Nurses take pride in the practice of their profession. They are passionate about patient advocacy, support reform of the health delivery system and go the extra mile. Nurses Day celebrations are well orchestrated, and Gallup polling repeatedly shows that nurses are the most trusted workforce in the United States.
When the Institute of Medicine (IOM) released its 2010 report, The Future of Nursing: Leading Change, Advancing Health, many nurses felt affirmed by the spotlight this prestigious group focused on nursing. The eight IOM recommendations and strategies for achieving them make sense.
Support from AARP, AARP Foundation and the Robert Wood Johnson Foundation (RWJF) for Campaign for Action, an initiative to advance comprehensive health care change based on the Future of Nursing report, further bolstered nursing spirits. To date, 36 states have instituted Action Coalitions charged with implementing IOM recommendations. Participants in the campaign, by design, represent health care providers, consumer advocates, policymakers and business, and also include academic and philanthropic leaders (Center to Champion Nursing in America, n.d.). Nurses are responding to the challenge. It remains to be seen if nursing will speak with one voice.
Even as nurses and nursing organizations organize to respond to the exhilarating action occurring on many fronts, there is reason to pause and reflect on what the IOM recommendations are really saying to nursing. Is there deeper significance behind AARP and RWJF support of the Campaign for Action and their selection of stakeholders from beyond nursing to participate in the campaign?
In 1999, the IOM report To Err Is Human: Building a Safer Health System generated widespread interest and concern. For the first time, it was publicly acknowledged that mistakes—far too many mistakes—were occurring in health care delivery. The report enumerated the human toll of these mistakes: the unnecessary suffering and needless deaths, the loss of trust in the system, and the frustration and lowering of morale among health care professionals. The nationwide cost at that time of preventable hospital mistakes was estimated to be between $17 billion and $29 billion per year. In recommending strategies to build a safer system, the IOM (1999) established a goal of reducing errors by 50 percent in five years.
To Err Is Human misses target
The goal was overly optimistic. As of 2007, the health care error problem remained unresolved to the extent that the Center for Medicare and Medicaid Services (CMS) announced that, beginning in 2009, Medicare would no longer pay for costs associated with preventable conditions, mistakes and infections resulting from a hospital stay. Such errors include surgery- and catheter-related infections, pneumonia, falls, bedsores and air emboli (Medical News Today, 2007). Nearly all these problems are nurse-sensitive.
As a result, hospitals now take prevention of errors quite seriously, as does The Joint Commission. For example, in its Annual Report on Quality and Safety 2011, The Joint Commission identifies top-performing hospitals and provides detailed information on improvements in quality over time.
Concurrently, the American Nurses Credentialing Center (ANCC) Magnet Hospital Recognition Program has gained prominence for its strategies to achieve quality care. One of the factors considered in awarding Magnet status is proportion of BSN-prepared nursing staff (ANCC, n.d.). Magnet status is not an inconsequential achievement for a hospital. As of 2011, The Leapfrog Group (n.d.), a voluntary program focused on mobilizing employer purchasing power, includes Magnet designation as one of its criteria in ranking top hospitals.
More BSNs and MSNs = better patient outcomes
Quality nursing care is achieved not just by reducing the number of errors committed, but also by reducing errors of omission—those instances when evidence-based nursing care is not provided—and that statistic relates directly to educational preparation of nurses. Studies have shown that every 10 percent increase in the proportion of BSN nurses in a hospital’s staff is associated with a 4 percent decrease in risk of death (National Advisory Council on Nurse Education and Practice, 2010).
Hospital staffs with higher proportions of Bachelor of Science (BSN)- or Master of Science in Nursing (MSN)-prepared nurses demonstrate increased productivity and better patient outcomes (Aiken, Clarke, Cheung, Sloane, & Silber, 2003; Aiken, Clarke, Sloane, Lake, & Cheney, 2008; Curtin, 2003; Estabrooks, Midodzi, Cummings, Ricker, & Giovannetti, 2005; Tourangeau et al., 2007). At a time when care delivery systems must improve outcomes to assure reimbursement, educational preparation of nurses is a critical factor for hospitals to consider.
BSN in Ten recognizes the contributions of AD- and diploma-educated nurses and provides bridge time for them to earn the BSN degree.
In 2008, the House of Delegates of the American Nurses Association (ANA) resolved to support initiatives that require associate degree (AD) or diploma-prepared registered nurses to obtain a BSN within 10 years after initial licensure. Exempted in the resolution were those individuals that were licensed or enrolled as students in AD or diploma programs when such legislation was enacted.
Two years later, the Tri-Council for Nursing (2010), comprised of ANA, American Organization of Nurse Executives (AONE), National League for Nursing (NLN) and American Association of Colleges of Nursing (AACN), issued a consensus statement calling for “all registered nurses to advance their education in the interest of enhancing quality and safety across healthcare settings” (para. 1).
BSNs 20, ADs 6
Aiken, Cheung and Olds (2009) examined data from the 2004 National Sample Survey of Registered Nurses about the nearly 1.4 million RNs who obtained either an AD or BSN degree between 1970 and 1994. They learned that, of the 59 percent whose initial RN preparation was the AD, only 6 percent had earned the MSN or PhD by 2004, whereas nearly 20 percent of nurses who were initially BSN-prepared had done so. The authors noted that “just under 159,000 nurses obtained graduate education in a quarter of a century and thus were eligible to teach in nursing schools or to become nurse practitioners (NPs)” (Educational composition of the workforce, para. 3). Despite decades of encouragement, relatively few AD and diploma graduates earn BSN and higher degrees. As long as nurses’ credentials do not approximate those of other professionals, nurses will not be taken seriously as leaders.
