RN-to-BSN Education: The Imperative for Rapid Change

RN-to-BSN Education: The Imperative for Rapid Change Susan Sportsman, PhD, RN, ANEF Director, Academic Consulting Group Nursing is unique among all health professions because it has multiple educational pathways leading to an entry-level license to practice. The variety and volume of available pre-licensure nursing education programs has increased access to nursing education throughout the country. However, the question of the extent to which each type of education prepares the nurse for the current practice environment has been debated by nurses, nursing organizations, academics, and a variety of other stakeholders for more than 40 years. While this discussion has been evolving, the competencies necessary to practice, particularly in the areas of community and public health, geriatrics, leadership, health policy, quality, safety, systems improvement and change, research and evidence-based practice, and inter-professional collaboration, have expanded (IOM, 2011). Although the national shortage of nurses currently seems less severe as a result of the economic recession than in the recent past, as baby-boomers begin to retire, the U.S. nursing shortage is projected to grow to 260,000 by 2025 (Buerhaus, 2009). As a result, nurse educators in all types of educational programs must be concerned with increasing the number of qualified graduates to meet the future need for nurses in this country. The landmark Institute of Medicine (IOM) study, The Future of Nursing: Leading Change, Advancing Health complicates the need to increase production by recommending that nurses must achieve higher levels of education and training through an improved education system that promotes seamless academic progression. Although the report encourages nurses, regardless of their initial preparation, to continue their education throughout the course of their careers, one of the important goals of this report is to have 80% of nurses prepared with at least a BSN degree by 2020. According to a 2008 HRSA report, only 50% of nurses hold a BSN or higher and only 16% of all nurses return to school for further schooling beyond their initial education. According to the 2008 HRSA National Sample Survey of Registered Nurses (the most recent data from that ongoing survey), there are 3.1 million RNs in the United States, of which 2.7 million are employed. Fifty percent of those nurses hold either an ADN or a diploma as their highest degree. To increase the percentage of nurses prepared at least at the baccalaureate level by 2020, a minimum of 405,000 to 465,000 of ADN/diploma nurses must return to school. Given that this number is not static and each year some nurses will retire and additional nurses will be prepared, the number of ADN/diploma nurses who will need additional education is huge. To attempt to reach the goal set by the IOM report, nurse educators must not only produce more nurses entering into practice, but also encourage those prepared at the associate degree/diploma Page 1 of 6

level to return to school sooner and in greater numbers than ever before. Several recent studies have identified barriers, such as lack of time for studying, the pressure of family obligations, the unavailability of a seamless transition from one program to another, and few incentives from employers as reasons they do not return to school (Sportsman & Allen, 2011; Spencer, 2008). However, encouraged by the IOM report, employers are increasingly providing positive and negative incentives for ADN/diplomaprepared nurses to return to school, ranging from educational benefits for employees to preferential hiring for new BSN graduates. The health care workplace is supporting further education for ADN or diploma-prepared professional nurses. What strategies should nurse educators now implement to take advantage of this change in the work environment? Facilitate Articulation and Transfer There are two components to facilitating the educational transition of RNs to a BSN program. The first is to accept nursing credits from entry level programs and build upon content in which nurses have already demonstrated competence through the NCLEX-RN examination. Nursing programs may initiate articulation agreements among specific partners or they may develop a plan where universities accept nursing credits for all Registered Nurses. This strategy has been used across the country for a number of years and has already incentivized nurses to enroll in RN-to-BSN programs. The transfer of pre-requisite and general education courses of ADN/diploma nurses earn has been more problematic. Often, each college and university has slightly different graduation requirements. Some of these differences are driven by faculty, some by state legislatures or regulatory bodies. For example, some community colleges may require chemistry for their ADN graduates; others do not. As a result, a practicing Registered Nurse may be required to take chemistry as a prerequisite in order to earn a BSN, resulting in a barrier to pursuing further education. In an effort to simplify transfer processes, faculty at both the local and state level must consider which required courses are necessary to practice effectively as a BSN. Educators may consider the question, Does the ADN/diploma nurse who has passed the NCLEX-RN exam have sufficient knowledge of chemical concepts to practice, even if he/she has not formally taken a chemistry course? Curriculum Revision Traditionally, RN-to-BSN programs require students to take courses that emphasize research, theoretical concepts, professional issues, leadership/management and community health. Depending on the philosophy of the school, they may also be required to take pathophysiology and/or health assessment. Often, courses offered to upper-level BSN students are repackaged for the RN-to-BSN student. The content is the same, although generally RN-to-BSN students attend different classes than pre-licensure students. All of these courses include content that can be applied in specific work settings; unfortunately, content is often presented as if it can only be implemented in specific roles or settings. For example, community health content, which deals with care of aggregates, is often presented in the Page 2 of 6

