Reflection Paper
The IOM published report, “Future of Nursing: Leading Change, Advancing Health,” (attached) makes recommendations for lifelong learning and achieving higher levels of education.
In 1,000 words, examine the importance of nursing education and discuss your overall educational goals.
Include the following:
- Discuss your options in the job market based on your educational level.
- Review the IOM Future of Nursing Recommendations for achieving higher levels of education. Describe what professional certification and advanced degrees (MSN, DNP, etc.) you want to pursue and explain your reasons for wanting to attain the education. Discuss your timeline for accomplishing these goals.
- Discuss how increasing your level of education would affect how your competitiveness in the current job market and your role in the future of nursing.
- Discuss the relationship of continuing nursing education to competency, attitudes, knowledge, and the ANA Scope and Standards for Practice and Code of Ethics.
- Discuss whether continuing nursing education should be mandatory. Provide support for your response.
You are required to cite to a minimum of three sources to complete this assignment. Sources must be published within the last 5 years and appropriate for the assignment criteria and relevant to nursing practice.
Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.
This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.
You are required to submit this assignment to LopesWrite. Refer to the
LopesWrite Technical Support articles
for assistance.
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The Future of Nursing: Leading Change, Advancing Health
(2011)
700 pages | 6 x 9 | HARDBACK
ISBN 978-0-309-15823-7 | DOI 10.17226/12956
Committee on the Robert Wood Johnson Foundation Initiative on the Future of
Nursing, at the Institute of Medicine; Institute of Medicine
Institute of Medicine 2011. The Future of Nursing: Leading Change, Advancing
Health. Washington, DC: The National Academies Press.
https://doi.org/10.17226/12956.
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The Future of Nursing: Leading Change, Advancing Health
Copyright National Academy of Sciences. All rights reserved.
I
The Future of Nursing Education1
Edited by Linda R. Cronenwett, Ph.D, R.N., FAAN
University of North Carolina at Chapel Hill School of Nursing
1 The responsibility for the content of this article rests with the authors and does not necessarily
represent the views of the Institute of Medicine or its committees and convening bodies.
SUMMARY AND CONCLUSIONS
“Learn the past, watch the present, and create the future.”
In October 2009, Don Berwick and I were out of the country when we re-
ceived invitations from Susan Hassmiller to co-author a background paper on the
future of nursing education for the Robert Wood Johnson Foundation/Institute of
Medicine (RWJF/IOM) Committee on the Future of Nursing. Initial conversa-
tions led to long lists of potential topics to be covered. Inevitably, we kept coming
back to the question: What would be useful to committee members who deserved
a base for their deliberations that was focused and helpful? In the end, we decided
that detailed descriptions of the current challenges and recommendations for the
future of nursing education from two people were not the answer. Instead, we
requested and received permission to challenge five leaders, in addition to our-
selves, to write short papers focused on recommendations addressing the most
important three issues from each of their perspectives.
With input from the RWJF/IOM Committee members and staff, we chose
five esteemed (and busy) leaders and asked them to rise to this challenge within
10 weeks. Each person agreed, and each met the deadline. There were no group
discussions, and, since each of us submitted our papers at the same time (no one
finished early!), no one altered his or her content based on reading someone else’s
contributions.
4��
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The Future of Nursing: Leading Change, Advancing Health
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4�� THE FUTURE OF NURSING
The seven papers are reprinted below, followed by a summary of the themes
that emerged across papers. How does it match what you would have written?
SUMMARY
The authors of the preceding papers came from the Northeast, South, Mid-
west, and Western parts of the country. One is a distinguished physician col-
league, and the nursing educators are comprised of three professors (one a dean
emeritus) and three current deans. Each has exerted leadership—in science,
teaching, practice, and policy—for multiple decades. Each leads initiatives that
extend beyond the boundaries of their places of employment. One is the current
president of the American Academy of Nursing. What can we learn across the
issues each chose to raise?
The style of the papers differed, so what was called a recommendation, con-
clusion, or issue varies. I extracted each major point, regardless of label. These
major points from all authors are included in the categories below. Following
each theme, authors for whom this was a major point are listed in regular font.
Some additional authors mentioned the same point but not at the level of recom-
mendations, conclusions, or major issues, and their names are listed in italics.
Finally, I organized themes using categories that the RWJF/IOM committee chose
for panel presentations at their upcoming meeting (what to teach, how to teach,
where to teach), adding a few remaining categories so that all major points were
included.
What to Teach (or What Students Should Learn)
• Competencies necessary for continuous improvement of the quality and
safety of health care systems—patient-centered care, teamwork and col-
laboration, evidence-based practice, quality improvement, safety, and
informatics (Berwick, Cronenwett, Tanner)
− Mastery of knowledge of systems, interpretations of variation, human
psychology in complex systems, and approaches to gaining knowl-
edge in real-world, local contexts (Berwick)
− Skills and methods for leadership and management of continual im-
provement, for nurse-teachers and nurse-executives (Berwick)
• Competencies needed in new care delivery models
− Population health and population-based care management
(Tanner)
− Care coordination (Tilden)
• Knowledge based on standardized science prerequisites (Dracup,
Tanner)
• Health policy knowledge, skills, and attitudes (Tilden)
• Competencies related to emerging health needs—e.g., geriatrics
(Tanner)
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The Future of Nursing: Leading Change, Advancing Health
Copyright National Academy of Sciences. All rights reserved.
APPENDIX I 4��
How to Teach
• Guide students in integrating knowledge from clinical, social, and be-
havioral sciences with the practice of nursing to enhance development
of clinical reasoning skills (Cronenwett, Dracup, Tanner, Tilden)
• Enhance opportunities for interprofessional education (Cronenwett,
Dracup, Gilliss, Tilden, Tanner)
− Evaluate and test models of interprofessional education, including
timing, determination of what levels of students should learn together,
and what content is most effectively delivered with interprofessional
learners (Tilden)
• Develop and test new approaches to pre-licensure clinical education,
including use of simulation (Dracup, Tanner)
• Involve students in interprofessional quality improvement projects
(Berwick, Gilliss, Cronenwett)
• Develop model pre-licensure curricula that incorporate best practices in
teaching and learning and can be used as a framework for community
college–university partnerships (Tanner)
Where to Teach
• In baccalaureate and higher degree programs (Aiken, Cronenwett,
Dracup, Gilliss, Tanner, Tilden)
− Significantly increase the number and proportion of new registered
nurses who graduate from basic pre-licensure education with a bac-
calaureate or higher degree in nursing (Aiken, Cronenwett)
− Require the BSN for entry into practice (Dracup, Tilden)
− Support community college/university partnerships that increase the
number of associate degree graduates that complete the baccalaureate
degree (Dracup, Tanner)
− Allow community colleges to provide baccalaureate degrees
(Dracup)
• In post-graduate residency programs
− Develop and test clinical education models that include post-graduate
residency programs (Tanner)
− Implement requirement of post-graduate residency for initial re-
licensure (Cronenwett, Tanner)
• In health care settings that foster day-to-day change and improvement
(Berwick)
• In programs built on strong academic–practice setting partnerships
(Cronenwett, Gilliss)
− At Academic Health Centers, promote governance structures that
combine the strategic, rather than operational, oversight for nursing
(Gilliss)
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The Future of Nursing: Leading Change, Advancing Health
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4�0 THE FUTURE OF NURSING
• In settings that are models of integrated care where care coordination
skills can be developed (Tilden)
Who Teaches (Characteristics of Desired Faculty Members of the Future)
Increase the number of faculty members:
• Whose criteria for appointment and advancement include recognition of
practice-based accomplishments, including engagement in the work of
improving health care (Berwick, Gilliss, Dracup, Cronenwett)
• Who can move easily during careers between practice and academe
(Gilliss)
• Who shorten their career paths from BSN to doctoral degree (Aiken,
Dracup)
• Who maintain professional certification and/or clinical competence
(Gilliss)
• Who build alliances with faculty in other disciplines (medicine, engi-
neering, business, public health, law) (Gilliss)
• Who are capable of leading efforts to advance interprofessional educa-
tion (Dracup, Tilden)
Recommendations: To Nursing Organizations
• Ensure that schools produce ever-increasing numbers of nurse practi-
tioners for primary care roles at a time when expanded access to health
care will increase society’s need for primary care providers (Cronenwett,
Gilliss)
− Challenge current credit-heavy requirements and test teaching in-
novations that improve competence while reducing program credits
(Gilliss)
• Support the faculty development necessary to bring about the magnitude
of reforms in nursing education recommended in the Carnegie study,
necessitated by advances in nursing science and practice and guided by
advances in the science of learning (Tanner)
• Advance post-master’s DNP education, maintaining specialist prepara-
tion at the master’s program level (Cronenwett, Gilliss)
− Fund initiative to facilitate professional consensus that DNP programs
should be launched as post-master’s program for the foreseeable fu-
ture (Cronenwett)
− Clarify the expectations for nurse scientists interested in translational
research—will both the DNP and the PhD be required? Will the DNP
alone be sufficient for tenure-track positions in research-intensive
universities? (Dracup)
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The Future of Nursing: Leading Change, Advancing Health
Copyright National Academy of Sciences. All rights reserved.
APPENDIX I 4�1
• Include as accreditation criteria for nursing education programs:
− Substantive nursing education–service partnerships, e.g., in shared
teaching and clinical problem solving (Cronenwett, Gilliss)
− Interprofessional education (Cronenwett, Dracup, Gilliss, Tilden)
− Development of competencies in health policy (Tilden)
− Student/faculty participation in or leadership of teams that work to
improve health care (Berwick, Cronenwett)
− Student competency development related to health policy (Tilden)
• Identify top ten areas of needed faculty development and provide public
recognition for success (Gilliss)
• Support a learning collaborative of state boards of nursing willing to
implement regulatory requirements for transition to practice residency
programs as a prerequisite for initial re-licensure (Cronenwett)
• Require proof of a nurse’s participation in or leadership of teams that
work to continuously improve the health care system for renewal of
certification (Berwick)
• Urge testing of interprofessional teamwork and collaboration and health
policy competencies in licensure exams (Tilden)
Recommendations: To Government and Other Organizations
• Increase scholarships, loan forgiveness, and institutional capacity
awards to increase the number and proportion of newly licensed nurses
graduating from baccalaureate and higher degree programs (Aiken,
Cronenwett)
• Increase scholarships, loan forgiveness, and institutional capacity awards
for graduate nurse education at master’s and doctoral levels (Aiken,
Dracup)
• Redirect Medicare GME nursing education funds to support graduate
nurse education (Aiken, Dracup, Tanner)
• Redirect Medicare GME nursing education funds from hospital-based
pre-licensure programs to postgraduate residency programs (Cronenwett,
Tanner)
• Promote innovation and evaluation of novel approaches to improving
preparation for the practice of nursing through expanded Title VIII fund-
ing (Cronenwett, Tanner)
• Invest in nursing education research, related particularly to the evalua-
tion of multiple pathways to licensure (Tanner)
• Use CTSA or other research facilitation structures to promote knowledge
development at the point of care, translation of knowledge into prac-
tice, practice improvements, and interprofessional education (Dracup,
Gilliss)
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The Future of Nursing: Leading Change, Advancing Health
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4�2 THE FUTURE OF NURSING
• Create a federal health professions workforce planning and policy capac-
ity in the Executive Branch (Aiken)
• Expand authorities for Title VII/VIII funds to support development and
evaluation of interprofessional education innovations (Gilliss)
• Expand Nurse Faculty Loan Programs and other loan forgiveness/
scholarship programs that produce more faculty (Aiken, Dracup)
• Encourage public and private resource investments that incentivize stu-
dents and nursing programs to expedite production of qualified nurse
faculty by shortening the trajectory from entry into basic nursing pro-
grams through doctoral and post-doctoral study (Aiken, Dracup)
• Use Perkins funds to incentivize community college nursing programs
to increase the proportion of their nursing students who complete their
initial education with a BSN (Aiken)
• Increase programs that support greater production of nurse practitioners
for primary care (and remove legal barriers to interprofessional educa-
tion and practice) (Aiken, Cronenwett)
• Fund a longitudinal study to track state-based data on number and
proportion of new nurse graduates from ADN vs. BSN/higher degree
programs (Cronenwett)
− Advance media attention to states that exemplify “best practices” in
the distribution of new nurse graduates from ADN vs. BSN programs
(Cronenwett)
• Include health services research (in addition to drug and treatment in-
tervention trials) in initiatives to enhance comparative effectiveness
research (Aiken)
• Require universities and colleges (presidents, provosts, deans) to support
infrastructures and mandates for interprofessional education (Tilden)
CONCLUSION
The recommendations of seven leaders committed to the development of
future generations of health professionals included some expected diversity of
views. Nonetheless, given the long list of issues that would have been covered
had we chosen to write one comprehensive paper, a remarkably small number of
themes emerged. Hopefully, these rich ideas and themes can be used to inform the
deliberations of the RWJF/IOM Committee on the Future of Nursing. Even more
hopefully, a collective national response to these important issues will create a
future that meets nursing’s obligations to the society it serves.
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The Future of Nursing: Leading Change, Advancing Health
Copyright National Academy of Sciences. All rights reserved.
APPENDIX I 4�3
NURSING EDUCATION POLICY PRIORITIES
Linda H. Aiken, Ph.D., FAAN, FRCN, R.N.
University of Pennsylvania
Nursing is one of the most versatile occupations within the health care
workforce. In the 150 some years since Nightingale developed and promoted
the concept of an educated workforce of caregivers for the sick, modern nursing
has reinvented itself a number of times as health care has advanced and changed
(Lynaugh, 2008). As a result of nursing’s versatility, new career pathways for
nurses have evolved attracting a larger and more diverse applicant pool and a
broader scope of practice and responsibilities. Nursing, because of its versatil-
ity, has been an enabling force for change in health care along many dimensions
including but not limited to the evolution of the high-technology hospital, the pos-
sibility for physicians to combine office and hospital practice, length of hospital
stay among the shortest in the world, reductions in the work hours of resident
physicians to improve patient safety, extending national primary care capacity,
improving access to care for the poor and rural residents, and contributing to
much needed care coordination for the chronically ill and frail (Aiken et al.,
2009). Indeed, with every passing decade, nursing has become a more integral
part of health care services to the extent that a future without large numbers of
nurses is impossible to envision.
A POLICY CHALLENGE
From a policy perspective, nursing’s versatility is important to note for the
simple reason that nursing has evolved faster than public policies affecting the
profession. The result is that nursing’s forward progress to better serve the public
is hampered by the constraints of outdated public policies involving govern-
ment education subsidies, workforce priorities, scope of practice limitations and
regulations, and payment policies. An important priority in national health care
reform is achieving better value for the expenditures made on health services.
Since health care is labor intensive, getting more value will depend in large part
on enhancing productivity and effectiveness of the workforce. Nurses represent
a large and unexploited opportunity to achieve greater value.
The purpose of this paper is to identify and discuss several key changes in
nursing education policy that are critically needed to shape the nurse workforce
to best serve the health care needs of the American public in the years ahead. It
is written with the assumption that nurse scope of practice and payment policy
reforms will take place over the near term to remove some of the existing barri-
ers to nurses practicing to the full extent of their education and expertise. This
assumption is based on steady progress in removing barriers to nursing practice
at the state level and language in current national health reform legislation show-
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The Future of Nursing: Leading Change, Advancing Health
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4�4 THE FUTURE OF NURSING
ing greater neutrality in the designation of types of health professionals who can
participate in and lead new initiatives in primary care and chronic care coordina-
tion. Changes in nursing education policies are needed to ensure that the nurse
workforce of the future is appropriately educated for anticipated role expansions
and changing population needs.
Five priority recommendations regarding the future of nursing education are
advanced for consideration by the RWJF Committee on the Future of Nursing
at the IOM:
• Increase and target new federal and state subsidies in the form of schol-
arships, loan forgiveness, and institutional capacity awards to signifi-
cantly increase the number and proportion of new registered nurses
who graduate from basic pre-licensure education with a baccalaureate
or higher degree in nursing.
• Increase federal and state subsidies for graduate nurse education at the
master’s and doctoral levels in the form of scholarships, loan forgive-
ness, and institutional capacity with a priority on producing more nurse
faculty.
• Encourage public and private resource investments to incentivize students
and nursing programs to expedite production of qualified nurse faculty by
shortening the trajectory from entry into basic nursing education through
doctoral and post-doctoral study by expedited bachelor of science in
nursing (BSN) to PhD programs and comparable innovations.
• Create a federal health professions workforce planning and policy capac-
ity in the Executive Branch with authority to recommend to the President
and the Congress health workforce policy priorities across federal agen-
cies and departments.
• Recommend the inclusion of health services research on various forms of
nursing investments in improving care outcomes including comparisons
of the cost effectiveness of improving hospital nurse-to-patient ratios,
increasing nurse education, and improving the nurse work environment.
At present comparative effectiveness research is more focused on drug
and treatment intervention trials than on innovations in care delivery
including workforce interventions.
PRIORITY FUNDING TO INCREASE INITIAL BSN GRADUATES
Every year the percent of new registered nurses graduating from associate
degree programs increases, and it is now over 66 percent of all new nurse gradu-
ates. Multiple blue ribbon panels on nursing education, including the just released
Carnegie Foundation Report on Nursing Education (Benner et al., 2010) as well
as health workforce reports to Congress for two decades, have concluded that
there is a substantial shortage of nurses with BSN and higher education to meet
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Copyright National Academy of Sciences. All rights reserved.
APPENDIX I 4��
current and future national health care needs. Advances in medical science and
technology, the changing practice boundaries between medicine and nursing, and
the increase in the share of the population with multiple chronic health conditions
create a level of complexity in health care that requires a more educated health care
workforce. Nursing is the least well educated health profession by far but the one
experiencing the greatest expansion in scope of practice and responsibilities. The
National Advisory Council on Nurse Education and Practice (NACNEP) (1996),
policy advisors to the Congress and the U.S. Secretary of Health and Human
Services on nursing issues, urged almost 15 years ago that policy actions be taken
to ensure that at least 66 percent of nurses would hold a baccalaureate or higher
in nursing by 2010; the actual result is closer to 45 percent. As described in the
sections below, growing evidence suggests that the shortage of nurses with BSN
and higher education is adversely affecting a number of dimensions of health care
delivery now and these problems will only become exaggerated in the future.
Quality of Hospital Care
A growing body of research documents that hospitals with a larger propor-
tion of bedside care nurses with BSNs or higher qualifications is associated with
lower risk of patient mortality. Aiken and colleagues (2003) in a paper published
in the Journal of the American Medical Association (JAMA) showed that in 1999,
each 10 percent increase in the proportion of a hospital’s bedside nurse workforce
with BSN qualification was associated with a 5 percent decline in mortality fol-
lowing common surgical procedures. A similar finding was published by Friese
and associates for cancer surgical outcomes (Friese et al., 2008). Aiken’s team
has replicated this finding in a larger study of hospitals in 2006. Similar results
have been published for medical as well as surgical patients in at least three large
studies in Canada and Belgium (Estabrooks et al., 2005; Tourangeau et al., 2007;
Van den Heede et al., 2009).
This research has motivated the American Association of Nurse Executives,
the major professional organization representing hospital nurse chief executive
officers who employ 56 percent of the nation’s nurses, to establish the BSN as
the desired credential for nurses. Many hospitals, particularly teaching hospitals
and children’s hospitals, are acting on the evidence base by requiring the BSN
for employment. Nurse executives in teaching hospitals have a goal of 90 percent
BSN nurses, and community hospital nurse executives aim for at least 50 percent
BSN-prepared nurses (Goode et al., 2001). Since only 45 percent of bedside care
nurses have a BSN, many executives cannot reach their goals.
Access and Costs
There is some research evidence that the cost effectiveness of nursing im-
proves with a more educated workforce. In Aiken’s JAMA paper, evidence was
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4�� THE FUTURE OF NURSING
presented to show that the mortality rates were the same for hospitals in which
nurses cared for 8 patients each, on average, and 60 percent had a BSN and for
hospitals in which nurses cared for only 4 patients each but only 20 percent had
a BSN (Aiken, 2008; Aiken et al., 2003). More research is needed to assess the
comparative value of investing in different nursing strategies that evaluate the
relative cost and outcomes of increasing nurse staffing, educational levels, and
improving the organizational context and culture of the nurse work environment.
At this point the evidence is encouraging that a more educated hospital nurse
workforce might allow for a smaller nurse workforce without adversely affect-
ing patient outcomes. If confirmed in future research, this finding could have
important implications for both cost of hospital care and for the number of nurses
actually needed in the future to staff hospitals.
In the ambulatory sector, there is a strong research base documenting that
nurses with advanced clinical training, usually master’s degrees in advanced
clinical practice, provide primary care with outcomes comparable to, and in some
domains like symptom control and satisfaction better than, those of physicians
and with lower costs (Griffiths et al., 2010; Horrocks et al., 2002). Rand research-
ers estimated, for example, that the state of Massachusetts could save up to $8
billion over a decade by attracting more advanced practice nurses and removing
barriers that prevent them from practicing at the full level of their education and
expertise (Eibner et al., 2009). Increased use of advanced practice nurses is one
of the very few practice innovations currently underconsidered in national health
reform, including medical homes and chronic care coordination, that would yield
net cost savings nationally according to Rand researchers (Hussey et al., 2009).
