minnesota Alliance for Nursing Education (MANE), modeled after work done by the Oregon Consortium for Nursing Education, is a competency based program that ensures that students can completion the BSN in four years. o North Carolina: The RIBN Regionally Increase Baccalaureate Nurses initiative is a community college/university partnership that utilizes a dual 10
enrollment and four year shared curriculum pathway for students to achieve the BSN in four years. Opposing Perspectives on Seamless Academic Progression Strategies It is the opinion of many nurse educators in California that other states may want to spearhead legislation in order to expedite development of shared or common curriculum that will support seamless academic transition. However, unlike what occurred in California, nursing needs to move the agenda forward and determine how the legislation should role out to ensure that legislators are not dictating curriculum the academic voice should be informing legislation. States continue to struggle to secure sufficient clinical placements for both ADN and BSN students. As the employer trend continues for preferential hiring of BSN nurses, many also have decided to offer only clinical placements to BSN programs. While this may be seen as positive in terms of supporting preparation of BSN nurses, it adversely impacts AD programs at a time when these programs serve as an important entry point for large populations of diverse students that may not otherwise be able to pursue a nursing career. Beyond models that are focused on transition from ADN to BSN degree, a number of stakeholders acknowledged that we need to also be looking at options to advance educational preparation at all levels LPN to BSN and RN to MSN. There is no question that articulation agreements have been an important mechanism for increasing access to baccalaureate programs. Mandated, statewide or individual articulation agreements are in place in all respondent states. However, their effectiveness was questioned, especially given that the majority of the nursing workforce remains ADNprepared. IV Summary Meeting the IOM recommended 80/20 goal for BSN-prepared nurses requires the profession to take an inclusive, rather than exclusive approach. Given the multiple variables that impact reaching 80 percent, no one strategy will get us to that level any time soon. However, the current climate in the overwhelming majority of states would preclude legislation, particularly with regard to BSN in10, from being passed. Partnerships between nursing educators in community colleges and universities are already reaping desired benefits and need to be expanded. Benefits include: Expanding articulation agreements to support RN-BSN education opportunities. Creating shared curricula to eliminate duplication in courses required to complete the BSN. Designing and implementing new models that immerse students in baccalaureate level courses regardless of where they enter their studies, and provide a continuous avenue for completion of the BSN in four years resulting in BSN-prepared nurses entering the workforce at a faster pace. Developing competency based curricula that will facilitate more effective, efficient and successful transition of new graduates into practice settings. Expanding educational capacity by allowing community colleges to award the BSN. 11
As progress continues to be made on the educational front, additional areas need to remain on the radar screen because they are intricately related to the successful expansion of the BSNworkforce. These include: Incumbent ADN workforce: There is no question that seamless academic progression is a key component of any strategy to motivate this large cohort of RNs to return to work. What other levers need to be used? What role do employees need to play in order to demonstrate the value of advanced education, i.e., preferential hiring practices, time limits for ADNs to obtain BSN, salary differentials, career advancement options? ADN workforce outside of acute care: There is increasing support for BSN education from employers in the acute care sector, primarily in the urban areas. How can we encourage associate degree nurses in other settings to pursue advanced education when employers may not be as supportive and able to provide appropriate incentives? Capacity to meet demand and shortage of faculty: At a time when expansion of the BSN-prepared workforce is gaining significant support and momentum, the educational community grapples with having the capacity to successfully produce BSN graduates at the pace required. Faculty shortages are at critical levels in many states and qualified students continued to be turned away. Clinical placement availability: How should we be looking at clinical placement going forward? How does it need to be structured to prepare nurses to meet the demand of the changing health care environment? Establishing metrics to monitor progress and demonstrate outcomes: As new initiatives and models are rolled out, it is never too early to begin establishing metrics to assess outcomes. 12