From 50 to 80 in eight years
The 2010 IOM report mentioned at the beginning of this article—The Future of Nursing: Leading Change, Advancing Health—calls for a nurse workforce by 2020 that is 80 percent BSN-prepared. At present, according to that report, 50 percent of the U.S. nurse workforce has a BSN. Success in increasing the BSN portion of the workforce is integral to the IOM recommendation that the number of doctorally prepared nurses double by 2020. It is unlikely that IOM workforce goals can be met without legislation requiring new nurses to earn the BSN within a reasonable period of time.
A significant increase in the number of nurses attaining the BSN degree is essential to assure adequate numbers of expert nurses at the bedside, sufficient credentialed faculty for all levels of education, more advanced practice nurses to deliver primary care as access improves, well-qualified nurse administrators and senior executives to lead the way in achieving acceptable care outcomes and new nurse researchers who contribute to the evidence base of the profession. A February 2012 report from the U.S. Bureau of Labor Statistics projects that 712,000 new RN positions will be added to the workforce between 2010 and 2020. Also projected are 706,000 new home health aide positions and 607,000 new personal care aide positions. Nurses also train and supervise new health care workers.
Nurse organizations are adding their collective voices. In 2010, AACN expressed concern about the availability of adequate nurse faculty, citing already increasing vacancy rates that were expected to increase dramatically over the next 10 years as faculty members retire. They called for policymakers to take decisive action to maximize enrollment in graduate nursing programs.
AONE actively fosters practice partnerships with academic institutions to help nurses advance to BSN and MSN degrees. In the January 2012 issue of Voice of Nursing Leadership, Caramanica and Thompson stated, “A well-educated nurse is better prepared for changes in technology, advanced treatments and protocols and most important, can offer better and safer patient care” (p. 18).
Nursing is an exemplar for access to higher education for women and minorities, as well as for career mobility for students enrolled in AD and diploma programs. AD and diploma educators have long urged their graduates to continue to the BSN. Articulation programs connect education for the licensed practice nurse (LPN) with AD, diploma and BSN programs. New AD and diploma nurses help fill entry-level positions and will be relied on as older nurses retire, the population ages and access to care improves. The recession has slowed retirements but will not postpone them indefinitely. A nursing shortage of varying magnitudes is expected, and the need for AD and diploma graduates continues.
BSN in Ten
The World Health Organization’s (2009) Global Standards for the Initial Education of Professional Nurses and Midwives, developed between 2005 and 2007 with participation from Sigma Theta Tau International, called for all nurses to be educated with the bachelor’s degree. The standards note that work toward university-level education requires country-specific strategies, because resources, history and environments differ. Canada, Sweden, Portugal, Brazil, Iceland, South Korea, Greece and the Philippines require the BSN (Boyd, 2011). The United Kingdom adopted the BSN standard in 2000. In the United States, where AD and diploma programs produce more than half of nurse graduates each year, the strategy should be congruent with the educational system. “BSN in Ten” initiatives in 18 states provide such a strategy (Boyd, 2011).
BSN in Ten recognizes the contributions of AD- and diploma-educated nurses and provides bridge time for them to earn the BSN degree. BSN completion programs are widely available online and in adult-degree formats. BSN completion curriculums do not repeat, but rather extend, what is contained in AD and diploma programs, and many employers provide tuition assistance.
State boards of nursing are legally accountable for implementing nurse practice acts that protect the safety and well-being of the public. Evidence that nurses’ educational preparation affects outcomes of care is evidence on which boards of nursing should act. The profession sets standards of care on which boards of nursing rely in regulating practice. Time has demonstrated that educational preparation of nurses will not reach targets without a mandate. Legislation that requires that the BSN be earned within 10 years of initial licensure is the responsible action to take. Similar legislation has been enacted for other professions.
Hospital chief nursing officers, citing increasing complexity in the practice environment, are implementing hiring and retention policies that require the BSN. Academic and nurse practice partnerships in medical centers are well positioned to assist BSN in Ten initiatives by bringing to bear their institutional lobbying resources.
Nurses practicing in long-term care and all community-based care delivery settings also work in complex, high-acuity environments. Competencies in planning, implementing and evaluating population-based care, as well as health promotion, are gained in baccalaureate and master’s degree programs.
What is the IOM report on the future of nursing really telling us? Yes, it’s informing us that nursing is integral to the safe and effective functioning of the health care delivery system as it undergoes radical transformation with regard to access to care, quality of care and cost of care. But, implicit in the report is the message that, with regard to evidence available about educational preparation of nurses, the profession must also be accountable to the consumers it serves.
What are AARP, AARP Foundation and RWJF telling us? With consumer protection in mind, they are looking to nursing to take a leadership role in bringing about change to advance health. Advocacy is integral to nursing, but can we move past historical barriers to achieve accountability in education? If we can’t, consumer groups will wonder why. Our society can’t afford business as usual. RNL
Doris S. Edwards, EdD, RN, is dean of nursing emerita at Capital University in Columbus, Ohio, USA.
Acknowledgment: The following people contributed to this essay by reviewing the draft and making suggestions: Susan E. Hassmiller, PhD, RN, FAAN; Jeri A. Milstead, PhD, RN, FAAN; Mary Beth Mathews, PhD, RN, BC; and Ann Peden, DSN, RN.
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. doi: 10.1001/jama.290.12.1617
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