How the Shortage of BSN Nurses Impacts Future Nurse Supply
As argued above, the shortage of BSN nurses has implications for health care
quality and safety, access, and costs of care. A less well recognized consequence
of the shortage of BSN nurses is a shortage of faculty which could have a long-
term impact on national production capacity of nurses for the future.
The Department of Labor estimates that 600,000 new jobs will be created
for nurses over the next 10 years, the highest rate of new job production for any
profession (Bureau of Labor Statistics, 2009). In addition, over a half million
nurses in the current workforce, which has an average age of around 48, will
reach retirement age over the same period, resulting in the need for over a mil-
lion nurses to be added to the national workforce. The good news is that there is
tremendous interest in nursing as a career in the United States after a century of
difficulty attracting the best and brightest to nursing. The reasons for this unprec-
edented interest are multifaceted, having to do with attractive incomes, averaging
nationally $65,000 a year and higher in some locations, better job prospects than
in other employment sectors, and perceptions of personally satisfying work help-
ing others. If we can take advantage of this unprecedented interest and expand
nursing school production, future nursing shortages could be greatly attenuated.
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The Future of Nursing: Leading Change, Advancing Health
Copyright National Academy of Sciences. All rights reserved.
APPENDIX I 4��
The bad news is that nursing schools do not have the capacity to absorb
the great windfall in applicants. Estimates suggest that at least 40,000 qualified
applicants to nursing schools are being turned away each year (AACN, 2009).
There are several reasons why nursing schools are unable to accept the influx of
applicants. Nursing schools have expanded enrollments steadily for more than
a decade with graduations increasing from about 75,000 in 1994 to 110,000 in
2008. Resources of all kinds are now stretched and schools are having difficulty
expanding further. Institutions of higher education in general are experiencing
serious budget constraints and as a result are slowing enrollment growth. Addi-
tionally the shortage of nursing faculty has become a major constraining factor.
A strategy for ameliorating the nurse faculty shortage that has received
little attention to date is to increase entry-level education of nurses to produce
a larger pool of nurses likely to obtain graduate education. In a recent paper in
Health Affairs Aiken and colleagues provided a cohort analysis to determine
the highest education achieved by nurses receiving their basic or initial nursing
education between 1974 and 1994 (Aiken et al., 2009). We found that choice of
initial nursing education program—associate degree or baccalaureate—was the
major predictor of final educational attainment. Close to 20 percent of nurses ir-
respective of initial nursing education obtain a higher degree. However, of the 20
percent of associate degree nurses who obtain an additional degree, 80 percent
stop at the baccalaureate degree. Of the 20 percent of nurses with a baccalaureate
degree who go on for additional education, almost 100 percent obtain at least a
master’s degree. This is an important finding for the design of policy interventions
since investments in encouraging BSN education have not distinguished between
RN-to-BSN programs and basic BSN programs. The yield for teachers is entirely
different between the two types of programs. If the current scenario of distribu-
tion of nurses by type of basic education had been reversed since 1974 and 66
percent of nurses had graduated from BSN programs instead of 33 percent, we
estimate that there would be over 50,000 more nurses with master’s and higher
degrees today.
We concluded in our Health Affairs paper that it was a mathematical im-
probability that the nurse faculty shortage could be solved without changing the
distribution of nurses by type of basic education. There are simply not enough
nurses who obtain a master’s or higher degree to meet the dramatic increase in
demand for clinicians, administrators, teachers, and leaders who require a gradu-
ate degree.
What would be the expected yield in terms of nursing faculty that would be
likely to obtain by increasing basic BSN education? To answer this we undertook
an analysis of the National Sample Surveys of Registered Nurses over time to ex-
plore whether career trajectories of nurses with graduate education had changed
over time. The answer is yes—significantly. For example, in 1982, 17 percent
of nurses with master’s degrees and 62 percent of nurses with doctorates were
in faculty positions compared to only 7 percent of master’s and 41 percent of
nurses with PhDs in 2004. Nurses with graduate degrees are selecting positions in
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4�� THE FUTURE OF NURSING
clinical care and administration in ever larger numbers. The yield for teachers is
clearly greater for those who earn doctoral degrees which argues for policies that
aggressively recruit BSN nurses into expedited doctoral education thus bypassing
the master’s, which has a very clinical curriculum and a different end objective
focused on producing clinicians. Probably for historical reasons, many schools
build their curricula sequentially from BSN to MSN to doctoral degree. However,
the clinical master’s in specialty practice has little to do with learning to teach or
to conduct research. The clinical masters is not a building block for doctoral study
but a terminal degree like the MBA or the Masters in Engineering. In order to ad-
dress the faculty shortage two things would have to happen simultaneously. More
nurses would need to initiate basic nursing education at the baccalaureate level
AND expedited BSN to PhD programs would need to be expanded to interest
students in teaching careers earlier and expedited to bypass the clinical masters
that emphasize career trajectories in clinical care. The clinical master’s is not a
building block for doctoral education but a different career pathway.
Tying educational loan forgiveness to teaching is a reasonable supplemental
strategy along with a focus on BSN to PhD education to help offset lower incomes
in faculty positions. Actually closing the gap between practice and academic sala-
ries is not feasible. The gap exists in every practice discipline including medicine,
law, business, and engineering. University faculty salaries vary for different fields
depending upon market factors but not enough to close the gap between teaching
and practice within disciplines. Combining clinical and academic responsibilities
for nurse faculty is a potential strategy for enhancing faculty incomes. However,
in only a few nursing specialties like nurse anesthesia or executive positions are
rates of remuneration for clinical nursing care high enough to offset lower aca-
demic salaries for teachers with joint clinical appointments.
Articulation programs aimed at facilitating additional education for RNs
with less than a baccalaureate degree have been tried for decades and do little
to produce more teachers. Once nurses qualify for licensure, 80 percent do not
seek further education. Oregon has the most innovative approach to improving
articulation between associate degree and baccalaureate programs by standard-
izing requirement; the Oregon program has twice the success rate of the national
average with 40 percent of associate degree nurses obtaining the BSN. However,
the Oregon articulation initiative would not solve the shortage of teachers be-
cause most of those who get the BSN will not go for a second additional degree.
RN-to-MSN programs would have a somewhat higher yield for teachers than
RN-to-BSN completion courses but not nearly as high a yield as BSN-to-PhD
programs.
Associate degree education is appealing to policy makers because it seems
to offer upward mobility and it is less expensive and more geographically acces-
sible. However, data suggest in the case of registered nurses that initial qualifica-
tion for licensure at the associate degree level actually constrains educational and
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career mobility compared to those who initially qualify at the bachelor’s degree
level. The advantages of associate degree education, lower out-of-pocket costs
and geographic proximity, can be offset in the case of nursing by public subsi-
dies for educational costs and distance learning. The length of associate degree
and baccalaureate programs are not significantly different because of licensure
requirements. Maintaining three (including diploma) educational pathways for
nurses that at least on the surface do not seem radically different have a dramatic
impact on the upward educational mobility of nurses thus contributing to the
shortage of faculty and other nurses requiring graduate-level education.
The majority of countries with health care comparable to the United States
have moved to standardize nursing education at the baccalaureate entry level
including the European Union. States have the authority in the United States to
set licensure requirements for nursing. Prospects for standardizing education of
nurses through licensure changes across 50 states are not good. However, finan-
cial incentives imbedded in public subsidies for nursing education could have a
significant effect on changing patterns of education just as payment incentives
change medical practice patterns.
The IOM Committee should recommend increasing public subsidies for ba-
sic nursing education—federal and state—and tying these funds to the production
of baccalaureate graduates. Policies should be neutral on types of institutions—
community colleges or 4-year colleges and universities—that could benefit from
funding. Capitation funding on the basis of BSN graduates from basic education
programs could be effective in shifting the proportion of graduates toward more
with BSN qualifications. Coupled with increased funding for graduate nurse edu-
cation, this could be an effective strategy for addressing the faculty shortage along
with shortages of advanced practice nurse clinicians and administrators.
IOM committee members in a previous discussion of this option asked what
the yield would be for faculty positions in increasing baccalaureate graduates. Ad-
ditional research is needed to answer this important question directly. However,
we know from existing research that BSN initial graduates are three times more
likely to get a master’s degree and twice as likely to get a doctoral degree than
associate degree nurses (Aiken et al., 2009), which would likely produce more
teachers. Because the current yield of teachers is relatively low overall among
nurses with graduate degrees—only 7 percent of master’s graduates and 41 per-
cent of doctoral graduates electing faculty positions—policies to increase bac-
calaureate initial education would have to be accompanied by efforts to increase
the teacher yield. Promising strategies to increase the teacher yield among those
with graduate credentials include scholarship and educational loan repayment for
those in teaching roles and funds to expand BSN-to-PhD expedited programs.
And investments in more baccalaureate nurse graduates would also likely return
additional benefits in the form of better quality, improved access, and efficiency
for those electing clinical practice roles, an outcome in the public’s interest.
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INCREASED FEDERAL AND STATE FUNDING
FOR GRADUATE NURSE EDUCATION
The evidence is strong that the growth of advanced nurse practice has con-
tributed to improved access to general care (Aiken et al., 2009). Over the past
decade advanced practice nurses have largely staffed the new retail clinics that
currently provide about 3 million ambulatory visits a year at an estimated per
visit cost of below the average cost to a physician office. Additionally, advanced
practice nurses have enabled the largest expansion of Community Health Centers
(CHCs) since the Great Society Program; CHCs currently provide over 16 mil-
lion visits in 7,300 sites to largely underserved people. In total, advanced practice
nurses are estimated to provide up to 600 million ambulatory patient visits a year,
a national primary care capacity enhancement that will become increasingly criti-
cal to access in a context of primary care physician shortage.
The rate of production of new advanced practice nurses (APNs) which
had been growing steadily since the 1970s has been flat in recent years. Inter-
est among nurses in advanced practice roles appears strong but the shortage of
student financial aid for graduate nurse education has a chilling effect on enroll-
ment growth. It is difficult for many nurses to forego employment income to
attend graduate programs full time without scholarships or loans which are in
short supply. The major source of funding for graduate nurse education is Title
VIII annual appropriations which currently total about $60 million (estimate for
graduate education only, not all of Title VIII funding), compared to $2.4 bil-
lion for direct graduate medical education for physicians. A large proportion of
APN students pursue graduate education on a part-time basis which slows the
production of new graduates. Employer tuition benefits, an important source of
educational assistance for practicing nurses, have been reduced during the eco-
nomic downturn, eroding available financial support for graduate nurse education,
particularly at the master’s level which is generally required for advanced nurse
clinical practice.
Medicare, since its inception, has paid for a share of graduate medical
education. It has also reimbursed some hospitals for a portion of their nurs-
ing education costs. An analysis we conducted of 2006 HCRIS data from the
Centers for Medicare and Medicaid Services (CMS) suggested that Medicare
funding for nursing education was slightly less than $160 million annually, a
small amount compared to medical education investments, but almost as much
as all of Title VIII funding for nursing in that year. CMS has a larger estimate of
$300 million in Medicare payments for nursing education but we cannot verify
that estimate with publicly available data. But whether Medicare funding is $160
million or $300 million annually, policies governing expenditures are very dif-
ferent from how the funds are spent in support of medical education, the amount
is large relative to other sources of federal support for nursing education, and the
funding does not materially affect the supply of nurses or the quality of nursing
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APPENDIX I 4�1
care for the elderly (Aiken and Gwyther, 1995). Most of the funds are limited to
hospital-sponsored diploma nursing schools which currently prepare less than 5
percent of new RNs annually. Also five or six states account for almost half of
Medicare nursing education funding because of the location of the relatively few
surviving diploma nursing schools.
A number of workforce studies and commissions, including a 1997 IOM
committee, have called for the realignment of Medicare funding for nursing
education to graduate nursing education (IOM, 1997). The health reform bill
passed by the Senate proposes a small demonstration of up to five hospitals to test
Medicare payments for graduate nursing education. While better than no progress
at all, the proposed demonstration is too small to significantly advance a change
in Medicare policy that is long overdue.
There is sufficient information available now as suggested by the Institute
of Medicine in 1997 to realign Medicare nursing education funding to graduate
nursing education. This could be a budget-neutral programmatic shift which
would more than double current federal funding levels for graduate nursing edu-
cation and serve as a significant stimulus for increased production of advanced
practice nurses to meet the multitude of existing and emerging needs resulting
from the continuously changing boundaries between nursing and medicine.
FEDERAL AUTHORITY ON HEALTH WORKFORCE POLICIES
There is little effective health workforce policy-making at the federal level.
The modest nursing policy capacity is located within the Health Resources and
Services Administration, an agency within the Department of Health and Human
Services (HHS) with little of its own funding and no authority to engage CMS
which controls Medicare nursing education funding or the Department of Educa-
tion, where the largest funding for nursing education resides in the form of Carl
Perkins Act funding for community colleges.
Patterns of basic pre-licensure education for nurses have changed dramati-
cally in the 45 years since the nation’s last major health reform—Medicare and
Medicaid. In 1965, over 85 percent of nurses received their basic education in
hospital-sponsored diploma programs; now less than 5 percent do. The percent-
age of registered nurses receiving training in associate degree programs was
less than 2 percent in 1965 but is over 66 percent today. Baccalaureate nursing
programs produced about 10 percent of new nurses in 1965, which increased to
about a third of new nurses by 1980 and has been stable there for 30 years (Aiken
and Gwyther, 1995). Current Medicare policies for support of nursing educa-
tion as implemented by CMS are still based on nursing education patterns that
existed when Medicare was passed but that are practically irrelevant today. CMS
has been resistant to proposals to realign existing Medicare support for nursing
education to graduate nursing education through multiple different administra-
tions in Washington.
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The single largest source of federal support for nursing education is the
Department of Education’s funding for community colleges through the Carl
Perkins Act. Perkins funds exceed $8 billion annually. A high priority should be
set on examining whether and how Perkins funds could be targeted to incentivize
community college nursing programs to increase the proportion of their nursing
students who complete their initial education with a BSN. There are numerous
feasible strategies to do this including having community colleges offer the BSN
as in Florida and other states as well as innovative partnerships with 4-year col-
leges and universities perhaps using state-of-the-art distance learning technolo-
gies supported by Perkins funding.
The most influential of the many commissions on nursing over the decades
was the 1982 IOM study Nursing and Nursing Education: Public Policies and
Private Actions. That study made a recommendation involving an organizational
change within HHS that dramatically altered national nurse leadership and nurs-
ing education. The recommendation was to move the responsibility and budget
authority for nursing research from HRSA to NIH where research was highly
visible and influential. The establishment of the National Institute of Nursing
Research within two decades fundamentally transformed the engagement of
nursing in evidence-based innovations to improve health outcomes, helped create
new and important interdisciplinary research and research training collaborations,
and improved the relevance and quality of nursing education in universities. The
proposal to establish a nursing workforce authority at a higher level of the fed-
eral government could have an equally influential impact on the adequacy of the
national nurse workforce.
FINAL THOUGHTS
The Commission on the Future of Nursing has considered many important
aspects of the education and practice of nursing. Of the many types of recommen-
dations the committee might consider, recommendations regarding federal (and
state) funding of nursing education are among the most actionable and potentially
influential in creating a future for nursing that serves the public’s interests in
patient-centered accessible health services at affordable costs. What is good for
the public is genuinely good for nursing. Using public nursing education policy
as a vehicle for achieving a better balance between the qualifications of nurses
and national health care needs could result in great return on investment now and
in the years ahead.
REFERENCES
AACN (American Association of Colleges of Nursing). 2009. “Nursing Faculty Shortage Fact Sheet,”
http://www.aacn.nche.edu/Media/pdf/FacultyShortageFS (accessed 5 May 2008); and
Geraldine Bednash, executive director, AACN, personal communication, 9 February 2009.
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APPENDIX I 4�3
Aiken L.H. “Economics of Nursing,” Policy, Politics, and Nursing Practice 9 no. 2 (2008): 73-79.
Aiken L.H. and M.E. Gwyther, “Medicare Funding of Nurse Education: The Case for Policy Change,”
Journal of the American Medical Association 273, no. 19 (1995): 1528-1532.
Aiken L.H., et al., “Education Policy Initiatives to Address the Nurse Shortage,” Health Affairs 28,
no. 4 (2009): w646-656 (published online 12 June 2009; 10.1377/h1thaff.28.4.w.646).
Aiken L.H., et al., “Educational Levels of Hospital Nurses and Surgical Patient Mortality,” Journal
of the American Medical Association 290, no. 12 (2003): 1617-1622.
Benner P., et al., Educating Nurses: A Call for Radical Transformation (San Francisco: Jossey-Bass,
2010).
Bureau of Labor Statistics, U.S. Department of Labor, Occupational Outlook Handbook, 2008–09,
http://www.bls.gov/OCO (accessed 14 May 2009).
Eibner C., et al., Controlling Health Care Spending in Massachusetts: An Analysis of Options (Los
Angeles: The Rand Corporation, 2009).
Estabrooks C., et al., “The Impact of Hospital Nursing Characteristics on 30-Day Mortality,” Nursing
Research 54, no. 2 (2005): 74-84.
Friese, C., Lake, E.T., Aiken, L.H., Silber, J., Sochalski, J. 2008. Hospital nurse practice environments
and outcomes for surgical oncology patients.” Health Services Research, 43(4), 1145-1163.
Goode C.J., et al., “Documenting Chief Nursing Officers’ Preference for BSN-prepared Nurses,”
Journal of Nursing Administration 31 (2001): 55-59.
Griffiths P., et al., “Nurse Staffing and Quality of Care in UK General Practice.” British Journal of
General Practice 60 (2010):34-39.
Horrocks S., et al., “Systematic Review of Whether Nurse Practitioners Working in Primary Care Can
Provide Equivalent Care to Doctors,” British Medical Journal 324 (2002): 819-823.
Hussey P., et al., “Controlling U.S. Health Care Spending—Separating Promising from Unpromising
Approaches,” New England Journal of Medicine 361, no. 22 (2009): 2109-2111.
IOM, On Implementing a National Graduate Medical Education Trust Fund (Washington: National
Academy Press, 1997).
Lynaugh J.E., “Kate Hurd-Mead Lecture: Nursing the Great Society: The Impact of the Nurse Train-
ing Act of 1964,” Nursing History Review 16, no. 1 (2008): 13-28.
NACNEP (National Advisory Council on Nurse Education and Practice), Report to the Secretary
of the Department of Health and Human Services on the Basic Registered Nurse Workforce
(Rockville, Md.: DHHS, 1996).
Tourangeau A.E., et al., “Impact of Hospital Nursing Care on 30-day Mortality for Acute Medical
Patients,” Journal of Advanced Nursing 57, no. 1 (2007): 32-44.
Van den Heede K., et al., “The Relationship between Inpatient Cardiac Surgery Mortality and Nurse
Numbers and Education Level: Analysis of Administrative Data,” International Journal of
Nursing Studies (United Kingdom) 46 vol. 6 (2009): 796-803.
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4�4 THE FUTURE OF NURSING
PREPARING NURSES FOR PARTICIPATION IN AND
LEADERSHIP OF CONTINUAL IMPROVEMENT
Donald M. Berwick, M.D.
Institute for Healthcare Improvement
“I see.” said the nurse,
“You’re saying that I have two jobs: doing my job, and making my job better.”
In the 20 years since I first heard that comment from my colleague, Paul
Batalden, MD (retold January 2010), who was quoting a participant in a course
he was teaching on health care improvement, I have never heard a more succinct
summary of the modern view of the pursuit of quality in a complex system. It is a
deceptively simple idea, replete with implications for the preparation, self-image,
support, and daily life of the professional. It represents a comprehensive goal for
the modern nurse and for those who wish to prepare people for that role.
The capacity to “make my job better” is not inborn. Nor is it usually taught
in professional education. What professional education, including nursing educa-
tion, has more reliably focused on is the content of the job—the subject-matter
knowledge and cognitive and manipulative skills to care for patients in existing
processes and institutions. Standards exist for how one ought to perform tasks,
including dynamic tasks like problem-solving; professional preparation instills
mastery of those tasks, and professional licensure and certification allege to as-
sure achievement of that mastery.
W. Edwards Deming, one of the great theorists and teachers of improvement
in systems contexts, distinguished this discipline-specific and subject-matter
knowledge, which tells one, in effect, “how to be a nurse,” from what he called
“Knowledge for Improvement” (or, less felicitously, “Profound Knowledge”)
(Deming, 1994), which would tell one “how to improve nursing” or, more ac-
curately, “how to help improve the system of which nursing is a component.”
Mastery of the first—subject-matter mastery—does not confer mastery of the
second—knowledge for improvement. This form of knowledge invites attention
to the system in which professional work is conducted.
In some ways it is surprising how little our pedagogy promotes appreciation
of systems of care. Arguably, most graduates of most health professional educa-
tional programs suffer from considerable “functional illiteracy” about the systems
in which they work. Few emerge from their studies with a well-developed sense
of responsibility for the performance of these systems, even though they work in
those systems and depend on them every day.
