Karen Morin and Linda Aiken continue their conversation about Aiken’s research career—what motivated her to follow the path she took, her most recent findings and their implications for the future of nursing.
Morin: Before we talk about policy implications of your findings, I’m going to change the conversation a little bit and talk about leadership. I listen to you talk, and I think, “Wow! Here’s this fabulous scientist who really is also a leader in the discipline, certainly a leader in a particular, focused area.” But, considering that education prepares you for leadership, would you have started off initially to do this? What have you learned along the way from a leadership perspective?
Aiken: I was in school in the day when totally de novo baccalaureate programs were being developed. And there was a very strong ethos in those programs that every graduate is going to be a leader. That’s why you are here in this university, to be a leader. So, from a very early age, I was imprinted with the idea that everybody who graduated from the University of Florida was going to positively affect nursing and patient care in our country and the world. And I proceeded through my career with that assumption, and I had great mentoring.
Over time, I began to learn how important data could be if used strategically, and that just encouraged my enthusiasm about research. You know, numbers really speak in health care, but most of the numbers are about money, and there are few numbers on anything else. Nursing, in particular, is really vulnerable to these arguments about money, because nursing resources tend to be cut when there’s not enough money.
Having observed that throughout my career, I wanted to have the numbers to counterbalance that. I wanted to find ways to communicate what the consequences would be on both patient care and even the business side of these institutions if they cut nursing in ways which, as we knew from our evidence, would yield poor outcomes and cost these institutions a lot in the long term.
Over time, I began to learn how important data could be if used strategically, and that just encouraged my enthusiasm about research.
So, I started being able to show that, and other people began to get interested that it could be shown, and that was a big boost for nursing leadership everywhere. Suddenly, we had a lot of nurses who were looking to us to produce the numbers they needed, so it wasn’t just me producing these numbers and publishing papers. Now there were nurses everywhere, in every institution, in every kind of setting, who were so hungry for numbers to use in their own institution. And that’s where I began to get this idea that I could impact the care of millions of patients and millions of nurses if I did research instead of caring for patients one by one.
All of us in nursing, I think, have some ambivalence about doing anything other than taking care of patients one by one. But, over time, I convinced myself that I needed to provide better information for the nurses who were taking care patients one by one. I also learned more about being a leader, what you have to do to get people to use your data. That’s another very big part of leadership. You have to mobilize all the other leaders to take up your data and recognize the possibilities for change.
Morin: A great response! That ability to mobilize individuals is key. It’s a refined skill that I think we develop over time. Having data to be able to make the argument and recognizing early on how critical those data are in influencing decisions positions an individual to play a leadership role. Now, if you would, expand a bit on what you see as the most significant policy implications.
Aiken: I think the policy implications are twofold, in showing better patient outcomes associated with a better workforce. You take this idea of nursing education out of the kind of narrow stakeholder debates we’ve had in the past, which some have said are elitist, and put them squarely in the public interest. What these research findings suggest is in the public interest. It is in the public interest for nurses to be more educated. As this whole area of inquiry grows, it will become more and more clear that it’s in the public interest for nurses to have more education. So that’s one part of it.
It changed the nature of the conversation, and I think this relates to why we had such a long debate, starting way back before 1965, and it has taken us so long to come to grips with what we should do in terms of standards for nursing education. It’s because we were having more of an inside conversation that didn’t really engage the public. Well, now the public is engaged, and I think we can see that from the recommendations of the Institute of Medicine (2010) report The Future of Nursing, in which they have recommended that, by 2020, 80 percent of nurses in the United States have a baccalaureate degree. And they did that, not because they are favoring one subgroup of nursing, or any of those things. They did it because it is in the public interest. When an issue moves to the public arena, the whole dialogue starts to change. So that’s one major thing.
The other thing, and what I am doing now, and still having trouble getting people to fully understand my point, has to do with how basic nursing education affects the pipeline into graduate education, and the shortage of faculty and advanced practice nurses. It’s in the public’s interest to have more educated nurses so that outcomes are better. It’s also in the public’s interest to have enough faculty to train the next generation of nurses. There are 3 million nurses in the United States alone. It takes a lot of faculty to grow that 3 million and keep replenishing it, and we have a major faculty shortage now. Likewise, we’ve now demonstrated how important nurse practitioners are to improving access to care, which is another public issue, but we don’t have enough of them. So my pipeline work has been to show that, unless we move basic education to the baccalaureate level, we’ll not solve this problem from a numbers perspective.
I wrote a perspective in the New England Journal of Medicine (2011) where I said it’s mathematically impossible to solve the nurse faculty shortage unless all nurses get a baccalaureate degree in their first nursing education program. That is because only 20 percent of nurses at any degree level go on for another degree. So we have two-thirds of all nurses now who are graduating with an associate degree. Only 20 percent of them will go on, and of those who do go on to get any degree, the vast majority of them will get only a baccalaureate degree and then stop. That means that almost all of the two-thirds of the new workforce we’re creating every year will never get to the master’s level, and they will never be teachers and they will never be advanced practice nurses. That’s why the pipeline is just too small to create enough faculty and enough advanced practice nurses.