context of providing care to neighborhoods or communities. Rarely do students have the opportunity in community health to deal with aggregates in areas where they currently work, which is frequently the acute care setting. Perhaps a broader approach to baccalaureate content, which recognizes its universal applicability, would entice more RNs to return to school. A conceptual approach to curriculum using concepts identified as important to the baccalaureate graduates is an excellent method of addressing this concern. There are a variety of frameworks that outline baccalaureate competencies, including the American Association of Colleges of Nursing (AACN) Essentials of Baccalaureate Education (2008). States such as Texas may have differentiated the competencies of the baccalaureate graduate compared to other entry-level nurses (Poster, et. al., 2010). Finally, the Institute of Medicine s report highlights competencies related to leadership, cultural competencies/diversity, inter-professional collaboration, and quality and safety, as those required by the nurse of the future. These competencies may also be used as a guideline. Support for Clinical Experience for the RN-to-BSN Student Recently, the Commission on Collegiate Nursing Education (CCNE) (2012) clarified that practice experiences are required in all BSN programs, including RN-to-BSN programs. Developing proficiency in performing psychomotor skills, applying communication strategies to client and interpersonal interaction, and acquiring a professional identity are specifically mentioned as important skills gained from clinical assignments. Since RN-to-BSN programs are often largely delivered online, some may see this requirement as a stumbling block to facilitating RN-to-BSN education. However, the effective use of preceptors and the wise use of simulation, unfolding case studies, and student-driven electronic health records can offer clinical experiences for the RN-to-BSN students to ensure their development, without raising unnecessary barriers to returning to school. Addressing the Needs of the Students Revising the RN-to-BSN curriculum to make it more meaningful to the RN s practice will certainly encourage them to return to school. However, many RNs are motivated to return to school by a desire to change roles (e.g., become a nurse practitioner or nurse educator) or because of job demands that can only be met through a MSN. Programs which allow a streamlined movement from an ADN to a MSN degree, through advanced credits or other approaches, will certainly encourage students to return to school. Historically, ADN/diploma nurses returned to school a decade or more after becoming licensed. In the intervening years, these nurses developed from novice or advanced beginners, as described by Benner (1984), to competent or expert. When they return to school, their performance is informed by their previous practice, although they return to a novice or advanced beginner level when faced with Page 3 of 6

new nursing material. As the practice environment continues to change, ADN/diploma students are more likely to return to school sooner after graduation from their ADN program. In a survey regarding BSN education, 45.9% of the 416 ADN respondents indicated they planned to return to school immediately upon graduation (Sportsman & Allen, 2010). As the work environment continues to encourage higher educational achievement and students transition more quickly from the ADN/diploma to BSN programs, they will be at different place in their progression toward competence (Benner, 1984) than students with significant nursing experience. Nurse educators must be able to address the disparate educational needs of these students. Again, the use of simulation and other technologies may be particularly helpful in supporting and validating the competence of a nurse who has not been practicing for a long period of time. The educational transition necessary to increase the number of RNs holding a BSN degree or higher will be a great challenge for nurse educators in this country. This white paper provides some suggestions for re-thinking the educational process for these nurses. The list of resources below may also provide some additional suggestions, as nurse educators across the country develop innovative ways to meet the ongoing educational need of registered nurses. Further Resources Regarding RN-to-BSN Education General Information regarding RN-to-BSN Programs Altman, T. (2011) Registered nurses returning to school for a bachelor s degree: Issues emerging from a meta-analysis. Contemporary Nurse. 39(2) 256-272. Kubsch, S., Hansen, G., Huyser-Eatswell, V. (2008) Professional values: The case for RN BSN completion education. The Journal of Continuing Education in Nursing. 39(8) 375-383. Maneval, R., Teeter, M. (2010) The student perspective on RN plus 10 Legislation: A survey of associate degree and diploma nursing students. Nursing Education Perspective. 31(6) November-December. 358-361. Megginson, L. (2008) RN-BSN education: 21 st century barriers and incentive. Journal of Nursing Management. 16. 47-55. Orsolini-Hain, L. Waters, V. (2009) Education evolution: A historical perspective of associate degree nursing. Journal of Nursing Education. 48(5) 266-271. Spenser, J. (2008) Increasing RN-to-BSN enrollments: Facilitating articulation through curriculum reform. The Journal of Continuing Education in Nursing. 39(7) 307-313. Zittel, B. (2012) Advancing the education of nurses: The New York initiative. Journal of Nursing Regulation. 2(4)10-14. Page 4 of 6