The evidence of serious deficiencies in the performance of health care as a
system is overwhelming and incontrovertible. It fueled the findings and recom-
mendations of the landmark Institute of Medicine report, Crossing the Quality
Chasm, in the year 2001, which claimed: “Between the health care we have and
the care we could have lies not just a gap but a chasm” (IOM, 2001, p. 1). Its
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diagnosis—incapable systems of care: “In its current form, habits, and environ-
ment, American health care is incapable of providing the public with the quality
health care it expects and deserves” (IOM, 2001, p. 43). The Chasm report estab-
lished six “Aims for Improvement” of care, which now compose a canonical list:
• safety (reducing harm from care);
• effectiveness (increasing the reliability of alignment between scientific
evidence and practice, reducing both underuse of effective practices and
overuse of ineffective ones);
• patient-centeredness (offering patients and their loved ones more con-
trol, choice, self-efficacy, and individualization of care);
• timeliness (reducing delays that are not instrumental, intended, and
informative);
• efficiency (reducing waste in all its forms); and
• equity (closing racial and socioeconomic gaps in quality, access, and
health outcomes).
In the decade since the Chasm report, the social imperative for all six of these
improvements has increased, with perhaps special emphasis lately on “efficiency”
as the costs of American health care have come to appear less and less sustain-
able. Activities in health care policy, management, and payment have increased,
with more or less coherence, in pursuit of those goals. Yet the response from
health professionals (and the faculties who train them) to shoulder accountability
for health system performance has been limited, and in many places virtually
absent.
If, as the Chasm report alleges, the current system of care is “incapable” of
the needed improvement, then, logically, pursuit of the IOM Aims for Improve-
ment requires that the system change. Nursing, like any health care profession,
can become an object of change, or an agent of change. The latter role will require
a new form of professionalism with new skills in system redesign.2
Nursing is positioned well to be a change agent. One recent national project
to reduce patient injuries, the Institute for Healthcare Improvement’s 100,000
Lives Campaign (McCannon et al., 2006) translated the IOM aims of “safety”
and “effectiveness” into operational form as “bundles” of evidence-based care
procedures, such as the “Central Line Bundle” to prevent catheter-associated
2 Some elements of that new professionalism have been labeled in the reformulation of goals
of resident training by the Accreditation Council for Graduate Medical Education (ACGME) as
“systems-based practice” and “practice-based learning and improvement.” The Association of Boards
of Medical Specialties (ABMS) were “partners” in the definition of competencies both for initial
certification (after residency) and for Maintenance of Certification—a process adopted now by each
medical specialty member of the ABMS. The latter means that every practicing medical specialist
will be required to demonstrate performance improvement in practice in order to maintain their board
certified specialty status.
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bloodstream infections, the “Ventilator Bundle” to present respirator-associated
pneumonias, and Rapid Response Teams to intercept patient deterioration with
early warning, diagnosis, and treatment. Hundreds of hospitals reported success
in improved patient outcomes, and a recurrent pattern included activated nurses,
supported to standardize their own processes of care according to the Institute
for Healthcare Improvement (IHI) “bundles,” and empowered and supported
to monitor and enforce those standards across disciplines, including with their
physician colleagues (Berwick et al., 2006). Present steadily at the point of care,
committed to excellence and reliability, equipped to measure locally, biased to-
ward teamwork, and, crucially, encouraged to innovate locally to adapt changes
to local contexts, nurses proved the ideal leaders for changing care systems and
raising the bar on results.
Some relevant education innovation are well under way. The pioneering work
of the Quality and Safety Education for Nurses (QSEN) project (Cronenwett et
al., 2007) and the adoption by the American Association of Colleges of Nursing
of the QSEN quality improvement competencies in The Essentials of Baccalaure-
ate Education for undergraduate nursing education is heartening and opens the
possibility that students across the professions will develop similar competen-
cies for the improvement of care. Further, QSEN’s work on faculty development
(Cronenwett et al., 2009a) and graduate nursing education (Cronenwett et al.,
2009b) to extend these ideas into all of nursing professional development is ex-
citing. IHI’s Open School for the Health Professions is an interprofessional edu-
cational community that helps students from all the health professions to acquire
the skills to become change agents for health care improvement.
From the viewpoint of nursing education, the capacity to help improve
systems of care has two big elements: (a) personal skills and (b) a context of
leadership and management that allows those skills to thrive in action. Nursing
education fit for the needs of the 21st century will attend to both.
PERSONAL SKILLS: THE CATEGORIES OF
KNOWLEDGE FOR IMPROVEMENT
Deming’s four “profound knowledge” categories offer a useful framework
for education goals and achievements for nurses capable of helping to improve
systems:
1.
Knowledge of Systems
2.
Knowledge of Variation
3.
Knowledge of Psychology
4.
Knowledge of How to Gain Knowledge
Let us explore each.
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Knowledge of Systems
“Knowledge of Systems” refers to understanding the technical characteristics
of complex systems, in which factors like interdependency, feedback loops and
other nonlinear dynamics, uncertainty, and sensitivity to small changes constantly
operate. Without systems knowledge, one approaches work (or life in general) as
a series of lists, with a mentality of checking off tasks, with assumptions of direct
and linear cause-and-effect dynamics. The world, or the organization, is modeled
like a machine, and simplification seems helpful. In health care, of course, things
rarely work that way. In clinical work, medications can have remote, delayed, and
confusing side effects; organs interact in complex and powerful ways; patient
status can be unstable, with feedback loops that spiral into sudden disasters and
unwelcome surprises. Well-trained nurses are familiar with system dynamics
of that sort: they understand the pituitary-adrenal-hypothalamic axis; they have
studied family systems; and they are alert always to medication interactions and
the effects of organ failure on physiology. Each of these requires “knowledge of
systems,” that is, knowledge of the body as a system, for appropriate diagnosis
and response.
Where “knowledge of systems” is less robust in the preparation of nurses (as
well as most other health professionals) is in understanding the work of health
care as a system. This ignorance is the harvest less of intent than of historical
accidents. In effect, modern health care is an assemblage of component roles,
disciplines, and institutions built up more or less independently, and often without
much regard for their interactions. Nurses and doctors who will work together
for their entire professional lives rarely train together for even a single day. Tasks
are compartmentalized. In many medical records “nursing notes” remain sepa-
rate from “physicians’ notes,” and in many hospital wards the “Nurses’ Confer-
ence Room” and “Nursing Rounds” are separate from the “Doctors’ Conference
Room” and “Medical Rounds.” The fragmentation runs deep, as reflected in
language, oaths, uniforms, schedules, and prerogatives.
In addition, the processes of care themselves, by which I mean the flows and
steps through which patients, specimens, information, and ideas pass, are often
unclear and designed, if at all, only unconsciously. No one is really sure what all
the steps are that a patient traverses from admission to diagnosis to treatment to
discharge, and no one is in charge of the entire flow. In Paul Batalden’s words,
health care lacks the “catwalks” that make processes visible, and therefore ana-
lyzable, in manufacturing. It is very hard to manage and improve what one can-
not see or understand, and “process illiteracy” confounds health care redesign
often.
This is not inevitable. “How do we do that?” is a perfectly reasonable and
tractable question for almost any set of interdependent deeds in health care, just
as long as someone is in a position to ask and to mobilize the information to find
the answer. The answer may prove embarrassing—there may be no stable process
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at all, or the one that does exist can look, upon inspection, absurdly wasteful or
unscientific; but, the ability to examine and study processes opens the door to
changing processes, which is on the road to improving them.
I am not a nurse, but my guess is that nursing educators will have no diffi-
culty at all recognizing some educational goals in which “knowledge of systems”
is already a high priority. For example, I suspect that nursing training for some
specialist roles, such as for participation in an open heart surgery team, is full of
attention to system dynamics of all sorts. No patient has ever gotten successfully
onto and off of a heart–lung machine without exquisite attention by an entire
team to process steps, interdependencies, and interactions, likely very consciously
designed and monitored.
The task in modernization of nursing education is to generalize the pursuit
of system knowledge into all that nursing is and does. Topics of relevance may
include (a) health care as a system, (b) general systems theory, (c) queuing
theory and flow in care systems, (d) reliability and reliability engineering, (e)
lean production, and (f) resilience (Spear, 2008). In the important and special
arena of safety, system topics include (g) human factors science (Reason, 1990),
(h) team communications and collaboration, (i) failure mode and effect analysis,
and (j) properties of high-reliability organizations (Weick and Sutcliffe, 2007),
to name a few.
Knowledge of Variation
Professor George Box has said, “All systems produce information on the
basis of which they can be understood.” The new professional capable of leading
and participating in improvement knows how to hear and use that information.
Measurement is abundant in health care, as nurses well know. Nurses spend
an inordinate proportion of their time documenting and recording things; they
measure all the time. However, measuring is not at all the same task as using
measurement, especially using measurement to improve. When measuring for
improvement (as opposed to measuring for judgment or measuring for selection),
one is either (a) observing variation to extract ideas or (b) introducing variation
to study the consequences.
Observing variation is what nurses do every day in recording a patient’s
vital signs, for example. The aim is inference: either that the patient is stable, or
that a systematic or sudden change in status is under way. In effect, every blood
pressure or temperature measurement is a test of a hypothesis that either “some-
thing special is going on” or “nothing special is going on.” Nurses in that role
are like other scientists—continually measuring and making repeated inferences
(Berwick, 1991).
How well they do that helps to determine patients’ outcomes. “Is the anti-
biotic working as expected?” “Is the blood pressure coming under control?” “Is
the patient entering, or staying in, proper fluid balance?” Upon the answers to
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APPENDIX I 4��
those questions, based on proper interpretation of variation, rest crucial decisions
about maintaining or changing theories and therapies. The challenges of proper
interpretation are significant, and neither physicians nor nurses yet today receive
sufficient instruction in how to understand variation correctly. The consequence
of failure are what Dr. Deming referred to technically as two forms of “tamper-
ing.” The first form is to react to a random change in a measurement—such as
a temporary rising temperature or a temporarily falling blood pressure—as if it
were informative (“the antibiotic is not working,” or “this patient needs more
pressor”) when, in fact, the observed fluctuation is only random, and would revert
if nothing new were done. The converse form of tampering is to classify a change
as characteristic of a system when, in actual fact, it is not at all likely to be repre-
sentative of the general system from which it comes. This misinterpretation can
lead one to make a wholesale change in response to a special event, as when our
transportation security system radically alters inspection regimes in response to
a single, unlikely-to-be-repeated threat.3
As modern medical care and monitoring multiply the volume of information
and the number of measurements flooding the nurse at the front line, the demand
for technical sophistication in interpreting physiological and biochemical varia-
tion rises steadily. The modern nurse should be equipped as never before with
the knowledge to interpret variation correctly, to avoid tampering, and to increase
agility in appropriate response.
What applies to patients applies to systems of care, as well. The “vital signs”
of health care as a system are numerous and, like measurements of patients,
increasing in availability daily. System characteristics include, for example, wait-
ing times and delays, rates of complication and outcomes of surgery and other
interventions, infection, and mortality, patient satisfaction, costs and levels of
waste and efficiency, safety levels and adverse events, and levels of variation in
approaches to diagnosis and treatment. Many such measurements are appearing
in new forms of accountability of health care organizations and professionals to
payers, regulators, accreditation agencies, consumer groups, and licensing bodies.
The psychology of such external measurement can be quite negative, inducing
fear, anger, and sometimes deceptive practices even among the most committed
professionals, but this negative cycle ought not to obscure a basic fact: that the
improvement of health care systems requires very much the same type of mea-
surement, used internally, that scrutiny bodies demand and use for other purposes
externally (James et al., 2003). Ideally, even if no one else required measurement
of infection rates or surgical outcomes, clinicians, themselves, ought to seek them
avidly as a crucial resource for making care better.
3 The technical description of the first form of tampering is “reacting to common cause variation
is if it were of special cause”; the second form is “reacting to special cause variation as if it were of
common cause.” Knowing the difference between “special cause” and “common cause” variation is
at the heart of modern statistical process control.
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Modern nurses will, of necessity, have to learn the tasks involved in measure-
ment for scrutiny and compliance—that’s the hard fact. But, modernized nursing
education will emphasize far more the role and use of system metrics as a support
to the continual improvement of health care along all six of the IOM dimensions.
Individual nursing practice will, in that mode, include avid measurement and
sophisticated interpretation to answer questions of the form: “How is our system
doing at X, and what can the variation tell us about how to do better?”
Measurement for improvement goes far beyond mere observation. It includes
systematic, local interventions—making changes in processes of care and assess-
ing and learning from the consequences of those changes. An important boundary
exists between formal scientific investigations—experiments that ought to invoke
the whole apparatus of planning and human subjects protection that are now re-
quired in some settings—and the daily practice of continual improvement through
the introduction and assessment of better local processes—the “Plan-Do-Study-
Act” approach that is at the core of modern improvement methods, and about
which we will have more to say below. That said, the modern nurse ought to be
equipped to participate in and often to lead systematic changes in work processes,
and to assess their effects on the outcomes desired (Langley et al., 2009).
Knowledge of Psychology
Largely because interdependency, especially interdependency among people,
is so much a characteristic of complex systems like health care, human nature and
psychology play a strong role in the success or failure of improvement efforts.
Dr. Deming had in mind a rather long list of the components of “psychology”
whose understanding and mastery underpin successful improvement work. One
short subset of relevant skills is this:
• Conflict resolution and negotiation;
• Group process and meeting management;
• Forging and maintaining cooperation and coalitions;
• Adult learning;
• Understanding motivation, especially intrinsic motivation;
• Communication and signaling; and
• Maintaining a culture of safety.
The unifying concept among these topics is “managing and improving inter-
personal relationships,” which can be daunting in a context of high pressures on
production, historical boundaries among disciplines and subsystems, hierarchy,
and high risk. Scholars of so-called high reliability organizations (HROs) (Weick
and Sutcliffe, 2007) nonetheless find that it is exactly under conditions of stress,
risk, and complexity that relationships matter the most in determining success.
It may be impossible for nurses unilaterally to effect better relationships unless
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APPENDIX I �01
other professionals aim to do the same, but nurses are so central to health care
processes that they may well be able to take the lead.
Knowledge of How to Gain Knowledge
Learning in complex systems is, itself, complex. Nonlinear systems con-
found attempts to develop and enforce simple models of cause and effect, and so
traditional, hypothetico-deductive methods to explore cause and effect often fail.
We know that in the daily life of parenting, marital relationships, and team sports,
where “continual learning and improvement” replaces “planned experiment” as
an approach for gaining knowledge.
Even where firm, cause-and-effect knowledge exists in science-based health
care—the knowledge, for example, that antibiotic A will almost always kill bac-
terium B—the application of that knowledge runs straightaway into the messy
world of complex systems. That is, reliably getting the antibiotic safely into the
body of a patient with that germ turns out to be a constant challenge as systems
fail (the order got lost), unpredicted side effects occur (the patient is on an in-
compatible other drug), local circumstances become highly relevant (the drug is
unfamiliar to the new doctor), and errors multiply (the bacteriological report was
on the wrong patient). The fact is frustrating and inescapable: in health care, as
in any complex enterprise, the simple, scientific facts lie fallow without continual
adaptation to local contexts.
The consequence for improvement is this: almost all effective improve-
ments require continual, local experimentation—local growth in knowledge. All
improvement requires change (although not all changes are improvements), and
proper change requires continual learning. A modern workforce, including mod-
ern nurses, is fully equipped to act as “scientists at work.” When the nurse quoted
at the top of this essay said, “I have two jobs: my job and improving my job,” she
was entering a world of continual trial and learning for both of those roles.
We might call the subject, scarily, “epistemology,” for it involves, after all, a
theory of knowledge, itself: the idea that human beings in complex systems best
acquire new knowledge by making changes and studying the effects of those
changes. But, it is in fact not so arcane at all. This is the form of learning that all
healthy people use in almost all the common endeavors of their daily lives—the
endeavors that they care about and are in some degree of control over: sports,
hobbies, loving relationships, cooking, dieting, and getting a good night’s sleep.
In every single case, the individual who wishes to get better finds ways continu-
ally to test new approaches, knowing that, as we all know: “If you continue to
do what you’ve always done, you’ll always get what you’ve always gotten.”
That’s not good enough for your tennis game or your gardening, and it’s not good
enough for the work of health care, either.
The jargon of modern improvement is “PDSA”—“Plan-Do-Study-Act.” This
describes a simple, iconic cycle of aim-setting, testing, reflection, and change
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based on reflection. The modern nurse who intends to “improve the job” effec-
tively needs to be a master of the “PDSA Cycle” at work. Unlike in gardening
or tennis, PDSA at work is not a solo enterprise. Almost all forms of organized
quality improvement activity today involve teams; groups, not soloists, carry out
the tasks of will building, measurement, idea generation, design and conduct
of small-scale tests of change, reflection, and guidance to further action. These
compose quality improvement projects. For a modern nurse, participation and
leadership in such project work is the form taken of action based on “knowledge
about how to gain knowledge.”
LEADERSHIP AND MANAGEMENT SKILLS
The four areas of skill and knowledge explored above—systems, variation,
psychology, and epistemology—compose a strong set of goals for modernized
nursing education on behalf of quality improvement. One key element is missing,
however—the context of leadership and management that allows those skills to
thrive. Not all nurses will become formal system leaders during their careers, but
those who do will more effectively nurture system improvement if they under-
stand how to lead improvement.
A full exploration of “leadership for improvement” is beyond the scope of
this essay, and numerous resources are readily available attempting to describe
what leaders need to know in order to foster improvement in the systems they
lead (Reinertsen et al., 2008). However, a few leadership-dependent elements de-
serve special mention because they interact so strongly with the topics addressed
above:
• Setting Aims and Building Will to Improve
• Measurement and Transparency
• Finding Better Systems
• Supporting PDSA Activities, Risk, and Change
• Providing Resources
When leaders, including nursing leaders, establish these and other precondi-
tions in the work setting, they can effectively liberate the energy and wisdom of
the front-line staff and middle managers to incorporate continuous improvement
into their daily work, and they stand a better chance of ensuring that these good-
hearted, local improvement efforts align with and support the most important
strategic goals of the organization and system as a whole. Just as good teachers
in a classroom make it possible for students to become active learners, so do
good managers make it possible for nurses and all health professionals to become
active, curious, effective, and, ideally, joyous improvers.
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SUMMARY
Modern health care demands continual system improvement to better meet
social needs for safety, effectiveness, patient-centeredness, timeliness, efficiency,
and equity. Nurses, like all other health professionals, need skills and support to
participate effectively in that endeavor, and, often, to lead it. Nursing education
is poised to accelerate progress by embedding health care improvement skills in
all phases of professional formation.
Following are recommendations intended to support this vision:
1. Preparation of nurses should include mastery of knowledge of systems,
interpretation of variation, human psychology in complex systems, and
approaches to gaining knowledge in real-world contexts.
2. During professional preparation, nurses-in-training should experience
and reflect upon active involvement in multidisciplinary quality im-
provement projects and work settings that foster day-to-day change and
improvement.
3. During professional preparation, nurses-in-training should experience,
reflect upon, and develop the knowledge, skills, and attitudes that cre-
ate competence in patient-centered care, teamwork and collaboration,
evidence-based practice, quality improvement, safety, and informatics.
4. Preparation of nurse-teachers and nurse-executives should include ac-
quiring and practicing skills and methods for the leadership and manage-
ment of continual improvement.
5. Organizations that license and certify nurses or accredit nursing educa-
tion programs should require evidence of nurses’ preparation for par-
ticipation in or leadership of teams that work to continuously improve
health care systems and individual and population health.
REFERENCES
Berwick, D. M. 1991. Controlling variation in health care: A consultation from Walter Shewhart.
Medical Care 29(12):1212−1225.
Berwick, D. M., D. R. Calkins, C. J. McCannon, and A. D. Hackbarth. 2006. The 100,000 lives cam-
paign: Setting a goal and a deadline for improving health care quality. Journal of the American
Medical Association 295:324−327.
Cronenwett, L., G. Sherwood, J. Barnsteiner, J. Disch, J. Johnson, P. Mitchell, D. T. Sullivan, and J.
Warren. 2007. Quality and safety education for nurses. Nursing Outlook 55(3):122−131.
Cronenwett, L., G. Sherwood, and S. B. Gelmon. 2009a. Improving quality and safety education: The
QSEN Learning Collaborative. Nursing Outlook 57(6):304−312.
Cronenwett, L., G. Sherwood, J. Pohl, J. Barnsteiner, S. Moore, D. Taylor Sullivan, D. Ward, and J.
Warren. 2009b. Quality and safety education for advanced nursing practice. Nursing Outlook
57(6):338−348.
Deming, W. E. 1994. The New Economics for Industry, Government, Education (2nd ed.). Cambridge,
MA: MIT Press.
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�04 THE FUTURE OF NURSING
IOM (Institute of Medicine). 2001. Crossing the Quality Chasm: A New Health System for the 21st
Century. Washington, DC: National Academy Press.
James, B., D. M. Berwick, and M. J. Coye. 2003. Connections between quality measurement and
improvement. Medical Care 41(Suppl. 1):I30−I38.
Langley, G. J., R. D. Moen, K. M. Nolan, T. W. Nolan, C. L. Norman, and L. P. Provost. 2009. The
Improvement Guide (2nd ed.). San Francisco, CA: Jossey-Bass.
McCannon, C. J., M. W. Schall, D. R. Calkins, and A. G. Nazem. 2006. Saving 100,000 lives in US
hospitals. British Medical Journal 332:1328−1330.