It’s mathematically impossible to solve the nurse faculty shortage unless all nurses get a baccalaureate degree in their first nursing education program.
So I keep trying to say this over and over again, and then people say, “Oh, well, we could have more articulation programs to help existing RNs get BSNs.” Well, you know, it’s very difficult for people to keep getting degrees over and over again. Life goes on, people have families, and spouses move. It’s just very difficult for most of us to get one degree, and nurses with an associate degree need at least two more degrees to get to the master’s level.
Back in 1974, if two-thirds of all nurses earned a baccalaureate degree and only one-third an associate, today, we’d have 50,000 more nurses with a master’s degree than we have. So it’s mathematically impossible to solve the shortage of advanced practice nurses and the shortage of faculty unless we make it possible for every nurse who starts a basic nursing education program to leave with the baccalaureate degree.
And there’s been a lot of uptake on this so far. For example, Florida has made it possible for their community colleges to give a BSN, and there are other changes of these kinds that are being made. Certainly, there is no way we are going to get to 80 percent BSNs in 2020, if we are still asking nurses to go back to school to earn separate degrees, rather than getting it all at the same time.
So my proposal is that we use all the new money—new money for education, both for scholarships and loans, and for educational support for institutions—and tie it to students getting a baccalaureate degree in their basic program. In other words, we should use education money the same way we incentivize changes in health care. If we want hospitals to do something different, we change the way Medicare pays. If we want educational institutions to do something different, we should change the way educational subsidies flow. I believe we could hold students harmless, in terms of not asking them to take any more time than they are already taking and not spending any more money out of pocket, but to get the baccalaureate degree in their basic education.
Morin: Wow! I think that makes a tremendous amount of sense. It’s an idea I’ve actually argued for, without data, many a time. By not providing our colleagues an opportunity to earn a baccalaureate degree, we’ve deprived them of realizing their potential. It’s nice to know that we are now using more solid evidence because, without the evidence, it’s just an argument and an opinion.
Aiken: It is hard to change educational institutions. These are stakeholders, and it’s hard for any stakeholder to change. But the American way to achieve change is to incentivize with money. We know that works! Another thing that will rapidly incentivize basic students to get a BSN is for employers to change their requirements or preferences, and this is now happening in many markets throughout the country. I don’t think we’re really going to need legislation to change entry into practice, because there are strong signals from the employment market. Yes, we do need educational institutions to change to make it possible for nurses to get a baccalaureate degree, but there’s so much evidence supporting that now.
Right after we published our JAMA (2003) paper, the American Organization of Nurse Executives (In my big, local market of Philadelphia, which is one of the largest cities in the country, nurses have a hard time finding a job in a hospital unless they have a BSN. So employers are acting on the evidence. At the recent Magnet meeting in Baltimore, we heard the Magnet commission say that now they are going to use the “proportion BSN” research as evidence criteria for granting Magnet status. n.d.Morin: Yes. I was very pleased to hear that. I thought that was a nice compliment to your work and the work of others, as well, to support it and put some teeth behind the recommendation.) decided that the AONE, as an evidence-based organization, would set the BSN as a desired credential for hospital nursing practice. They were really the first organization to say that. Since then, we see hospitals, especially in particular markets and academic health centers, saying they are only going to hire BSN nurses.
If we want educational institutions to do something different, we should change the way educational subsidies flow.
Aiken: This comes back to your point about leadership, why leadership is so important, because there has to be a network of leaders who build on each other’s work. And this is what is finally happening in nursing. You see the AONE, where you have nurse executives, recognizing this. And you see it with the Magnet program. So nurses all over are networking this information, and leaders in all positions are making decisions that collectively are changing the face of nursing quite dramatically.
Morin: That’s a great point to make, because it’s that collaboration that really will result, we hope, in the changes we need to see. The leaders have to be there—leaders in the science, but also leaders in other arenas—willing to hear the information and then act on it. So you’re right. It will take a collaborative effort to change practice and education.
This has been wonderful. Is there is anything else we haven’t talked about that you would like to share?
Aiken: We have more reasons to be optimistic about the future of professional nursing than ever before. We see it everywhere. We see the public recognizing the tremendous expertise of nurses, the new career paths that are opening up. The fact that nursing is one of the most popular career choices and that we are turning away tens of thousands of students is exciting in the sense that nursing has finally matured and is getting the recognition it deserves. So it’s even more incumbent upon leaders to make sure we take this very special time in nursing and exploit it fully for the benefit of the public whom we serve.
Morin: Thank you, once again, for sharing your research journey, a journey that has established your expertise and made such significant contributions to increasing our understanding of factors in the workplace that improve patient outcomes. RNL
References
Aiken, L. (2011). Nurses for the future. The New England Journal of Medicine, 364, 196-198.
Aiken, L.H., Clarke, S.P., Cheung, R.B., Sloane, D.M., & Silber, J.H. (2003). Educational levels of hospital nurses and surgical patient mortality. JAMA, 290(12), 1617-1623. Retrieved from http://jama.ama-assn.org/content/290/12/1617.full
Institute of Medicine. (2010). The future of nursing: Leading change, advancing health. Washington, DC: Institute of Medicine.