Online Education in RN-to-BSN Education Abell, C., Williams, D., Jones, S.M. (2012) Transforming RN-to-BSN program to an online delivery. Kentucky Nurses. January, February, March. Hart, L., Morgan, L. (2010) Academic integrity in an online registered nurse to baccalaureate in nursing program. The Journal of Continuing Education in Nursing. 41(11) 498-505. Hsu, L., Hsieu, S. (2012) Factors associated with learning outcome of BSN in a blended learning environment. Contemporary Nurse. 38(1-2) 24-34. Little, B., (2009) The use of standards for peer review of online nursing courses: A pilot study. Journal of Nursing Education. 48(7) 411-415. Teaching Strategies Blum, C., Hickman, C., Parcells, D.A., Locsin, R. (2010) Teaching caring nursing to RN-to-BSN students using simulation technology. International Journal of Human Caring. 14(2)41-50. Lujan, J., Vasquez, R. (2010) A case study of the scaffolding clinical practice model: Is it culturally competent for Hispanic students. Journal of Nursing Education. 49(7) 394-397. Morris, A., Faulk, D. (2007) Prospective transformation: Enhancing the development of professionalism in RN-to-BSN students. Journal of Nursing Education. 46(10) 445-451. Oldenburg, N., Hung, W. (2010) Problem solving strategies used by RN-to-BSN students in an online problem based learning course. The Journal of Continuing Education in Nursing. 49(4) 219-222. Rush, K., Dyches, C., Waldrop, S., Davis, A. (2008) Critical thinking among RN-to-BSN students participating in human simulation. Journal of Nursing Education. 47(11) 501-507 Schutt, M., Hightower, (2009) Enhancing RN-to-BSN students information literacy skills through the use of instructional technology. Journal of Nursing Education. 48(2) 101-105. References for White Paper Benner, P. (1984). From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Menlo Park, CA: Addison-Wesley Publishing Company. Page 5 of 6

Buerhaus, P. (2009) The recent surge in nurse employment: Causes and implications. Health Affairs. July/August, http://content.healthaffairs.org/content/28/4/w657. Last accessed, June, 2012. Caldwell, L. (2012) Letter to CCNE constituents regarding clinical practice in BSN programs. Commission on Collegiate Nursing Education Board of Commissioners. April 30. HRSA (2010) The Registered Nurse Population: Findings from the 2008 National Sample Survey of Registered Nurses. U.S. Department of Health and Human Services Health Resources and Service Administration. http://bhpr.hrsa.gov/healthworkforce/rnsurveys/rnsurveyfinal.pdf. Last accessed, June, 2012. Institute for Medicine (2011) The Future of Nursing: Leading Change, Advancing Health. Washington, D.C. National Academy of Sciences. Poster, E., Curl, E., Sportsman, S. (2011) Differentiated essential competencies for graduate in Texas nursing programs. Journal of Regulation. 1(4) 46-20 Spencer, J. (2008) Increasing RN-to-BSN enrollments: Facilitating articulation through curricular reform. The Journal of Continuing Education in Nursing. 39(7) 307-313. Sportsman, S., Allen, P. (2011) Transitioning associate degree in nursing students to the Bachelor of Science in nursing and beyond: A mandate for academic partnerships. Journal of Professional Nursing. 27(6) November-December. e20-e27 About Academic Consulting Group Academic Consulting Group, a new initiative of Elsevier, is a coalition of experienced educators dedicated to helping nursing and health professions programs succeed in challenging times. ACG offers targeted consultations to identify opportunities for improvement and initiate the process for change, and faculty development workshops to help educators improve the way they work with both students and new technology. For more information, please visit http://academicconsulting.elsevier.com. Page 6 of 6