Reason, J. 1990. Human Error. Cambridge, UK: Cambridge University Press.
Reinertsen, J. L., M. Bisognano, and M. D. Pugh. 2008. Seven Leadership Leverage Points for
Organization-Level Improvement in Health Care (2nd ed.). Cambridge, MA: Institute for
Healthcare Improvement. http://www.ihi.org/IHI/Results/WhitePapers/whitepapersindex.htm
(accessed January 18, 2010).
Spear, S.J. 2008. Chasing the Rabbit: How Market Leaders Outdistance the Competition and How
Great Companies Can Catch Up and Win. New York: McGraw-Hill.
Weick, K. E., and K. M. Sutcliffe. 2007. Managing the Unexpected: Resilient Performance in an Age
of Uncertainty. San Francisco, CA: John Wiley & Sons, Inc.
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APPENDIX I �0�
NURSING EDUCATION PRIORITIES FOR
IMPROVING HEALTH AND HEALTH CARE
Linda R. Cronenwett, Ph.D., R.N., FAAN
University of North Carolina at Chapel Hill School of Nursing
The health professions derive autonomy for establishing professional stan-
dards and regulatory mechanisms from a social contract that assumes profession-
als will act in the best interests of the societies they serve. Proposed changes in
nursing education, therefore, must derive from broad societal aims. In the United
States, we face few challenges as daunting as the one before us, namely to si-
multaneously improve the health of populations, enhance the patient experience
of care (including quality, access, and reliability), and reduce, or at least control,
the per capita cost of care (Berwick et al., 2008). Among the many issues that
nursing educators could be called upon to address to meet these aims (Cleary et
al., 2010; Forbes and Hickey, 2009), I have chosen three that, if addressed, would
have significant impact on nursing’s ability to meet society’s needs as outlined
by the above “triple aim.”
CONCLUSION I. In order to meet the nation’s need for
nurses, people with strong academic preparation need to
be educated in collegiate nursing programs in far greater
numbers than they are today.
In 1992, Fagin and Lynaugh reviewed the history of nursing education and
proposed that societal needs for nursing as an occupation (i.e., a vital work serv-
ing the public) and as a profession (i.e., a living body of knowledge and skills)
were best met if the proportion of nurses prepared at the baccalaureate (BSN)
level exceeded those prepared in associate degree (ADN) and diploma programs
(Fagin and Lynaugh, 1992). They proposed three methods (direct transfer link-
age, partnership projects, and nurse associate programs) to end the bifurcation
of nursing education between universities and community colleges and to ensure
that graduation patterns did not result in a workforce with the majority of the
country’s nurses possessing the associate’s degree as their highest level of edu-
cational preparation. Although features of each of Fagin and Lynaugh’s (1992)
proposed methods can be found in programs implemented during the last two de-
cades (for instance, improvements in articulation agreements, partnership projects
like the Oregon Consortium for Nursing Education, and differentiation of North
Dakota licensure levels), our nation continues to produce far more pre-licensure
graduates from ADN than BSN programs annually (roughly 60/40 percent if one
includes RN–BSN transition degrees [Aiken et al., 2009]).
The literature debating the relative merits of pre-licensure education at ADN
and BSN levels is large and beyond the scope of this paper. Some evidence sug-
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gests that the percentage of nurses prepared at the BSN level on hospital units is
positively correlated with better patient outcomes (Aiken et al., 2003), and during
times when no shortage of nurses exists, the baccalaureate graduate is now the
preferred new graduate hire. Nonetheless, most states continue to educate greater
numbers of ADN than BSN graduates every year. In North Carolina, new pre-
licensure graduates who completed programs in 2006 included only 29 percent
who were graduates of BSN or entry-MSN programs (North Carolina Institute
of Medicine, 2007). Including the RN-BSN graduates, the total proportion of
BSN or higher degree graduates in 2006 rose to only 36 percent (North Carolina
Institute of Medicine, 2007). Some states graduate even lower proportions of
BSNs among their new nurse graduates each year (California Strategic Planning
Committee for Nursing, 2010). Fagin and Lynaugh’s (1992) predictions concern-
ing the diminishing educational levels of the overall composition of the nursing
workforce have come true.
States invest in the above combination of nursing pre-licensure programs
for many reasons, not the least of which are the lower costs in faculty salaries
and student tuition/fees associated with associate degree programs. But another
important factor is the geographic distribution of ADN programs, which are more
likely to be offered in rural and other medically underserved communities than
are BSN programs in American colleges and universities. The Urban Institute,
in its recent study of the nursing workforce, reported that medical personnel,
including nurses, tend to work near where they are trained, so the distribution of
support for nursing education matters (Bovbjerg et al., 2009). Nursing personnel
are needed in virtually every community in America, and ADN programs help
ensure that the nation has a broader geographic distribution of nursing personnel
than we could attain with BSN graduates alone.
Nonetheless, we have created a huge problem with our current educational
patterns. By educating more ADN than BSN graduates, we have narrowed the
pipeline of nurses likely to go on to graduate school.
The greater the number of nurses in basic practice, the greater the number
of nurses needed in advanced roles, such as nurse managers, nurse executives,
clinical nurse specialists, and faculty. Health care reform bills may enable greater
access to primary care, thus escalating the need for nurse practitioners and mid-
wives. All of these roles require that nurses seek graduate education.
Nurses who receive their pre-licensure education in colleges and university
programs are overwhelmingly more likely to go on to graduate school than
graduates of ADN programs. Using North Carolina licensure data, Bevill and
colleagues (2007) analyzed the pursuit of higher educational degrees of RNs from
two cohorts. They reported:
Only 26% of the 2,418 members of the 1983-84 cohort at 20 years and 17% of
the 4,211 members of the 1993-94 cohort at 10 years pursued higher degrees,
and just 19% and 12% of the respective cohorts did so in nursing. More than
80% of all nurses in either cohort who attained a master’s degree in nursing
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or a doctorate in any field began their nursing career with a bachelor’s degree.
(Bevill et al., 2007, p. 60)
Aiken and colleagues (2009) reported similar results from a national study.
They found that of the nearly 1.4 million nurses who obtained ADN or BSN
degrees between 1970 and 1994, only 6 percent of the nurses with original ADN
degrees had gone on to earn graduate (master’s or doctoral) degrees, whereas
nearly 20 percent of the original BSN graduates had done so. Though improving
overall educational levels with programs that smooth the pathway from ADN to
BSN are valuable, the critical need is to assure an adequate pipeline for graduate
education by expanding the capacity of current and future BSN programs.
One important innovation of the last decade has been the opening of ac-
celerated BSN (ABSN) programs for students who already have college degrees
in another field. A previous argument advanced in favor of ADN education as
a response to nursing shortages (that is, that you could produce new nurses in
2 years instead of 4), became obsolete as universities opened programs that edu-
cated BSN graduates in 12−18 months. Currently, there are 218 ABSN programs
in the United States and an additional 57 programs that accelerate students in
a direct path to a master’s degree (AACN, 2009a). ABSN programs, while ad-
dressing the need for new nurses in basic practice, have served as an unusually
successful pipeline for advanced practice (APN) master’s programs. They attract
students who bring rich backgrounds from other fields, academically successful
students, and students who are motivated and know what they want from a career
(AACN, 2009a). Bentley (2006) and Brewer and colleagues (2009) found that
the accelerated program graduates, when compared to traditional nursing bach-
elors degree graduates, were more likely to be male, nonwhite, and older, thus
addressing the need for increased diversity in nursing. Brewer and colleagues
(2009) also reported that the accelerated graduates often moved quickly into
management positions.
In February 2009, the American Association of Colleges of Nursing reported
2008−2009 survey data from 663 nursing schools (87 percent of total number of
collegiate-level programs) showing that almost 50,000 qualified applicants to col-
legiate nursing programs were turned away (AACN, 2009a). The most frequently
cited reason was insufficient faculty (63 percent) (AACN, 2009a).
To ensure the future ability of nursing education to meet societal needs,
therefore, we must increase our capacity to educate college/university-bound
students. These graduates will expand the number of nurses in basic practice,
but they will also address other critical needs, namely our shortages of nursing
faculty and primary care advanced practice nurses.
An additional benefit derives from the fact that students exposed to health
care leaders at early stages in their career, as collegiate students are, are likely
to become the nursing leaders of tomorrow. (Personal note: At the 2009 Sigma
Theta Tau International Biennial Convention, among the nursing leaders honored
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with prestigious Founders’ Awards, each in accepting their award spoke about the
importance of exposure to distinguished nursing leaders early in their careers.)
RECOMMENDATIONS
1. Fund a longitudinal national study to track the percentages of new nurse
graduates per year from ADN/diploma vs. collegiate pre-licensure programs
by state. Include tracking of data regarding faculty shortages, primary care
nurse practitioner and basic nursing shortages by state, with the goal of better
understanding the relationships between new nurse educational levels and
critical societal needs.
2. Advance media attention to states that exemplify “best practices” in the dis-
tribution of new nurse graduates derived from ADN versus BSN programs.
3. Through capitation approaches, direct enrollment expansion funds (from
private or public sources, especially federal Title VIII funds) that ensure ex-
pansion of pre-licensure programs at colleges/universities until such a time
as there is greater equity in production of new nurse graduates.
CONCLUSION II. To meet societal needs for primary care
providers, nursing education needs to expand the numbers
of annual graduations from programs that prepare nurse
practitioners.
Although health care reform legislation remains unfinished, the United States
may extend health insurance to more than 30 million Americans with a promise
that they (and all currently insured citizens) will have access to high-quality and
affordable care. Shortages of primary care physicians, nurse practitioners, and
physician assistants are severe under current conditions and will escalate dramati-
cally (as Massachusetts is currently experiencing) if Congress passes the bills
under consideration (New England Healthcare Institute, 2009). Health care costs
will have to be reduced or contained, or the nation will face an economic burden
that is unsustainable. Under any likely scenario, the need for nurse practitioners
(NPs) will increase dramatically.
In the most recent academic year, approximately 7,500−8,000 students grad-
uated from NP programs (AANP, 2009). Of the 125,000 NPs practicing today,
most qualify as primary care providers (49 percent family, 18 percent adult,
3 percent gerontological, and 9 percent pediatric specialties) (AANP, 2009).
Currently, the vast majority of students complete educational requirements for
certification exams in their NP specialty at the end of master’s (MSN) programs.
Recently, Doctor of Nursing Practice (DNP) programs have been introduced,
adding competencies related to organizational systems leadership for quality im-
provement, information systems and patient care technology, health care policy,
interprofessional collaboration and clinical prevention for improving patient and
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population health (AACN, 2006b). These competencies, currently provided in
post-master’s DNP programs almost exclusively, build on specialty practice edu-
cation received in MSN programs and, in most cases, practice experience from
basic practice, administrative, or faculty roles. It is beyond the scope of this paper
to describe fully the rationale for the practice doctorate (AACN, 2004), but major
reasons include the demand for formal practice-centered education and scholar-
ship opportunities beyond those provided by the master’s degree and equity issues
with other health professionals who have converted their professional master’s
programs to professional doctorates in programs equivalent in length to most
nursing master’s programs (e.g., physical therapy, pharmacy, etc.).
Most schools of nursing with graduate programs (approximately 475) feel
tremendous pressure (whether or not they have the resources to mount quality
DNP programs) to convert their master’s or post-master’s DNP programs to DNP
programs that prepare NPs for entry into practice because of the American As-
sociation of Colleges of Nursing position statements on the DNP, as represented
below:
AACN members have endorsed the transition from specialty nursing practice
education at the master’s level to the DNP by the target goal of 2015. AACN
recognizes the importance of maintaining strong interest in roles (e.g., nurse
practitioner, clinical nurse specialist, nurse midwife, and nurse anesthetist) to
meet existing health care needs. In response to practice demands and an increas-
ingly complex health care system, programs designed to prepare nurses for
advanced practice nursing will begin the transition to the practice doctorate for
nurses who initially want to obtain the DNP, as well as for nurses with master’s
degrees who want to return to obtain the practice doctorate. AACN will assist
schools in their transitioning to the DNP and in their efforts to partner with other
institutions to provide necessary graduate level course work. Specialty focused
master’s level programs will be phased out as transition to DNP programs oc-
curs. Master’s programs will continue to be offered and will prepare nurses for
advanced generalist practice. (AACN, 2006a, p. 12)
No licensure or certification requirements mandate this change to date. Even
the Commission on Collegiate Nursing Education (CCNE), the autonomous
accrediting agency associated with AACN which will accredit DNP programs,
has to date said nothing about requiring a transition to entry-to-practice DNP
programs
The entry-level DNP has been opposed by a minority within the profession
since its conception (Dracup et al., 2005; Meleis and Dracup, 2005). Recently,
some AACN member deans and the National Organization of Nurse Practitioner
Faculties submitted letters to the AACN Board requesting that they remove
the threat of the 2015 date for requiring the transition to entry DNP programs
(personal communications, November 2009). With a dearth of qualified faculty,
many programs of uneven quality are being mounted. But the bigger issue is that
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faculty members have begun to realize what a tremendous investment of faculty
and student time is required to complete the DNP. Doctoral requirements for in-
dependent projects/dissertations are important for building the capacity for DNPs
to contribute to quality improvement and translational science, but they take time
and commitment to scholarly approaches to inquiry. Schools are realizing that
they cannot educate the same numbers of DNPs per year at the entry level as they
are currently graduating at the MSN level.
Inevitably, a transition to DNP programs for entry into NP practice would
reduce the production of NPs at exactly the time when the country may experi-
ence a dramatic increase in need. We have not yet seen a decrease in the number
of MSN graduates per year, because only a small number of schools have phased
out MSN specialist programs to date. To increase, or even maintain, the current
annual graduation numbers of primary care NPs would require funds (from
students and schools) to pay for at least one additional year of study for each
graduate, sufficient numbers of qualified faculty members to teach the additional
year’s program content and supervise individual scholarship projects, and more
preceptors for the additional hours of supervised clinical time. These are signifi-
cant costs during a period of economic downturn that has reduced budgets for
almost all schools of nursing.
The irony is that the literature is replete with results of studies showing that
the NP workforce, as currently trained, provides patient care of high quality. Pohl
and colleagues (2010) reviewed the literature in a recent background paper for
the January 2010 Josiah Macy Conference, Who Will Deliver Primary Care and
How Will They Be Trained? Their summary stated:
NPs have practiced in a variety of models, and the outcomes of their practices
have been studied for more than 40 years. Repeatedly, when quality of care has
been assessed in studies that are highly rated on strength of evidence, NP pro-
viders have been found to provide equivalent, and in some cases, superior care.
Because of the supervision requirements and payment models that have funded
physicians as heads of practices, evidence about relative costs of care using vari-
ous primary care provider mix teams has been difficult to obtain. Such studies
are needed prior to implementation of any public policy that would reimburse
primary care at significantly higher costs. (Pohl et al., 2010, pp. 182−183)
Rather than mandating the increased costs to students, faculty and schools of
nursing that would be required to convert to entry DNP programs now, all pres-
sure to start DNP entry programs should be removed, allowing the external envi-
ronment (societal needs, school budgets, student and employer demand) to settle
the issue over time. At a minimum, nursing education should commit to a transi-
tion period that will not diminish production capacity at a time of critical societal
need. Many organizational leaders (maybe even AACN, and definitely CCNE)
would welcome an external voice that emphasized that the needs of patients and
society should take precedence over professional aspirations at this time.
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RECOMMENDATIONS
1. Fund a project that would include RWJF/IOM committee members and
representatives of relevant professional organizations involved in APN certi-
fication, accreditation, education and practice. Provide facilitative leadership
(like Ellen Kurtzman did for the RWJF-funded project to achieve consensus
on establishing a Nursing Quality and Safety Alliance) for reaching consen-
sus that DNP programs should be launched as post-master’s programs for
the foreseeable future so that nursing maintains or increases the numbers of
NP graduates each year.
2. As a secondary goal in the process above, ensure that nursing master’s pro-
grams remain targeted at specialist preparation, not generalist preparation as
currently proposed by AACN.
3. Fund the development of briefs aimed at state governors and attorney gener-
als that emphasize the importance (to the cost/quality of health care in their
states) of removing legal, regulatory, or reimbursement policy barriers to the
ability of nurse practitioners to serve as primary care providers or leaders of
patient centered medical homes or other methods of patient care delivery.
CONCLUSION III. New models of education are needed to
ensure that the competencies required to do the work and
improve the work of nursing and health care are embedded
in nursing education programs.
Nursing education programs began to transition out of hospital-based, ap-
prenticeship programs into academic settings (colleges/universities and commu-
nity colleges) over 50 years ago. Aligning nursing education with the dominant
American approach to professional preparation in other fields fostered numerous
gains for the advancement of knowledge, the development of faculty and ad-
vanced practice roles, and the quality of nursing education and practice. Through-
out the decades, however, nursing leaders have been challenged by the separation
of academic and practice worlds and the difficulties associated with building
sufficiently strong links between practice and academe to ensure that nursing
students develop the competencies that make them able to work effectively in
health care settings (Cronenwett and Redman, 2003; Fagin, 1986). Recent stud-
ies of newly licensed registered nurses illustrate that the gap remains (Kovner
et al., 2010; Pellico et al., 2009). For example, the new nurses in the study by
Pellico and colleagues called for more educational experiences involving 8-hour
clinical days, more realistic patient/nurse ratios, and better preparation for com-
munication activities such as change-of-shift reports, delegating, rounding with
physicians, and charting (Pellico et al., 2009).
Added to this perennial problem, the first decade of the 21st century was
marked by a series of IOM reports outlining the problems with health care qual-
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ity and safety. In response, the pace of change in practice settings escalated, as
new quality improvement processes and measures were adopted, and data about
quality and safety became transparent to the public. By and large, full-time fac-
ulty members in schools of nursing were uninformed about these changes as they
developed. Not surprisingly, Kovner and colleagues found that 39 percent of new
nurses in a 2008 survey thought they were “poorly” or “very poorly” prepared
or “had never heard of” quality improvement, although BSN graduates reported
significantly higher levels of preparation in evidence-based practice and assessing
gaps in teamwork and collaboration (Kovner et al., 2010).
Since 2005, RWJF has funded the Quality and Safety Education for Nurses
(QSEN) project (Cronenwett et al., 2007, 2009a, 2009b) to address the challenge
of educating nurses who will be prepared to continuously improve the health care
systems in which they work. Faculty have available two websites with resources
for developing teaching strategies aimed at the knowledge, skills, and attitudes
that must be developed to achieve competence in patient-centered care, teamwork
and collaboration, evidence-based practice, quality improvement, safety, and
informatics (Cronenwett et al., 2007)—namely the QSEN website at www.qsen.
org and the Institute for Healthcare Improvement Open School at http://www.ihi.
org/IHI/Programs/IHIOpenSchool/. A series of faculty development conferences
and national forums on this topic are being launched by QSEN (through UNC
and AACN) to provide further support for embedding these topics in nursing
programs.
The rapidity with which nursing faculty can become “out of touch” with the
requirements of current practice was made evident during this decade (Sherwood
and Drenkard, 2007), and there is much yet to learn about how to overcome the
negative consequences of the gaps between nursing education and practice. The
Carnegie Commission funded a study of professional formation across multiple
disciplines, and a recent book by Benner and colleagues (2009) described a
call for radical transformation of nursing education. To the point being raised
here, the multiyear study concluded that there needs to be better integration of
coursework with clinical experiences, so that coursework and classroom learning
are tied to what actually happens in patient care rather than being studied in the
abstract. Faculty, they argue, must help students make the connection between
acquiring and using knowledge, so that students develop clinical reasoning skills
for the diverse, complex practice that is nursing (Benner et al., 2009). Faculties
cannot perform these functions unless they possess clinical expertise or work
closely with nurses in practice at each step from curriculum design to develop-
ment of simulation, classroom and clinical teaching strategies, and assessment of
student performance. Likewise, there are great challenges associated with teach-
ing system competencies (as opposed to the competencies related to the care of
individual patients), such as interprofessional teamwork and collaboration, safety
sciences, or quality improvement, when faculty are not actually doing the work
of improving health care systems themselves.
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APPENDIX I �13
Nursing faculties and their practice partners have tried a variety of strategies
to continuously improve the preparation of students for practice. Some examples
(without citing a huge literature) are capstone courses with staff nurse preceptors,
dedicated education units, faculty practices, inter-professional learning experi-
ences, cross-appointing nursing staff on faculties and faculty members on patient
care units, requiring teachers of undergraduate students to practice at least a day
a week, hiring clinical experts to help faculty develop cases for simulated clinical
teaching, and keeping student clinical experiences in one institution for greater
depth in exposure to safety cultures, quality improvement projects, and electronic
health records. More innovation is needed, along with studies that will help iden-
tify “best practices” for dissemination.
The other major barrier to achieving effective practice competencies is the
lack of a structured and financially supported residency training program during
the first year of initial licensure as a nurse. Because schools of nursing prepare
pre-licensure graduates as generalists, newly licensed nurses, by definition are
not prepared with the knowledge and skill base for practice with specific patient
populations. Wherever a new nurse begins practice, a period of mentored super-
vision and support should be provided. The National Council of State Boards
of Nursing is working to promote criteria for the transition to practice period
that would need to be met before the new nurse was relicensed at the end of the
first year of practice (NCSBN, 2009). AACN and the University Healthsystem
Consortium offer support, and accreditation through CCNE, for nurse residency
programs aimed at BSN graduates (AACN, 2009b). Nonetheless, no consistent
requirement for nurse residencies reinforces the importance of this phase of edu-
cation for the practice of nursing.
RECOMMENDATIONS
1. Promote innovation and evaluation of novel approaches to improving prepa-
ration for the practice of nursing through designated Title VIII (HRSA,
USPHS) funding mechanisms.
2. Urge accrediting bodies (CCNE and NLNAC) to require evidence that fac-
ulty have the practice expertise or effective clinical partnerships to prepare
students for the work of nursing practice and improving the work of nursing
and health care.
3. Promote funding mechanisms for the development and testing of new meth-
ods of interprofessional education through simulation, case studies, and
clinical practice.
4. Promote innovation and evaluation of models that engage nursing faculty in
the work of improving health care.
5. Support learning collaboratives of state boards of nursing who are willing
to work out the issues related to implementing regulatory requirements for
transition to practice residencies as a prerequisite for initial relicensure.
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6. Require that any hospitals receiving GME monies for “nursing educa-
tion” devote those resources to supporting transition to practice residency
programs.
FINAL THOUGHTS
The exercise of choosing only three areas of focus for this paper makes me
realize the challenge that RWJF/IOM committee members face as you decide
what actions to take to ensure that nursing meets the needs of the public for the
foreseeable future. I hope the ideas from these collective papers on the future of
nursing education assist you in your difficult but important task.
REFERENCES
AACN (American Association of Colleges of Nursing). 2004. AACN Position Statement on the
Practice Doctorate in Nursing. http://www.aacn.nche.edu/DNP/pdf/DNP (accessed Janu-
ary 13, 2010).
AACN. 2006a. DNP Roadmap Task Force Report. http://www.aacn.nche.edu/DNP/pdf/DNProadma-
preport (accessed January 13, 2010).
AACN. 2006b. The Essentials of Doctoral Education for Advanced Nursing Practice. http://www.
aacn.nche.edu/DNP/pdf/Essentials (accessed January 13, 2010).
AACN. 2009a. 200�−200� Enrollment and Graduations in Baccalaureate and Graduate Programs
in Nursing. http://www.aacn.nche.edu/Media/NewsReleases/2009/workforcedata.html (accessed
January 13, 2010).
AACN. 2009b. UHC/AACN Nurse Residency Program. http://www.aacn.nche.edu/education/nursere-
sidency.htm (accessed January 13, 2009).
AANP (American Academy of Nurse Practitioners). 2009. AANP 200� Fact Sheet. http://www.aanp.
org/NR/rdonlyres/54B71B02-D4DB-4A53-9FA6-23DDA0EDD6FC/0/NPFacts6 (accessed
January 13, 2010).
Aiken, LH, Clarke, SP, Cheung, RB, Sloane, DM, and Silber, JH. 2003. Education levels of hospi-
tal nurses and patient mortality. Journal of the American Medical Association (JAMA), 290:
1617-1623.
Aiken LH, Cheung RB, and Olds D. 2009. Education policy initiatives to address the nurse shortage.
Health Affairs, 28(4):w646–w656.
Benner P, Sutphen M, Leonard V, Day L. 2009. Educating nurses: A call for radical transformation.
San Francisco: Jossey-Bass.
Bentley R. 2006. Comparison of traditional and accelerated baccalaureate nursing graduates. Nurse
Educator 2006:31(2):79-83.
Berwick DM, Nolan TW, Whittington J. 2008. The triple aim: Care, health and cost. Health Affairs
27(3):759-769.
Bevill JW, Cleary BL, Lacey LM, Nooney JG. 2007. Educational mobility of RNs in North Carolina:
Who will teach tomorrow’s nurses?: A report on the first study to longitudinally examine edu-
cational mobility among nurses. AJN. 107(5):60-70.
Bovbjerg RR, Ormond BA, Pindus N, The Urban Institute. 2009. The nursing workforce challenge:
Public policy for a dynamic and complex market. Report to the Jonas Center for Nursing
Excellence. August 2009. http://www.urban.org/UploadedPDF/411933_professionalnurse
(accessed January 13, 2010),
http://www.nap.edu/12956
The Future of Nursing: Leading Change, Advancing Health
Copyright National Academy of Sciences. All rights reserved.
APPENDIX I �1�
Brewer, CS, Kovner CT, Poornima S, Fairchild S, Kim H., Djukic M. 2009. A comparison of second-
degree baccalaureate and traditional baccalaureate new graduate RNs: Implications for the
workforce. J Prof Nurs. 25(1):5-14.
California Strategic Planning Committee for Nursing. Planning for California’s Nursing Work Force.
Phase III Final Report Executive Summary. http://www.cohs.uci.edu/nursing/pdf/cspcn/TheSu
mmary%20(phase%20III) (accessed January 13, 2010).
Cleary BL, Hassmiller SB, Reinhard SC, Richardson EM, Veenema TG, Werner S. 2010, Forging
partnerships to expand nursing education capacity. AJN 110(1):43-50.
Cronenwett L, Redman R. 2003. Partners in action: Nursing education and nursing practice. JONA,
33(2):131-133 and Nurse Educator, 28(4):153-155.
Cronenwett L, Sherwood G, Barnsteiner J, Disch J, Johnson J, Mitchell P, Warren J. 2007. Quality
and safety education for nurses. Nursing Outlook, 55(3):122-131.
Cronenwett L, Sherwood G, and Gelmon SB. 2009a. Improving quality and safety education: The
QSEN Learning Collaborative. Nursing Outlook, 57(6):304-312.
Cronenwett L, Sherwood G, Pohl J, Barnsteiner J, Moore S, Sullivan DT, Ward D, Warren J.
2009b. Quality and safety education for advanced nursing practice. Nursing Outlook,
57(6):338-348.
Dracup K, Cronenwett L, Meleis A, and Benner P. 2005. Reflections on the doctorate of nursing
practice. Nurs Outlook, 53(4):177-182.
Fagin C. 1986. Institutionalizing faculty practice. Nurs Out 34(3):140-144.
Fagin CM, Lynaugh JE. 1992. Reaping the rewards of radical change: A new agenda for nursing
education. Nurs Out 40(5):213-220.
Forbes MO, Hickey MT. 2009. Curriculum reform in baccalaureate nursing education: Review of
the literature. Int Jo Nurs Educ Sch http://www.bepress.com/ijnes/vol6/iss1/art27 (accessed
January 13, 2010).
Kovner CT, Brewer CS, Yingrengreung S, Fairchild S. 2010. New nurses’ views of quality improve-
ment education. Jo Comm Jo Qual & Patient Safety 36(1):29-35.
Meleis A, Dracup K. 2005. The case against the DNP: History, timing, substance, and marginalization.
Online Jo Issues in Nurs 10(3). www.nursingworld.org/MainMenuCategories/ANAMarketplace/
ANAPeriodicals/OJIN/TableofContents/Volume102005/No3Sept05/tpc28_216026.aspx (ac-
cessed January 13, 2010).
NCSBN (National Council of State Boards of Nursing). 2009. Transition to Practice Regulatory
Model. https://www.ncsbn.org/363.htm (accessed January 13, 2009).
New England Healthcare Institute. 2009. Remaking Primary Care: From Crisis to Opportunity.
http://www.nehi.net/publications/40/remaking_primary_care_from_crisis_to_opportunity (ac-
cessed January 13, 2010).
North Carolina Institute of Medicine. 2007. Task Force on the North Carolina Nursing Workforce Re-
port. http://www.nciom.org/docs/nursing_workforce_update (accessed January 13, 2010).
Pellico LH, Brewer CS, Kovner CT. 2009. What newly licensed registered nurses have to say about
their first experiences. Nurs Out 57(4):194-203.
Pohl JM, Hanson CM, Newland JA. 2010. Nurse practitioners as primary care providers: History,
context, and opportunities. Background paper for the Josiah Macy Conference, “Who Will
Deliver Primary Care and How Will They Be Trained?” January 8-11.
Sherwood G, Drenkard K. 2007. Quality and safety curricula in nursing education: Matching practice
realities. Nurs Outlook 55(3):151-155.
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�1� THE FUTURE OF NURSING
NURSING EDUCATION: RECOMMENDATIONS
FOR THE FUTURE
Kathleen Dracup, R.N., N.P., D.N.Sc.
University of California, San Francisco School of Nursing
The nature of nursing has changed drastically over the past few decades.
The complexity of care in many diverse settings, the role of advanced practice
nurses as independent providers, and the growing recognition of the important
role of scientific evidence upon which to base nursing practice have changed the
way nurses are viewed by the public and the way they should be educated. The
complex demands of practice combined with a shortage of experienced practi-
tioners in many of the health care professionals have created opportunity and,
in some areas, a state of potential crisis. As health care reform looms and the
population continues to age, nursing education must embrace these challenges,
expanding and improving on what it offers currently to better prepare the nurse
of the future.
Many issues face the nursing profession today; all seem to be filled with
odd contrasts.
• Nursing is a profession characterized by a highly complex practice with
nurses often making life and death decisions. Yet the formal education
required to prepare clinicians for this challenging practice is less than
any of the other health professions (i.e., nurses can currently practice
with a 2-year associate degree and 80 percent who enter the profession
with this degree choose not to get further formal education in the form
of another degree) (Aiken et al., 2009).
• The projections for nursing shortages in the near future are alarming, but
the urgency of those shortages are blunted by the current economic crisis
that has kept many nurses in the workforce and has reduced vacancy
rates. The seeming resolution of the shortage has diverted the attention
of the media and government to other problems and has reduced the
chances that nursing education will receive the resources it needs to
expand enrollments.
• A current and projected faculty shortage is a serious impediment to solv-
ing the preparation of new nurses, but nursing faculty remain one of the
most poorly compensated categories of nurses.
• Nursing is a profession that increasingly must be based on science and
strong empirical data and yet the number of scientists within it to gener-
ate new knowledge remains disappointingly small.
• Nursing is a profession charged to care for a highly diverse population of
patients and yet it remains highly nondiverse in gender, race, and ethnic-
ity. The lack of diversity among nurses, with the consequent discordance
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APPENDIX I �1�
between clinician and client, serves to reduce the effectiveness of the
care nurses provide.
• Finally, it is a profession that must have strong interprofessional rela-
tionships with other members of the health care team to be effective and
yet nurses (and other health professionals) are educated traditionally in
silos with little exposure to students in other health professions and no
formal opportunities to develop team skills.
This list is undoubtedly incomplete. Even taken alone, it underscores the
need for a critical reappraisal of how we educate the next generation of nurses
and what recommendations we make to federal and state governments, as well
as to the organizations responsible for accrediting nursing educational programs,
to provide appropriate preparation and economic support to the next generation
of nurses.
Three issues will be highlighted in this paper: the shortage of nurse scien-
tists, the lack of educational preparation for preparing nurses to provide patient-
centered care within an interprofessional team of health care providers, and the
lack of effective formal teaching in pre-licensure programs in the areas of nursing
science, natural and social sciences, humanities, and leadership. Two of the three
are particularly germane to university-based schools of nursing who are facing
severe faculty shortages and to practicing clinicians who make decisions each day
based on tradition rather than empirical evidence. The third area was highlighted
in the recent Carnegie Foundation Report on nursing education (Benner et al.,
2010) and has important ramifications for the entire nursing profession and for
the future health of our nation.
THE SHORTAGE OF NURSE SCIENTISTS
According to the most recent survey of the RN population conducted by the
Health Resources and Services Administration (HRSA) in 2004, the number of
RNs in the United States is 2.9 million (U.S. Department of Health and Human
Services, 2006). The number of nurses prepared at the master’s or doctoral level
rose to 376,901, which was an increase of 37 percent from 2000 (U.S. Depart-
ment of Health and Human Services, 2006). Although 13 percent of nurses
hold a graduate degree, only 1 percent have a PhD and are prepared to conduct
independent research in their field. In fact, only 555 students graduated with a
PhD in nursing in 2009, a number that has been relatively unchanged for the past
decade (AACN, 2009). Thus, the numbers of nurse scientists working to create
the empirical data upon which nursing practice is based is trivial compared to
the need.
Why do so few nurses pursue doctoral study? The problem is not access. The
number of PhD programs has doubled over the past two decades; however, the
number of nursing graduates prepared at the PhD level has remained essentially
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unchanged (AACN, 2009). Three reasons for the continuing shortage of nurse
scientists can be posited. First, educational preparation at the associate degree
or hospital diploma level serves as an impediment to easy access to graduate
study. In 2004, 34 percent of registered nurses (n = 981,238) reported the associ-
ate degree as their highest level of nursing or nursing-related education, while
18 percent (n = 510,209) held a hospital diploma (U.S. Department of Health
and Human Services, 2006). Over 50 percent of nurses today would face ap-
proximately 8–9 years of formal university-based education in order to receive a
PhD compared to the 4–5 years required to attain a PhD in other disciplines that
require a baccalaureate degree. Entry into the nursing profession at the associate
degree level serves as a disincentive for the majority of nurse graduates to con-
tinue further study to the PhD level (Cleary et al., 2009). Even more dishearten-
ing is that the fact that the number of nurses whose highest educational degree
in nursing is the associate degree has increased by 232 percent since 1980 (U.S.
Department of Health and Human Services, 2006). Moreover, the vast majority
of these nurses (i.e., those who obtain an associate degree to practice nursing) do
not pursue a bachelor’s degree anytime in their career. In 2004, only 21 percent of
RNs initially educated in associate degree programs had received a baccalaureate
degree, while only 6 percent of this population had gone on to obtain a MS or
PhD degree (Aiken et al., 2009). Thus, nurses prepared at the associate degree
level are highly unlikely to undertake doctoral study during their careers.
Second, nurses have more interruptions in their careers and often begin
doctoral study at a later age than individuals in other disciplines. The nurs-
ing profession traditionally has viewed clinical experience as a prerequisite to
graduate education and new graduates were encouraged to practice clinically by
faculty and peers between degrees rather than continuing straight on to obtain a
PhD. This career path has resulted in the norm of nurses returning for a master’s
degree in their mid-thirties to become an advanced practice nurse (e.g., nurse
practitioner or clinical nurse specialist) or administrator, then returning to the
workforce for another decade, and finally returning to graduate school to obtain
a PhD in their late thirties or even older. Nurse scientists complete their doctoral
degrees, on average, at the age of 46, which limits the number of years they
have to build a scientific program and contribute to the scientific base of nursing
practice (Dracup et al., 2009). To help reverse this trend, many nursing schools
have developed programs that admit students into graduate programs directly
from undergraduate or master’s programs and faculty are slowly changing their
commitment to this model of advisement.
Third, faculty salaries provide an important disincentive to return to school
to obtain a PhD. Although academics in all disciplines are rarely compensated
at the same level as their peers in industry, the disparity for nurses is one of the
largest. Nurses working as clinicians make, on average, 30 percent more than as-
sistant professors, who typically make from $50,000 to $70,000 at the assistant
professor level (Dracup et al., 2009). Advanced practice nurses make, on average,
100 to 150 percent more than assistant professors (Cleary et al., 2009). In a recent
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APPENDIX I �1�
survey conducted by the American Association of Colleges of Nursing (AACN)
to describe the nursing faculty shortage, respondents cited inadequate salary as
the number one cause of the faculty shortage (Fang and Tracy, 2009).
Besides the three reasons cited above to explain the low number of PhD-
prepared nurses, the development of a professional doctorate (i.e., the Doctor of
Nursing Practice or DNP) is also a trend worth noting. The degree was introduced
in 2004 by the American Association of Colleges of Nursing (AACN) with a
recommendation by its members to adopt the DNP degree for all advanced prac-
tice nurses by 2015. The degree is designed as the terminal degree for nursing
practice and may be combined with a PhD for nurses interested in conducting
translational science. The reasons given by the organization at the time of adop-
tion were the following: the rapid expansion of knowledge underlying nursing
practice; increased complexity of patient care; national concerns about the qual-
ity of care and patient safety; shortages of nursing personnel which demands a
higher level of preparation for leaders who can design and assess care; shortages
of doctorally prepared nursing faculty; and increasing educational expectations
for the preparation of other members of the health care team. The degree has been
a source of contention within the profession and has evoked concerns by various
physician and nursing organizations (AMA, 2010; Dracup et al., 2005). However,
DNP programs have mushroomed across the states with 92 currently awarding
degrees and another 102 in the planning process (AACN, 2009). Whether or not
DNP programs will attract applicants that would not have been interested in a
PhD is unknown and what affect it will have on future PhD applications is also
unknown. However, it is important to note that the program is focused on prepar-
ing its graduates “to fully implement the science developed by nurse researchers
prepared in PhD, DNSc, and other research-focused nursing doctorates” (AACN,
2010). Its graduates are not expected to contribute scientific discoveries or to lead
interdisciplinary teams of scientists. Thus, the DNP will not meet the need for
more nurse scientists and it may contribute to their shortage.
Recommendations Related to Shortage of Nurse Scientists
• Address the pipeline. A major impediment to attracting the large num-
ber of nurses scientists needed in the future is the high percentage of
nurses prepared in community colleges. Federal and state funding needs
to be allocated to creating innovative solutions to assisting graduates
of community colleges to get BS degrees such as allowing community
colleges to award BS degrees (a controversial but attractive option) or
developing programs like the Oregon model where all nursing students
are enrolled in the university and have the option of completing a fourth
year to attain their BS degree (Tanner et al., 2008).
It would be helpful if the committee clarified the role of the DNP for
the broader community and considered the impact of DNP programs on
the shortage of PhD graduates. It is currently not clear whether universi-
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�20 THE FUTURE OF NURSING
ties will appoint DNP graduates to tenure-track positions, but clarifica-
tion of this point will be important for the profession as it continues
to clarify the differences between the two doctoral degrees. Do nurse
scientists conducting translational research need both a DNP and a PhD?
If the answer is yes, the pipeline has just become longer.
• Augment federal and state funding for PhD students and their re-
search. One way to compensate for low faculty salaries is for nursing
students to be relieved of their educational debt. The Nurse Faculty Loan
Program under Title VIII creates a student loan fund within individual
schools of nursing that students can access. Students who teach at a
school of nursing following graduation cancel up to 85 percent of their
educational loans plus interest. In 2007 and 2008, 729 students were
funded nationally each year, a 43 percent decrease from the preceding
years.4 With almost 4,000 students in PhD programs in nursing during
those same years, as well as an unknown number studying in other
disciplines, this program needs to be strongly augmented and widely
publicized.
A second program under Title VIII provides educational grants to
schools (i.e., Advanced Education Nursing Grants) that can be used
to support students in graduate programs. Again, the amount available
for individual schools is paltry compared to the need. For example, the
University of California San Francisco School of Nursing receives an
average of $200,000 of AEN funds annually to support 720 graduate
students. Student debt is inevitable and the dream of a faculty position
fades quickly.
Funding for pre- and post-PhD research and study is available through
the National Institute of Nursing Research, but again this funding has
been severely limited. Historically the Institute was funded at one of the
lowest rates among all the institutes at the National Institutes of Health
since its inception, which limits its ability to support doctoral students.
Two other new sources of funding are pending and require strong sup-
port by the Committee on the Future of Nursing. Nursing organizations
have long urged Congress to redirect Medicare funding (GME funds)
that currently is restricted to hospital diploma nursing education toward
graduate education (Aiken et al., 2009). This change would give hospi-
tals incentive reimbursement for students and allow hiring of additional
faculty. Also, capitation grants (similar to the Nurse Training Acts of
1971 and 1975) would allow schools to recruit additional doctoral stu-
dents as well as improve facilities and hire faculty. The bleak outlook
4 Source: Division of Nursing, Health Resources and Services Administration 2006−2008 as sum-
marized in AACN’s Congressional Requests: A Focus on Promoting Access to Quality Health Care.
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APPENDIX I �21
for nursing faculty shortages will not change without massive changes
in federal support for nursing education.
A LACK OF INTERPROFESSIONAL COLLORATION IN EDUCATION
In both acute and chronic health care settings, there is mounting evidence
that interprofessional practice models are effective in improving patient out-
comes, patient and provider satisfaction, and health care costs (IOM, 2004;
Needleman and Hassmiller, 2009). However, these models of interprofessional
practice are not based on the educational experiences of health care profession-
als, who are most often taught in university departments or schools that function
as educational silos that encourage little or no contact with students from other
professions. Students from schools of medicine, nursing, and pharmacy, for
example, rarely share courses, participate in discussion groups, or experience
faculty (and therefore role models) from health care professions other than their
own during their formal education. The tradition of educational isolation in the
health care disciplines encourages the maintenance of historical stereotypes and
discourages the communication skills and understandings that are essential for
effective teams.
Unfortunately, assembling multiple professionals together in a single clini-
cal setting after graduation does not guarantee interprofessional collaboration
will occur, despite the fact that it is increasingly recognized as fundamental to
the quality and safety of patient care. Role confusion can abound. For example,
physicians and nurse practitioners share many of the same role functions despite
a very different philosophical orientation, which can be source of conflict and
differing priorities. Clinical nurses specialists and social workers both focus on
the family system, which may lead to confusion of responsibilities and functions.
Professional organizations may fuel professional rivalries by conducting various
turf protection exercises, particularly related to reimbursement. Hospitals, where
much of health care is delivered, have rigid organizational structures and profes-
sional hierarchies that often serve to create a “we” vs. “they” structure within
the different disciplines represented on a team that is the antithesis of a highly
functioning team. Students need to gain the skills of communication and collabo-
ration across health care disciplines early in their careers if they are to function
effectively in professional teams.
The benefits of creating an interprofessional educational experience are
great. Students are able to exchange different theoretical perspectives, address
historical stereotypes, and develop communication and leadership skills that are
critical to highly functioning teams in the clinical setting (Spear and Schmidhofer,
2005). An important benefit from the standpoint of university administrators is
the potential for sharing resources, including expert faculty, space, and physical
equipment. For example, an increasing number of universities are beginning to
build simulation centers designed for interprofessional student teams to par-
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ticipate in exercises designed to increase teamwork. Sharing a single simulation
center provides the various professional programs with opportunities for realistic
interprofessional learning that are difficult to arrange in real clinical practice. The
simulation exercises build confidence before contact with real patients and pro-
vide a safe environment where mistakes become learning opportunities. Working
together on patient scenarios and real-life case studies can also improve teamwork
and promote better understanding between professions.
So if collaboration and effective communication among disciplines is so
valuable, why is it so little in evidence in nursing education? Some of the reasons
are historical. Student nurses in hospital diploma programs were often taught by
medical faculty. When nursing education moved out of the hospital setting, some
nurse educators were eager to shed the tradition of medical faculty as well. Medi-
cal schools, in turn, migrated to universities decades before schools of nursing.
This difference in timing meant that many schools of medicine were established
without any school of nursing, and they still do not have a nursing program in
the same university. Nursing programs are now housed in community colleges or
in universities that do not have schools of medicine or other health disciplines.
Curricula for different health professions were developed without collaboration
from other disciplines. The most egregious symptom of the lack of collaboration
in education is the large number of medical programs that are on different aca-
demic calendars than the other health care disciplines in their same university,
making it difficult for students to have a platform for collaboration.
Ultimately it is the responsibility of educators in the various disciplines
to create a learning environment in which students, preceptors, and patients
may teach and learn from one another. They can do this through a variety of
strategies:
• A single orientation day for the health professions that introduces the
philosophy of interprofessional education,
• Joint faculty appointments,
• Shared courses across schools that includes the completion of assign-
ments by interdisciplinary teams,
• Interdisciplinary student-managed clinics,
• Social networking sites that include students from all health professions,
and
• Interprofessional social events sponsored by the university.
Educated in an interdisciplinary model, individuals entering the workforce will do
so with the mindset that collaboration among all health care practitioners is how
patient care should be approached. The mindful inclusion of interprofessional
educational experiences potentially will lead to more effective communication
across disciplines and ultimately patient care that is safe, cost-effective, and of
high quality.
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APPENDIX I �23
Recommendation Related to Interprofessional Collaboration in Education
• Develop and implement strategies to reward interprofessional col-
laboration in nursing education. The development of the Clinical and
Translational Science Awards by NIH is a model of how to develop a
culture of interdisciplinary teams where none existed. Creating an award
structure that demanded interdisciplinary collaboration among scientists
forged many researcher alliances on university campuses. Similarly, the
education of health professionals must be viewed through a different
lens than is currently used. Accrediting bodies and university review
committees should include interprofessional collaboration as part of
the criteria for a quality nursing program, as well as the programs of
other health professions such as medicine and pharmacy. Expectations
for interprofessional collaboration must be set in university program
reviews, accreditation criteria, and individual faculty promotion criteria
if a change in culture is to be achieved.
PRELICENSURE NURSING EDUCATION
This third area is the easiest and the hardest to present. It is the easiest because
it has recently been the topic of an exhaustive study by the Carnegie Foundation.
It is the hardest because the findings of their study are complex and required a
full-length book to present (Benner et al., 2010). After numerous site visits and
countless interviews, the authors made 26 recommendations that deserve serious
consideration by the committee. It seems that to ignore the major findings of the
first systematic study of nursing education in decades would be folly.
Briefly, the research team of Benner and colleagues focused on a variety of
basic nursing programs by which students are prepared to take the NCLEX-RN
examination and become registered nurses as well as one RN-to-BSN program.
They visited two community college programs (billed as 2 years in length but
often 4 years because of the required prerequisites and waiting list times), three
generic baccalaureate programs, two fast-track second baccalaureate degree pro-
gram of 14–18 months designed for students with a bachelor’s degree in another
field, a single diploma program offered through a freestanding school of nursing
affiliated with and sponsored by a hospital (2–3 years in length), and a single
master’s entry level program that provided a prelicensure program for students
with a bachelor’s degree in any subject followed by a 2-year master’s program.
The researchers identified three areas of apprenticeship in basic nursing pro-
grams: acquiring and using knowledge and science, developing skilled clinical
reasoning, and ethical comportment and formation. They found the latter two
areas adequately or more than adequately addressed in the educational programs
they reviewed. They found the former sadly deficient across all programs where
students were often subjected to thousands of power point slides as a substitute
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for knowledge transfer. Given the complexity of patient care in today’s demand-
ing environment and the increasing independence of nurses who must judge
among various treatment alternatives and select the best course of action, the lack
of nurses’ preparation for their role in terms of scientific principles and clinical
knowledge is somewhat astounding and clearly disturbing.
The review team found the variety of prerequisites across programs trou-
bling, particularly in light of the large number of applicants coming with a degree
from another bachelor’s degree program. Some nursing programs had stringent
science prerequisites while others had almost none. They were concerned that, in
particular, RN-to-BSN programs often did not have the depth of science courses
required for grounding appropriate clinical knowledge. Ultimately the sciences
required to prepare students for nursing education must be rigorous and similar
across programs.
Finally the pedagogies of the classroom were noted to be sadly deficient
compared to the effective pedagogies of teaching in the clinical setting. Class-
room instructors need to adopt the teaching methods that are so effective in the
clinical world of patient care, while also increasing the quality and level of nurs-
ing science, natural and social sciences, and humanities.
Recommendations Related to Prelicensure Education
• Standardize Prerequisites. The lack of standardization across differ-
ent programs means that students in the same program bring varying
degrees of preparation to their learning of the clinical science required
for care of patients. The profession must create a standard list of relevant
prerequisites in the humanities, natural sciences and social sciences that
all programs would be expected to adopt.
• Require the BSN for entry into practice. This is perhaps the most con-
tentious of recommendations but also the one that has eluded the profes-
sion for the past five decades. The various entry paths into the profession
have been confusing to the public and to other health professionals. It
will be important to provide incentives for nurses with AD degrees to
return for a BSN or, when possible, a MS degree. Articulated programs
will be crucial as we move towards an all BSN entry into the nursing
profession.
• Consider more effective teaching strategies related to the transfer
of clinical science in the preparation of new nurse graduates than
currently used. A great deal of research has been conducted over the
past two decades on problem-based learning and other teaching strate-
gies effective in engaging students in learning. According to Benner
and colleagues (2010), many of these have not been adopted by faculty
teaching the formal component clinical science. They recommend that
pedagogies be developed and used to keep students focused on the
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patient’s experience. Medical pathology and disease mechanisms are
best taught in direct association with patients’ illness experiences, psy-
chosocial responses, and needs for self-care. Simulation exercises, case
studies, and group experiences can all be used to enhance learning. Since
many of these learning strategies have been adopted by our colleagues
in the other health sciences, models are available. National repositories
of case studies would be of great support in this transition from the
“death-by-PowerPoint” lecture format to a more student-engaged and
patient-focused format.
REFERENCES
AACN (American Association of Colleges of Nursing). 2009. American Association of Colleges of
Nursing 2009 Annual Report. http://www.aacn.nche.edu/Media/pdf/AnnualReport09 (ac-
cessed January 16, 2009).
AACN. 2010. The Doctor of Nursing Practice Fact Sheet. http://www.aacn.nche.edu/Media/Fact-
Sheets/dnp.htm (accessed January 16, 2010).
Aiken LH, Cheun RB, Olds DM. 2009. Education policy initiatives to address the nursing shortage
in the United States. Health Affairs. 28 (4):646-56.
AMA (American Medical Association). 2010. American Medical Association House of Delegates
Resolution 211 (A-06). http://www.pacnp.org/files/resolution__211_-_nursing_doctorate
(accessed January 16, 2010).
Benner P, Sutphen M, Leonard V, Day L. 2010. Educating Nursing: A Call for Radical Transforma-
tion (The Carnegie Foundation for the Advancement of Teaching). Jossey-Bass, San Francisco,
p. 4.
Cleary BL, McBride AB, McClure ML, Reinhard SC. 2009. Expanding the capacity of nursing educa-
tion. Health Affairs 28 (4):634-645.
Dracup K, Cronenwett L, Meleis AI, Benner PE. 2005. Reflections on the doctorate of nursing prac-
tice. Nursing Outlook. 53:177-182.
Dracup K, Greiner DS, Haas SA, Kidd P, Liegler R, MacIntryre R, et al. 2009. Faculty shortages
in baccalaureate and graduate nursing programs: Scope of the problem and strategies for ex-
panding the supply. http://www.aacn.nche.edu/Publications/WhitePapers/FacultyShortages.htm
(accessed January 16, 2009).
Fang D, Tracy C. 2009. Special survey on vacant faculty positions for academic year 2009–2010.
http://www.aacn.nche.edu/IDS/pdf/vacancy09 (accessed January 16, 2009).
IOM. 2004. Keeping Patients Safe: Transforming the Work Environments of Nurses. Washington, DC:
The National Academies Press.
Needleman J, Hassmiller S. 2009. The role of nurses in improving hospital quality and efficiency:
Real-world results. Health Affairs. w-625-33.
Spear SJ, Schmidhofer M. 2005. Ambiguity and workarounds as contributors to medical error. Ann
Entern Med 142:627-30.
Tanner CA, Gubrud-Howe P, Shores L. 2008. The Oregon Consortium for nursing education: A re-
sponse to the nursing shortage. Policy, Politics and Nursing Practice 9 (3); 2003-09.
U.S. Department of Health and Human Services, Health Resources and Services Administration,
Bureau of Health Professions, The Registered Nurse Population: Findings from the March 2004
National Sample Survey of Registered Nurses, June 2006, http://bhpr.hrsa.gov/healthworkforce/
rnsurvey04/ (accessed January 16, 2009).
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�2� THE FUTURE OF NURSING
NURSING EDUCATION: LEADING INTO THE FUTURE
Catherine L. Gilliss, D.N.Sc., R.N., FAAN
Duke University School of Nursing
“Nursing is the protection, promotion, and optimization of health and abilities;
prevention of illness and injury; alleviation of suffering through the diagnosis
and treatment of human responses; and advocacy in health care for individuals,
families, communities, and populations.”
—Social Policy Statement (American Nurses Association, 2003)
INTRODUCTION
The educational preparation required for a career in nursing today is not what
it was in 1971, nor should it be. Sadly, Benner, Sutphen, Leonard, and Day (2010)
have reported that too often nurse educators replicate their own educational expe-
rience for students, failing to recognize the many reasons why such preparation
is inadequate to meet the needs of today’s nurse. In fact, nursing education is not
the business of preparing nurses for today, but for tomorrow.
The invitation to identify three critically important areas of reform in nursing
education has proven to be a more difficult assignment than was initially obvious
to me. A lifelong educator, I feel as though I have been given three wishes. If I
could “rub the lamp” and change three things, what would they be? Why would
I select these reforms and how would I undertake the needed changes? The in-
vitation, not a simple intellectual exercise, begs the question of me—“What am
I, in my capacity as a leader in nursing education, doing to address the future?”
And the personal vulnerability lies in confronting the possibility that if I identify
three reforms that have little relationship to my daily work, I may be part of the
problem.
To contextualize my comments, I offer a few observations about my career
and point of view. I have worked as a nurse educator in baccalaureate and higher
degree programs since 1974. My appointments have taken me to public and pri-
vate institutions, secular and religious, and most often to large academic health
centers. Over the last 25 years, my classroom and mentoring activities have
focused on the preparation of advanced practice nurses for primary care and the
preparation of nurse scientists; I have remained in contact with entering, second
degree students in nursing by teaching a course on leadership. Since 1993, I
have held major administrative responsibilities, first as a department chair, later
as a dean, and currently as a dean and vice chancellor in a large academic health
center within a university distinctive for its culture of interdisciplinarity.
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REFORMING NURSING EDUCATION:
THREE PRIORITIES FOR ACTION
The complexity of today’s world could not have been imagined when nursing
instructor Gwendolyn Fortune followed me from hospital room to hospital room
during my senior year clinical rotation in Team Leading. I have often recalled
her insistence that I make good use of my time while conducting patient rounds,
doing at least three or four things at once: check on the condition of the patient,
make sure the room is clean and the facilities are in good working order (e.g.,
night lights have working bulbs), that no unnecessary equipment has been left in
the patient’s room and that the members of the care delivery team have completed
their assignments as scheduled. Although I was a successful pupil, at 21 years of
age I found her to be a bit overbearing and exceptionally humorless. Years later,
I looked back on my educational experience with her and realized two things: (1)
being organized, observant and able to multi-task were all valuable assets; and
(2) her name was “Miss Fortune.”
The skills gained under the direction of Miss Fortune have continued to
be valuable to me, despite the changes in the patterns of care delivery and the
movement away from team leading. She introduced me to basic management
and I will always be grateful. The anecdote also serves as a reminder that while
some lessons are enduring, and the basic skill sets timeless, much of the content
of nursing education has changed. The body of knowledge required for safe
practice has grown geometrically, as have the tools for accessing information,
and the skills required for the safe delivery of care. Educational reforms must
address how we improve access to needed and relevant information for students
within nursing, how we develop the nurse’s ability to access and use information
following program completion and how the educational pathway is ordered to
assist in build a career pathway in clinical nursing. I believe the three reforms I
have selected will address these broad concerns.
REFORM 1. Place greater emphasis on the development of
committed partnerships that will enrich nursing education
programs, specifically partnerships with nursing service,
medical education, and a select group of disciplines that
are especially relevant to health and health care delivery
(engineering, business, policy, law, and the environment).
The fractured relationship between nursing education and nursing service
must be repaired. Although somewhat exaggerated, many would generalize that
academic nurses view nurses in service delivery as anti-intellectual and, con-
versely, the service delivery community views academic nursing as irrelevant and
out of touch. The chasm works against the progress of both communities, com-
munities that are actually one, separated by two distinct corporate missions.
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A variety of structures designed to bring nursing education and service
into closer alignment were implemented at the University of Florida (Dorothy
M. Smith), Rush (Luther R. Christman), Rochester (Loretta C. Ford), and Case
Western Reserve (Joyce Fitzpatrick) in the 1970s. In several of these models,
one leader was appointed to oversee both education and service delivery. Dually
appointed faculty members were expected to teach and deliver care or provide
leadership in the care delivery setting. Faculty complained that their days were
unending and the combined work of delivering clinical care and teaching was
impossible. By the 1990s these models unraveled and the leadership functions
were again assigned to separate leaders, one for education and one for service. By
necessity and given a world of competing demands, the delivery of care requires
an immediate focus on the life and death needs of patients, the “tyranny of the
urgent,” and this overrides the needs of students or scholarly projects, which are
less time-sensitive. But the separation of education and service has resulted in a
practice–education gap that is growing. Benner and colleagues suggest that the
problem is largely due to nursing education’s inability to keep up with changes
in the service sector (Benner et al., 2010).
The problem is not new. In 1983, the Institute of Medicine report, Nursing
and Nursing Education: Public Policies and Private Actions, included the fol-
lowing recommendation:
Closer collaboration between nurse educators and nurses who provide patient
services is essential to give students an appropriate balance of academic and
clinical preparation. (IOM, 1983)
That 27-year-old report urged the federal government to offer grants that would
promote collaboration.
The American Association of Colleges of Nursing has advocated for the de-
velopment of strategic partnerships between education and service and their web-
site includes profiles of selected arrangements that appear to be successful. The
American Organization of Nurse Executives website lists materials for education
and service partners to evaluate their collaborations. Calls for education–service
partnerships continue in the nursing literature (Gilliss and Fuchs, 2007).
Recommendation 1: Where possible, particularly at Aca-
demic Health Centers, promote governance structures that
combine the strategic, rather than the operational oversight
for nursing.
Recommendation 2: Require the demonstration of an
education–service partnership in accreditation criteria for
education and service settings, to include such activities as
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shared governance, shared teaching, shared clinical prob-
lem solving, and participation in continuing education.
Today’s faculty shortage is thought to relate, in part, to salary disparities
between education and service. The median annual salary for a beginning reg-
istered nurse (who may not have a college degree) was $62,089 in April 2009
(Salary Wizard, 2010); the median salary for a doctorally prepared assistant pro-
fessor was $89,973 in 2009 (Fang et al., 2009). Although the salary difference
of approximately $28,000 may seem a large increase, the additional educational
expenses combined with opportunity costs of returning to school may be daunting
for some nurses. The implementation of the Nursing Education Loan Repayment
Program has eased the financial pain for those nurses who wish to direct their
careers toward roles in education. The loan program now repays 60 percent of the
qualified loan balance in exchange for 2 years of service in an approved shortage
facility. An additional 25 percent may be negotiated for a third year of service
(HRSA, 2010). The program holds the promise of preparing more faculty mem-
bers to teach, but that does not address the development of specific competencies
required to teach in clinical areas. In fact, many newly doctorally prepared nurses
anticipate moving into faculty roles where they can redirect their careers toward
nonclinical pursuits. The faculty shortage is real, but the more specific problem
is identifying faculty talent to teach in the clinical area. Those competencies are
in short supply and we need to create incentives to promote the development or
maintenance of clinical expertise and clinical engagement.
Recommendation 3: Require nurse faculty members to
maintain professional certification and tie these qualifica-
tions to educational accreditation. Develop institutionally
based incentives for faculty to maintain clinical compe-
tency, such as participation in a faculty practice plan.
In many fields the careers may reflect a migration from industry to educa-
tion to public service and back. This has not been typical in nursing. Move-
ment from the practice setting to the educational settings and back has not been
valued. Rather, a distinct skill set and preparation has been identified for each
role. Increasingly, educators are expected to have a background in curriculum
design, tests and measurement and pedagogy. The criteria for advancement in
the academy represent yet another barrier. Adhering to the standards set by most
universities, academic nursing programs impose specific, rigorous and rather
narrow criteria for appointment and promotion. These criteria rely more heav-
ily on scholarly accomplishments than on practice acumen. The net effect is the
evolution of a professorate with limited knowledge and experience in the practice
environment (which is seen as a distraction to the development of a program of
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research) and limited understanding of how to prepare graduates for the realities
of practice.
Recommendation 4: Expand criteria for faculty appoint-
ment and advancement to include recognition of practice-
based accomplishments, including leadership, innovation
and evaluation. Normalize the career movement between
the practice and educational settings within nursing.
Every report published by the IOM for the last decade has called for the use
of teams for the delivery of care. (I am completely confident that one of my fel-
low authors will go into this issue in detail, but I will list the recommendation for
the record.) Reports suggesting that teams do affect better patient care outcomes
(Grumbach and Bodenheimer, 2004), but there is very little evidence that effec-
tive educational approaches for co-education of members of the health care team
have been enacted, evaluated, and replicated. Team work is an essential skill in
today’s health care delivery system and students must be prepared to function on
teams. Incentives must be direct programs toward making this change.
Recommendation 5: Promote funding initiatives that will
plan and implement classroom and clinical co-education of
health care providers, particularly nursing and medicine.
Explore existing federal mechanisms to sustain worthwhile
results, for example the combined use of Titles VII and VIII
for models within primary care.
Although universities organize themselves into orderly pods called disci-
plines, real-world problems seldom emerge as discipline-specific. The order
imposed by disciplines directs those within the discipline toward a quasi-propri-
etary body of knowledge, provides a set of tools for discovery, and frames data
elements systematically to promote problem solving. But, the down side of that
order is that disciplines tend to bring the same basic set of information and solu-
tions to novel problems. Said another way, if your only tool is a hammer, then all
your problems look like nails. Some believe that multidisciplinary collaboration
has moved from the periphery to the core of our work in universities (University
Leadership Council, 2009). The problems we face are simply too diverse and
complex to approach with old solutions. The content and problem solving ap-
proaches used within the discipline of nursing will be enhanced through closer
educational exchange with other disciplines.
Recommendation 6: Although others sources provide
greater detail on the specific curricular changes needed
(see Benner et al., 2010), alliances with other disciplines
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APPENDIX I �31
will yield new approaches to the problems faced in nursing
education and service delivery. In particular content and
practical experiences should be developed with engineering,
business, public and health policy, legal, and environmental
experts.
REFORM 2: Recognize the important role that translation
will play in strengthening nursing education, improving
nursing practice and connecting the two.
The IOM report, To Err is Human: Building a Safer Health Care System
estimated in 1999 that many as 98,000 people die in hospitals each year as a
result of medical error (IOM, 1999). Further, these errors have been estimated
to cost approximately $37.6 billion each year; roughly half of the expense is at-
tributable to preventable errors (AHRQ, 2010). In the decade since that report
was published the care delivery community has undertaken needed reforms to
appoint patient safety officers and promote cultures of safety that will assist in the
creation of a quality and safety conscious work environment. Within the educa-
tion community the Robert Wood Johnson Foundation sponsored the Quality and
Safety Education for Nurses (QSEN) project (Cronenwett et al., 2009), directed
by Linda Cronenwett. The lessons of the QSEN project provide some direction
for other areas in which there are education–practice gaps.
In brief, Cronenwett and colleagues found that faculty interested in creat-
ing a quality and safety curriculum acknowledged their limited expertise and
willingness to engage in a collaborative. With a relative small financial package,
teams from a group of 15 schools participated in an educational collaborative
that developed and implemented systematic curricular changes that were clini-
cally relevant. In this case, critically important knowledge was disseminated to
the educational environment.
Recommendation 7: Identify the top ten priority areas for
faculty learning and use similar, evidence-based approaches
to accelerating the development of expertise/capacity (learn-
ing collaborative) in key areas. Provide public recognition
for those educational environments that have developed
expertise in the ten areas. Encourage a service-delivery fo-
cused organization, such as the American Organization of
Nurse Executives, to lead the identification of topics and the
development and implementation of the recognition.
Conversely, useful evidence produced within the academy does not always
find its way into clinical practice. Numerous sources cite the frequent disconnect
between practice decisions and the evidence that would support them (IOM,
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2001; Melnyk and Fineout-Overholt, 2005). The management of information,
though improved through technology, requires additional resources for use in
the clinical setting.
Recommendation 8: Enlist nursing education (that is, fac-
ulty and students) in clinically based activities supporting
knowledge development and process improvement at the
point of care.
The establishment of the Doctor of Nursing Practice (DNP) has been con-
troversial within nursing (Dracup et al., 2005; Meleis and Dracup, 2005) and
beyond (Landro, 2008). The design and implementation of DNP programs has
varied considerably from Columbia University’s focus on the development of
doctorally prepared advanced practice nurses who can utilize skills and knowl-
edge to independently provide expert nursing care in all care settings (Columbia
University, 2010), to programs like Duke’s that focus on leadership, innovation,
and translation and aim to a prepare nurse leaders for interdisciplinary health care
teams who will work to improve systems of care, patient outcomes, quality and
safety (Duke University, 2010).
Although one can argue that the lack of curricular standardization in these
programs is problematic for the public and the profession, their popularity is
clear. In 2009, the AACN reported that 92 DNP programs were currently enroll-
ing students and another 102 DNP programs were in the planning stages. From
2007 to 2008, DNP program enrollments nearly doubled from 1,874 to 3,415.
During that same period, the number of DNP graduates increased from 122 to
361 (AACN, 2010). Data available from the AACN’s 2009 Enrollment Survey
indicate that enrollments in research-focused doctoral nursing programs have
continued to increase slightly (from 3,439 in 2004 to 3,976 in 2008) while DNP
enrollments increased from 170 to 3,415 during the same interval (Fang and
Bednash, 2009). The obvious conclusion is that the programs are meeting a need.
Anecdotally, our students report they would never have been interested in a PhD;
they want to advance their understanding of how to effect improvements in the
health care environment.
Recommendation 9: Advance the Doctor of Nursing Prac-
tice (DNP) as a vehicle for the preparation of advanced
practice nurses for leadership roles in translation—to in-
clude examination of evidence, innovation, policy revision,
and dissemination.
At Duke we have developed the Duke Translational Nursing Institute (DTNI),
housed within and partially funded by the NIH-supported Clinical and Transla-
tional Science Award (the Duke Translational Medicine Institute). We have hired
experts to facilitate inquiry by staff nurses at the point of care; hired experts to
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APPENDIX I �33
facilitate the evaluation of innovative models of care; and hired experts to study
the barriers and facilitator of dissemination of change. We have begun a small
grants program and hired staff to consult on research design and analysis, and
manuscript development.
Recommendation 10: Promote the creation of research fa-
cilitation structures that promote knowledge development
at the point of care, the testing and evaluation of innovative
models of care, and the study of implementation. Build in-
centives into funding mechanisms that encourage a variety
of forms of similar collaboration. Explicitly promote the
development of and translation of knowledge into nurs-
ing practice and practice improvements through the CTSA
mechanism.
REFORM 3: Commit to the preparation of masters pre-
pared specialists in nursing, and prepare these graduates to
deliver care that is safe, culturally competent, high value/
low cost, and patient-centric.
For over 30 years, the research literature has consistently substantiated the
safety and quality of care delivered by masters-prepared nurses, particularly nurse
midwives and nurse practitioners delivering primary care (Brown and Grimes,
1995). Today 1,400 Certified Nurse Midwives (CNMs), 28,000 Certified Regis-
tered Nurse Anesthetists (CRNAs), 125,000 Nurse Practitioners (NPs), and over
2,300 Clinical Nurse Specialists (CNSs) are providing advanced practice nursing
in the United States. The proposal to move all specialty preparation to the doc-
toral level and use the master’s degree in nursing to prepare generalist by 2015,
as advanced by the American Association of Colleges of Nursing, has not been
based on evidence that this will improve the quality of care delivered.
Further, the probability is high that an extended educational pipeline would
deter qualified nurses from continuing through the doctorate. At a time when the
nursing education community is being called upon to produce more primary care
providers to meet the growing national need for primary care, such a proposal
seems ill timed, if not irresponsible. Justifications that current masters program
curricula are over-credited should not substitute for more careful examination of
how to teach the specialty content in a fewer number of credits.
Finally, current employers of masters prepared nurses have expressed con-
cern that there are no roles/no needs for the masters prepared generalists and they
are unlikely to hire them.
Recommendation 11: Advocate for the continued prepara-
tion of the specialist at the masters level; encourage market
forces, rather than professional societies and educational
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accrediting groups, to drive a change that appears
profession-centric, rather than in the interests of improv-
ing patient care.
Recommendation 12: Challenge the current credit-heavy
requirements in existing masters programs to test inno-
vations in teaching that would improve competence and
reduce program credits. If models of care delivery using
masters prepared nurse generalists are available, conduct
rigorous evaluations of their use and outcomes, including
value, to serve as the basis of proposed changes.
Upon reflection, this list of reforms and specific recommendations does cor-
respond to many of my ongoing responsibilities; however, the opportunity to re-
view the work of others and consider the limits of my own actions has served as a
catalyst to do more next week. The responsibility for the educational and personal
development of the nursing work force has vast and far reaching consequences
for nursing and for health care. Rapid social changes, acceleration in knowledge
development, and the development of new tools for managing information will
not go away. We must change our approach to ensure that it addresses the context
and the goal. We must lead with the future in mind.
REFERENCES
AACN (American Association of Colleges of Nursing). 2010. AACN Fact Sheet: The Doctor of
Nursing Practice. http://www.aacn.nche.edu/Media/FactSheet/dnp.htm, (accessed January 10,
2010).
AHRQ (Agency for Healthcare Research and Quality). 2010. Medical Errors: The Scope of the
Problem. Fact Sheet. Publication No. AHRQ 00-P037. Rockville, MD: AHRQ. http://www.ahrq.
gov/qual/errback.htm. (accessed January 10, 2010).
American Nurses Association. 2003. 2003 Nursing’s Social Policy Statement (2nd ed.). Washington,
DC: American Nurses Publishing.
Benner, P., M. Sutphen, V. Leonard, and L. Day. 2010, Educating Nurses: A Call for Radical Trans-
formation. San Francisco, CA: Jossey-Bass.
Brown, S., and D. Grimes. 1995. A meta-analysis of nurse practitioners and nurse midwives in pri-
mary care. Nursing Research 44(6):332−339.
Columbia University. 2010. Columbia University School of Nursing: Doctor of Nursing Practice.
http://sklad.cumc.columbia.edu/nursing/programs/dnp.php (accessed January 10, 2010).
Cronenwett, L., G. Sherwood, and S. Gelmon. 2009. Improving quality and safety education: The
QSEN learning collaborative. Nursing Outlook 57(6): 304−312.
Dracup, K., L. Cronenwtt, A. Meleis, and P. Benner. 2005. Reflections on the doctorate of nursing
practice. Nursing Outlook 53(1):177−182.
Duke University. 2010. Duke University School of Nursing: Doctor of Nursing Practice. http://nurs-
ing.duke.edu/modules.son_ academic/index.php?id=5 (accessed January 10, 2010).
Fang, D., and G. Bednash. 2009. AACN Enrollment Survey. Washington, DC: AACN.
http://www.nap.edu/12956
The Future of Nursing: Leading Change, Advancing Health
Copyright National Academy of Sciences. All rights reserved.
APPENDIX I �3�
Fang, D., C. Tracy, and G. Bednash. 2009. 2008−2009 Salaries of Instructional and Administra-
tive Nursing Faculty in Baccalaureate and Graduate Programs in Nursing. Washington, DC:
AACN.
Gilliss, C., and M. Fuchs. 2007. Reconnecting nursing education and service: Partnering for success.
Nursing Outlook 55(2):61−62.
Grumbach, K., and T. Bodenheimer. 2004. Can health care teams improve primary care practice?
Journal of the American Medical Association 291:1246−1251.
HRSA (Health Resources and Services Administration). 2010. Nursing Education Loan Repayment
Program. http://bhpr.hrsa.gov/nursing/loanrepay.htm (accessed January 14, 2010).
IOM (Institute of Medicine). 1983. Nursing and Nursing Education: Public Policies and Private
Actions. Washington, DC: National Academy Press.
IOM. 1999. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy
Press.
IOM. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington,
DC: National Academy Press.
Landro, L. 2008. Making room for “Dr. Nurse.” The Wall Street Journal, April 2.
Meleis, A., and K. Dracup. 2005. The case against the DNP: History, timing, substance, and mar-
ginalization. Online Journal of Issues in Nursing 10(3):Manuscript 2. www.nursingworld.
org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/
Volume102005/No3Sept05/tpc28_216026.aspx.
Melnyk, B., and E. Fineout-Overholt. 2005. Evidence-based Practice in Nursing and Health Care.
Philadelphia, PA: Williams and Wilkins.
Salary Wizard. 2010. RN Salaries. http://swz.salary.com/salarywizard (accessed January 13, 2010).
University Leadership Council. 2009. Competing in an Era of Big Bets. Washington, DC: The Ad-
visory Board Company.
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TRANSFORMING PRE-LICENSURE NURSING
EDUCATION: PREPARING THE NEW NURSE TO
MEET EMERGING HEALTH CARE NEEDS
Christine A. Tanner, R.N., Ph.D., FAAN
Oregon Health & Science University School of Nursing
ABSTRACT
Evidence is accumulating that nurses completing pre-licensure programs are not
equipped with the essential knowledge and skills for today’s nursing practice,
nor prepared to continue learning for tomorrow’s nursing. Citing the need to
improve quality and increase capacity, this paper offers three recommendations
for transforming nursing education: (1) Create new nursing education systems
which use existing resources in community colleges and universities and which
provide for common prerequisites and a shared competency-based nursing cur-
riculum and instructional materials. (2) Convene one or more expert panels to
develop model pre-licensure curricula which: (a) can be used as a framework
by faculty in community college-university partnerships for development of
their local curriculum; (b) are based on emerging health care needs and widely
accepted nursing competencies as interpreted for new care delivery models; (c)
incorporate best practices in teaching and learning. (3) Invest in a national initia-
tive to develop and evaluate new approaches to pre-licensure clinical education,
including a required post-graduate residency under a restricted license. The au-
thor notes that these changes will require significant investment in the reforms,
as well as in nursing education research and faculty development. The return on
investment would be improved educational capacity and a better prepared nurs-
ing workforce, responsive to emerging health care needs and rapidly changing
health care delivery systems.
TRANSFORMING PRE-LICENSURE NURSING
EDUCATION: PREPARING THE NEW NURSE TO
MEET EMERGING HEALTH CARE NEEDS
The Carnegie Foundation for the Advancement of Teaching joins a chorus of
calls for transformation of pre-licensure nursing education (Benner et al., 2009b).
Citing the shift of significant responsibility to nurses for managing complex med-
ical regimens, as well as increasing complexity of community based practices,
Benner and colleagues concluded that nurses entering the field are not equipped
with the essential knowledge and skills for today’s practice nor prepared to con-
tinue learning for tomorrow’s nursing (p. 31). They found (1) weak curricula in
natural sciences, technology, social sciences and humanities, and in developing
cultural competency; (2) weak classroom instruction and limited integration
between classroom and clinical experiences; (3) limited strategies in helping
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students develop habits of inquiry, raising clinical questions, seeking evidence
for practices; (4) faculty and student perception that students are ill prepared for
their first job and dissatisfaction with the teaching preparation of current nursing
faculty; (5) and multiple pathways to eligibility for the licensure examination,
with tremendous variability in prerequisites, the curricular requirements, and the
quality of offerings.
The Carnegie study is one of many citing the inadequate preparation of
nurses for today’s practice in complex, acute care environments (Berkow et al.,
2008; Burritt and Steckel, 2009; Joint Commission on Accreditation of Health-
care Organizations, 2002; NCSBN, 2001) There is a growing body of evidence
that confirms registered nurses are indeed essential to patient safety (AHRQ,
2007) and experts warn of further compromise in patient safety and care quality
as experienced nurses retire in droves and the ratio of new graduates to experi-
enced nurses increases (Orsolini-Hain and Malone, 2007) . While 84−88 percent
of new graduates are employed in hospital-based practice for their first position
(Kenward and Zong, 2006; Kovner et al., 2007), increasing numbers of nurses
have migrated to non–acute care settings. Currently only 60 percent of all nurses
practice in hospitals while over 40 percent of nurses practice in non–acute care
settings, such as ambulatory clinics, nursing homes, schools and public health
(HRSA, 2004). As care continues to shift from hospitals to community-based
settings, as the population ages and care management in the community becomes
more complex, and as new health care needs emerge, a new kind of nurse will be
needed. Educational programs must be redesigned to better prepare this nurse.
In addition to these quality issues, educational capacity issues must also be
addressed. The projected shortage of nurses is well documented (Buerhaus et
al., 2009) and academic institutions have done a remarkable job of increasing
enrollments (AACN, 2010; NLN, 2009a) but without further action, the supply
of new nurses will fall well short of the demand as a result of serious limitations
in educational capacity. In the 2006–2007 year, over 40 percent of qualified ap-
plicants for pre-licensure programs did not gain admission (NLN, 2008) and in
2008−2009, approximately 40,000 qualified applicants were turned away from
nursing programs (Kovner and Djukic, 2009). Principal causes for limitations in
educational capacity: shortage of qualified faculty, insufficient number, quality
and type of sites for clinical education and budgetary constraints (AACN, 2010;
NLN, 2006, 2009a, 2009b).
In this paper, I offer three recommendations related to transformation of
pre-licensure education which address the quality and capacity issues and which
provide for the possibility of leveraging existing resources in order to make
critical changes. I will use models currently being tested in Oregon, the Oregon
Consortium for Nursing Education (Gubrud-Howe et al., 2003; Tanner et al.,
2008), as well as in Hawaii and regions of California as an exemplar of some of
these recommendations.
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Recommendation 1: Create new nursing education systems
which use existing resources in community colleges and
universities and which provide for common prerequisites, a
competency-based nursing curriculum and shared instruc-
tional resources.
Rationale
Entry into practice at the bachelors level, as recommended in the Carnegie
report, has been on the profession’s agenda since 1965. Few would argue against
the notion that more education is better, and there is growing evidence that the
level of education is strongly correlated with patient outcomes (Aiken et al., 2003,
2008; Estabrooks et al., 2005; Torangeau et al., 2007). Yet community colleges
are a vital resource to meet educational capacity requirements. The roughly 1,000
community college nursing programs (NLN, 2009a) provide access to education
in rural and underserved communities, educating approximately 60 percent of all
new graduates each year (HRSA, 2004). The nearly 700 baccalaureate programs
prepare approximately 31 percent of new graduates each year (AACN, 2010;
HRSA, 2004). There are nearly 600 baccalaureate completion programs, many of
which boast articulation agreements that smooth the transition from associate de-
gree to the bachelors, yet only 20.6 percent of associate degree graduates continue
for the bachelors’ degree (HRSA, 2004). The net effect of a disproportionately
small pool of bachelors’ degree graduates is simply fewer nurses who are eligible
and likely to continue for the advanced education necessary to become faculty
(Aiken et al., 2009).
One approach to capitalizing on community college nursing program re-
sources to increase the number of baccalaureate graduates is to allow community
colleges to offer the bachelors’ degree. Sixteen states have changed regulations
to allow community colleges to offer baccalaureate degrees, and several have
launched bachelors in nursing programs (Community College Baccalaureate
Association, 2008).
The current patchwork of educational programs is inefficient. Community
college “two-year programs,” typically take 3 or more years to complete. Pre-
requisites vary widely across programs; students who may meet the course re-
quirements for admission to one school’s program do not meet those of another
school. Nursing curricula, while containing similar content and meeting similar
accreditation standards, are also quite variable in terms of sequence and credit
hour allocation; program faculty varying in number from as few as 4 or 5 faculty
in smaller programs to well over 50 each invest considerable time and resources
in developing and maintaining their own program’s curriculum and instructional
resources. The variation in curricula creates additional challenges in clinical
education: staff nurses who frequently provide supervision for students from
multiple programs, at varying levels, and differing instructional goals, may end
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APPENDIX I �3�
up very unclear about what students might be safely expected to do (MacIntyre
et al., 2009).
Exemplar
One model for addressing these inefficiencies and for improving access to
baccalaureate education is a partnership between community college and uni-
versity programs. The Oregon Consortium for Nursing Education (OCNE) was
designed to increase capacity for baccalaureate education by making best use of
scarce faculty, classrooms, and clinical education resources (Gubrud-Howe et
al., 2003; Tanner et al., 2008) Eight community colleges and the five campuses
of the public university school of nursing developed and implemented a shared,
competency-based curriculum that culminates in a bachelors degree. What sets
this model apart from traditional articulation agreements is that the curriculum
is standard across all partner campuses: nursing faculty from full partner schools
developed and approved a common curriculum plan (including competencies,
benchmarks, course titles, descriptions, credit hour allocation and outcomes) as
well as academic standards for student admission and progression. The potential
for increasing faculty capacity and productivity is beginning to be realized, as
faculty from one campus can fill in and teach a course on another campus, and
as instructional materials (such as examinations, case studies, scenarios for simu-
lations) are developed and made accessible to all faculty through a web-based
searchable database linked to the curriculum.
OCNE admitted its first class of students in fall of 2006, and is engaged in a
Robert Wood Johnson Foundation (RWJF)–funded evaluation study of outcomes,
including student performance measures and degree completion. Early results
are encouraging, as roughly 40 percent of graduates from community college
partner schools have enrolled in the courses required for baccalaureate comple-
tion (Tanner et al., 2008). Needs for program improvements are being identified,
including improved advisement and services for students transitioning from com-
munity college to the university, development and implementation of statewide
interprofessional educational experiences, and provision for ongoing faculty
development. Similar statewide or regional university–college partnerships are
being planned in at least five other states with the Hawaii statewide consortium
positioned to implement in fall 2010.
Recommendation 2: Convene one or more expert panels to
develop a model pre-licensure curriculum which: (1) can
be used as a framework by faculty in community college–
university partnerships for development of their local cur-
riculum; (2) is based on emerging health care needs and
widely accepted nursing competencies as interpreted for
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new care delivery models; (3) incorporates best practices in
teaching and learning.
Rationale
Demands for a new kind of nurse have been abundant for the last two decades,
fueled, in part, by vast changes in the nursing practice environment, including a
tremendous increase in the complexity and acuity of patient care in the hospital
setting, decreased lengths of stay and the shift of care and recovery to the home
and community, explosion of new technologies, exponential growth of informa-
tion and knowledge, clear identification of the “quality chasm” (IOM, 2001) and
the recognition of the significance of nursing in patient safety (IOM, 2003). New
competencies have been promulgated to address the quality chasm and patient
safety goals (IOM, 2003; Cronenwett et al., 2007), geriatric care (AACN, 1998),
clinical prevention, and population-based care (Allan et al., 2005) among many
other areas and incorporated into requirements for accreditation (CCNE, 2009;
National League for Nursing Accreditating Commission, 2008).
Demographic changes alone demand different a different focus in pre-
licensure programs. The number of older adults in the United States will almost
double between 2005 and 2030, presenting multiple challenges for the health
care system (He et al., 2005). The majority of older adults suffer from at least
one chronic health condition. The fastest growing segment growing segment of
the population is the “over 85” age group, and it is estimated that a minimum
of 50 percent of this group will require help with activities of daily living (He
et al., 2005; IOM, 2008). Direct care workers are the primary providers of paid
hands-on care to older adults, and together with families, provide the majority of
care for adults in community based care settings. Registered nurses in commu-
nity-based settings have responsibility for guiding, teaching and/or supervising
these caregivers, yet have little training or experience in how to work effectively
with them.
While the amount of geriatric/gerontologic content and experiences in pre-
licensure programs has increased in the last decade, it is still uneven, and effective
teaching is hampered by lack of faculty expertise (Berman et al., 2005; Gilje et
al., 2007; Ironside et al., 2010). Most curricula are organized around traditional
nursing specialties (e.g., maternal–child, pediatrics, medical–surgical, or some
slight variation in name such as adult-health) and clinical experiences are largely
centered in acute care settings (McNelis and Ironside, 2009). Clinical educa-
tion which focuses geriatrics occurs principally in nursing homes (with some
noteworthy exceptions), and often in the first year of the nursing program when
students may fail to appreciate the complexities of providing care to older adults
(Ironside et al., 2010). Although interprofessional geriatrics education has been
promoted (AACN, 1998) and geriatrics competencies (AACN, 1998) are similar
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APPENDIX I �41
across disciplines (Mezey et al., 2008), most health profession education contin-
ues to occur in silos (Barnsteiner et al., 2007).
Curricular changes over the last decade have tended to be additive, rather
than transformative, i.e., adding content or circumscribed courses as new com-
petencies appear in the literature (Ironside, 2004; NLN, 2003). The majority of
nurse educators first learned to be nurses in content-laden, highly structured cur-
ricula, and few have received advanced formal preparation in curriculum develop-
ment, instructional design, or performance assessment. Faculty, tending to teach
as they were taught, focus on covering content (Duchscher, 2003), a practice
reflected more recently in the Carnegie study; they see curriculum mandates as a
barrier to creating engaging, student-centered learning environments within their
schools (Schaefer and Zygmont, 2003).
O’Neil (2009) makes a compelling argument for a major overhaul of nursing
curricula. He suggests that traditional nursing competencies such as care man-
agement, patient education, public health intervention, and transitional care will
dominate in a reformed health care system, as it inevitably moves toward em-
phasis on prevention and management over acute care. But he points out that
“. . . these traditional competencies must be reinterpreted for students into the
settings of the emergent care system, not the one that is being left behind. This
will require faculty to not only teach to these competencies but also creatively
apply them to health environments that are only now emerging” (p. 318). It is
critical that we revisit possible and optimal expectations for entry level nurses,
based on population needs and likely changes in care delivery models, then align
pre-licensure and residency programs accordingly. Revamping curricula col-
laboratively with other health professions schools (Mezey et al., 2008) provides
opportunity for meaningful interprofessional collaboration.
Advances in the science of learning also support curriculum overhaul. While
nursing education research is sparse, a growing body of research on learning from
a variety of other fields supports the need for active engagement of the learner,
and a focus on deep learning of the discipline’s most central concepts (Bransford
et al., 2000; Weimer, 2002). As pointed out in the Carnegie study, the typically
content-laden nursing curriculum results in superficial coverage of content, a
failure to engage students in rehearsing for clinical practice by grappling with
real-life clinical situations, and a failure to integrate across knowledge, clinical
reasoning, skilled know-how and ethical comportment. Faculty complain about
the demand to cover content, fearing that students will not pass their licensure
examination (Schaefer and Zygmont, 2003) and, as the Carnegie study suggests,
faculty need guidance in what is essential content in the curriculum, as well as
how to teach it in a way that engages students. Bain (2004), from his study of
expert teachers describes this practice:
Teachers in our study . . . believe that students must learn facts while learning to
use them to make decisions about what they understand or what they should do.
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To them, “learning” makes little sense unless it has some sustained influence on
the way the learner subsequently thinks, acts, or feels. So they teach the “facts”
in a rich context of problems, issues and questions. (p. 29)
The integrative teaching described in the Carnegie study is in stark contrast
to the belief and related practices that “students cannot learn to think, to analyze,
to synthesize, and to make judgments until they ‘know’ the basic facts” (Bain,
2004, p. 29).
A recent example illustrates ways in which content can be reduced in order
to provide for pedagogies of integration and engagement. In separate studies,
Giddens (2007) and Secrest, Norwood, and Dumont (2005) showed that only one
fourth to one third of approximately 120 health assessment techniques typically
taught in the standard health assessment course are used routinely by nurses in
practice across settings. They suggest that this content could be significantly
reduced, teaching fewer techniques well, and adding others only as they relate to
specific situations and can be taught in the context of clinical judgment. Changes
like this could result in a significant reduction of content, overall, providing op-
portunity for the integrative teaching and learning that is so aptly illustrated in
the Carnegie study.
The content-laden curriculum, and resulting ineffective teaching practices,
is a long-standing problem which is likely to be exacerbated as practices change,
and new competencies are mandated. It is a problem which is unlikely to be suc-
cessfully resolved by the individual faculty in the over 1,700 nursing programs
across the county. Guidance from an expert panel, proposing curriculum models
which meet the growing list of competencies, with processes for rapid cycle
changes in curriculum content, will be necessary to lead essential changes in
pre-licensure curricula.
Exemplar
The curriculum developed and implemented by OCNE partners is based
on assumptions such as these above. Faculty assumed that their students would
practice in an environment vastly different from the current one, one in which
there would be fewer RNs; by equipping RNs with expanded skills related to
delegation, coordinating care, community-based and population-based practice,
use of data to affect outcomes and collaborative team management, better use can
be made of RNs’ full scope of practice, skills, and expertise. In this curriculum,
fundamentals of nursing have been redefined as evidence-based practice, cultur-
ally sensitive and relationship-centered care, leadership and clinical judgment,
with these concepts and others introduced early in the context of health promo-
tion and spiraled throughout the curriculum. Through a 2-year faculty develop-
ment program, faculty leaders in the OCNE partner programs applied advances
in the science of learning by intentionally reducing content, to focus principally
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APPENDIX I �43
on the most prevalent health problems and practices. Instructional approaches
have been dramatically altered toward case-based instruction, integrating simu-
lation, drawing on best practices in the development of these approaches. In
this competency-based program, the faculty role is shifting from the delivery of
content to the development of learning activities that will lead students to com-
petent performance. The RWJF study of the OCNE program includes measures
of classroom teaching fidelity which allow for study of teaching practices linked
with learning outcomes.
Recommendation 3. Invest in a national initiative to de-
velop and evaluate new approaches to pre-licensure clinical
education, including a required post-graduate residency
under a restricted license.
Rationale
Pre-licensure clinical education has remained essentially unchanged for at
least 40 years (Tanner, 2006). As a derivation of hospital-based apprenticeships,
students are placed in clinical settings, mostly acute care, and assigned to pro-
vide care for one or more patients. They learn through providing care to these
patients, while being supervised by clinical faculty, with varying degrees of
support by staff nurses employed by the clinical agency (McNelis and Ironside,
2009; Chappy and Stewart, 2004). Because the experience is organized around
individual patients, students may be rarely engaged with the full scope of nurs-
ing decision making, including linking patient outcomes with larger systems
issues (MacIntyre et al., 2009) or population-based care management. The na-
ture and quality of students’ clinical experience is highly dependent on events
that occur during the time of placement, leaving to chance such experiences as
interdisciplinary teamwork, managing crisis situations, and working with fami-
lies in the provision of care (Gubrud-Howe and Schoessler, 2008). Because the
focus of learning is necessarily on acute care, there is little practical experience
in strategies for management of chronic conditions, health behavior change, or
coordinating care across settings. There is scant empirical literature supporting
the traditional model of clinical education; indeed, the evidence that graduates
feel unprepared for practice (Benner et al., 2009b) and that first-line managers are
dissatisfied with the level of preparation suggest that the model is not effective
(Berkow et al., 2008).
Importantly, the pervasive use of this approach as the primary clinical educa-
tion model results in limited capacity; the number clinical sites is cited as a major
barrier to enrollment expansions (AACN, 2009) and effective clinical teaching
(McNelis and Ironside, 2009).While the use of high-fidelity simulation has been
proposed as a solution to these limitations in capacity, and early studies about its
effectiveness are promising (Harder, 2010), there is little evidence that it expands
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faculty capacity, and little guidance about what portion of clinical experience can
be replaced with simulation.
The required number of clinical hours varies widely from one program to
another, and most state boards of nursing do not specify a minimum number of
clinical hours in pre-licensure programs (NCSBN, 2008). It is likely that many
of the clinical hours do not result in productive learning. Students spend much of
their clinical time doing routine care tasks repeatedly, which may not contribute
significantly to new learning. Faculty report spending most of their time super-
vising students in hands-on procedures leaving little time focused on fostering
development of clinical reasoning skills (McNelis and Ironside, 2009).
There have been some advances in clinical education, resting on strong
academic–service partnerships. Preceptorships are widely used, and a recent
integrative review suggests that they are at least as effective as traditional ap-
proaches (Udlis, 2006), while conserving scarce faculty resources. The Dedicated
Education Unit (DEU) is receiving increasing attention as a viable alternative for
expanding clinical education capacity (Moscato et al., 2007). In this model, units
are dedicated to instruction of students from one program. Staff nurses who want
to teach as clinical instructors are prepared for this role, and faculty expertise is
used to support the development and comfort of the staff nurse as clinical teacher.
Early results suggest the DEU can dramatically increase capacity and have a
positive effect on student and nursing staff satisfaction; a multisite study funded
by the RWJF is currently under way to evaluate outcomes of the DEU model. A
variety of other clinical partnerships have been designed to increase capacity in
the face of a nursing faculty shortage (Baxter, 2007; DeLunas and Rooda, 2009;
Kowalski et al., 2007; Kreulen et al., 2008; Kruger et al., 2010).
There is an expanding body of evidence supporting the cost-effectiveness
of postgraduate residencies. In 2002, the Joint Commission on Accreditation
of Healthcare Organizations recommended the development of nurse-residency
programs, a recommendation most recently endorsed by the Carnegie study.
Successful programs have been launched by Versant (Beecroft et al., 2001, 2004,
2006); the AACN and University Health System Consortium developed a model
for post-baccalaureate nurse residencies (Goode and Williams, 2004; Krugman et
al., 2006; Williams et al., 2007, and AACN recently adopted accreditation stan-
dards for these programs [CCNE, 2009]) The National Council of State Boards
of Nursing has developed a regulatory model for transition to practice programs,
recommending that state boards of nursing enforce a transition program through
licensure (NCSBN, 2008, 2009).
Residency programs are predominantly supported in hospitals and larger
health systems, with a focus on acute care. Indeed, this has been the area of great-
est need as most new graduates gain employment in acute care settings (Kovner et
al., 2007) and the proportion of new hires (and nursing staff) that are new gradu-
ates is rapidly increasing. It is clear that even the best nursing programs cannot
adequately prepare new graduates to work in the current acute care environment
(Goode et al., 2009).
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APPENDIX I �4�
It is essential that programs outside of acute care settings be developed and
evaluated. Given the demographic changes on the horizon, the shift of care from
hospital to community-based settings, the need for nursing expertise in chronic
illness management, care of the older adults in home settings, and in transitional
services, nurses need to be prepared for new roles outside of the acute care set-
ting. It follows that new types of residency programs appropriate for these types
of roles need to be developed and become part of the regulatory framework.
In sum, in order to increase educational capacity, improve educational out-
comes, and better prepare graduates for the seismic shifts likely to occur in
practice, there is an urgent need to develop and test new pre-licensure clinical
education models including postgraduate residencies.
Exemplar
One model is currently being implemented and evaluated by OCNE pro-
grams, funded by the Department of Education, Fund for Improvement of Post-
secondary Education (Gubrud-Howe and Schoessler, 2009), which includes some
of the following desired features (Tanner, 2006):
• Focus on learning outcomes, rather than on placements and completion
of clock hours, considering essential competencies such as the devel-
opment of clinical judgment, ethical comportment, interprofessional
teamwork, technical proficiency and new competencies required in con-
temporary professional practice.
• Contain a variety of learning activities, designed to achieve specific
learning outcomes, and taking into account the level of the student, the
acuity of the patient, the complexity of the desired learning, and the skill
of the faculty.
• Incorporate research on learning and best practices identified by the
Carnegie study pointing to (1) the type of preparation the student would
do in anticipation of the clinical learning; (2) the interaction between
faculty and student to support learning (e.g., questioning, guiding); (3)
the type of debriefing used to help the student learn the major lessons of
the activity; (4) approaches to assessing student learning; and (5) guid-
ance provided to the student for reflecting on the activity.
• Include integrative or immersion experiences which recognize and in-
corporate the growing body of literature about apprenticeships and situ-
ated learning (e.g., Lave and Wenger, 1991) deliberate practice (e.g.,
Ericsson, 2004), development of expertise in practice (Benner et al.,
2009a), preceptorships, and academic–service partnerships.
• Integrate simulation as a complement to “hands-on” clinical experience
using best available evidence to plan scenarios and incorporate into the
clinical education curriculum (Harder, 2010).
• Recognize the need to vary the student-to-faculty ratio and time on task,
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depending on the nature of the learning activity, the level of the student
and the patient population.
• Support clinical nursing staff in clinical instruction, without overtaxing
clinical resources, and at a level appropriate for the level of the student
and the patient population.
SUMMARY
Implicit in these recommendations is the need for significant investment in
nursing education research and in faculty development. While there is obvious
need for research in nursing pedagogies, there is also a critical need for evaluation
of the multiple pathways to nursing licensure. For example, fast-track curricula
for students with second degrees have increased exponentially in the last 5 years,
with very little evidence of their effectiveness, and virtually no study of curricular
structures and instructional methods appropriate for this population of students
(Cangelosi and Whitt, 2005). Yonge and colleagues (2005) reviewing nursing
education research spanning 1991−2000 found that 80 percent had no identified
funding source. Broome (2009) in calling for investment in the science of nursing
education, points to the link between quality of research and funding. It seems
implausible that the replacement of half of the nursing workforce during the next
decade can be effectively addressed without building a stronger scientific basis
for nursing education. Similarly, faculty development is critical in order to bring
about the magnitude of change recommended here and in the Carnegie study.
Taken together, these recommendations echo those of the Carnegie Founda-
tion study, calling for transformation of pre-licensure education. It will require
partnership across all levels of nursing education and health systems, redirecting
Medicare funding from hospital based pre-licensure programs to postgraduate
residency and advanced practice programs, expanding Title VIII funding, and
other federal resources for support of educational reform. The return on invest-
ment would be improved educational capacity and a better prepared nursing
workforce, responsive to emerging health care needs and rapidly changing health
care delivery systems.
REFERENCES
AACN (American Association of Colleges of Nursing). (1998). Older adults: Recommended bacca-
laureate competencies and curricular guidelines for geriatric nursing care. Washington, DC:
Author.
AACN. (2009). Student enrollment expands at U.S. nursing colleges and universities for the 9th year
despite financial challenges and capacity restraints American Association of Colleges of Nurs-
ing. Retrieved from http://www.aacn.nche.edu/Media/NewsReleases/2009/StudentEnrollment.
html.
AACN. (2010). Nursing shortage fact sheet (Fact Sheet. American Association of Colleges of Nursing:
Retrieved from http://www.aacn.nche.edu/Media/pdf/NrsgShortageFS .
http://www.nap.edu/12956
The Future of Nursing: Leading Change, Advancing Health
Copyright National Academy of Sciences. All rights reserved.
APPENDIX I �4�
AHRQ (Agency for Health Care Research and Quality). (2007). Nursing staffing and quality of
patient care. (Evidence Report/Technology Assessment Number 151) Retrieved from http://
www.ahrq.
Aiken, L. H., Clarke, S. P., Cheung, R. B., Sloane, D. M., and Silber, J. H. (2003). Educational levels
of hospital nurses and surgical patient mortality. Journal of the American Medical Association,
290, 1617.
Aiken, L. H., Clarke, S. P., Sloane, D. M., Lake, E. T., and Cheney, T. (2008). Effects of hospital
care environment on patient mortality and nurse outcomes. Journal of Nursing Administration,
38(5), 223.
Allan, J. D., Stanley, J., Crabtree, M. K., Werner, K. E., and Swenson, M. (2005). Clinical prevention
and population health curriculum framework: The nursing perspective. Journal of Professional
Nursing, 21(5), 259-267.
Bain, K. (2004). What the best college teachers do. Cambridge, MA: Harvard University Press.
Barnsteiner, J. H., Disch, J. M., Hall, L., Mayer, D., and Moore, S. M. (2007). Promoting interprofes-
sional education. Nursing Outlook, 55(3), 144. doi:10.1016/j.outlook.2007.03.003.
Baxter, P. (2007). The CCARE model of clinical supervision: Bridging the theory-practice gap. Nurse
Education in Practice, 7, 103-11.
Beecroft, P. C., Kunzman, L., and Krozek, C. (2001). RN internship: Outcomes of a one-year pilot
program. Journal of Nursing Administration, 31(12), 575-582.
Beecroft, P. C., Kunzman, L., Taylor, S., Devenis, E., and Guzek, F. (2004). Bridging the gap be-
tween school and workplace: Developing a new graduate nurse curriculum. Journal of Nursing
Administration, 34(7/8), 338-345.
Beecroft, P. C., Santner, S., Lacy, M. L., Kunzman, L., and Dorey, F. (2006). New graduate nurses’
perspective of mentoring: Six-year programme evaluation. Journal of Advanced Nursing, 55(6),
736-747.
Benner, P., Tanner, C., and Chesla, C. (2009a) Expertise in Nursing Practice: Caring, Clinical Judg-
ment & Ethics. New York: Springer.
Benner, P., Sutphen, M., Leonard, V., and Day, L. (2009b). Educating nurses: A call for radical trans-
formation. San Francisco: Jossey-Bass.
Berkow, S., Virkstis, K. S. J., and Conway, L. (2008). Assessing new graduate nurse performance.
Journal of Nursing Administration, 38(11), 468.
Berman, A., Mezey, M., Kobayashi, M., Fulmer, T., Stanley, J., Thornlow, D., and Rosenfeld, P.
(2005). Gerontological nursing content in baccalaureate nursing programs: Comparison of find-
ings from 1997 and 2003. Journal of Professional Nursing, 21(5), 268.
Bransford, J.D., Brown, A.L., and Cocking, R.R. (Eds) (2000). How people learn: Brain, mind, experi-
ence and school (Expanded edition). Washington, DC: National Academies Press.
Broome, M.E. (2009). Building the science for nursing education: vision or improbable dream. Nurs-
ing Outlook 57(4), 177-9
Buerhaus, P. I., Auerbach, D. I., and and Staiger, D. O. (2009). The recent surge in nurse employment:
Causes and implications. Health Affairs, 28(4), W657. Retrieved from published online 12 June
2009; 101377hlthaff.28.4.657.
Burritt, J., and Steckel, C. (2009). Supporting the learning curve for contemporary nursing practice.
Journal of Nursing Administration, 39(479).
Cangelosi, P. R., and Whitt, K. J. (2005). Accelerated nursing programs: What do we know? Nursing
Education Perspectives, 26(2), 113-116.
CCNE (Commission on Collegiate Nursing Education). (2009). Standards for accreditation of post-
baccalaureate nurse residency programs. Retrieved from www.aacn.nche.edu/accreditation/pdf/
resstandards08
Chappy, S.L.. and Stewart, S. (2004). Curricular practices in baccalaureate nursing education: Results
of a National Survey. Journal of Professional Nursing, 20, 369-373.
http://www.nap.edu/12956
The Future of Nursing: Leading Change, Advancing Health
Copyright National Academy of Sciences. All rights reserved.
�4� THE FUTURE OF NURSING
Community College Baccalaureate Association (2008). Baccalaureate conferring locations. Retrieved
from http://www.accbd.org/colleges_areas.php.
Cronenwett, L., Sherwood, G., Barnsteiner, J., Disch, J., Johnson, J., and Mitchell, P. (2007). Quality
and safety education for nurses. Nursing Outlook, 55(3), 122.
DeLunas, L. R., and Rooda, L. A. (2009). A new model for the clinical instruction of undergraduate
nursing students. Nursing Education Perspectives, 30(6), 377-380.
Duchscher, J. E. B. (2003). Critical thinking: Perceptions of newly graduated female baccalaureate
nurses. Journal of Nursing Education, 42, 14-27.
Ericsson, K. A. (2004). Deliberative practice and the acquisition and maintenance of expert perfor-
mance in medicine and related domains. Academic Medicine, 79(10 Suppl.) S70-S81.
Estabrooks, C. A., Midodzi, W. K., Cummings, G. C., Ricker, K. L., and Giovanetti, P. (2005). The
impact of hospital nursing characteristics on 30-day mortality. Nursing Research, 54(2), 72.
Giddens, J. F. (2007). A survey of physical assessment techniques performed by RNs: Lessons for
nursing education. Journal of Nursing Education, 46, 83-87
Gilje, F., Lacey, L. and Moore, C. (2007). Gerontology and geriatric issues and trends in US nursing
programs: A national survey. Journal of Professional Nursing, 23(1), 22.
Goode, C. J., Lynn, M. R., Krsek, C., and Bednash, G. D. (2009). Nurse residency programs: An
essential requirement for nursing. Nursing Economics, 27(3), 142-159.
Goode, C. J., and Williams, C. J. (2004). Post-baccalaureate nurse residency program. Journal of
Nursing Administration, 34(2), 71-77.
Gubrud, P., and Schoessler, M. (2009). OCNE clinical education model. In N. Ard and T. M. Valiga
(Eds.), Clinical nursing education: Current reflections (pp. 39). New York: National League
for Nursing.
Gubrud-Howe, P., and Schoessler, M. (2008). From random access opportunity to a clinical education
curriculum. Journal of Nursing Education, 47, 3-4.
Gubrud-Howe, P., Shaver, K. S., Tanner, C. A., Bennett-Stillmaker, J., Davidson, S. B., Flaherty-Robb,
M., Goudreau, K., Hardham, L., Hayden, C., Hendy, S., Omel, S., Potempa, K., Shores, L.,
Theis, S., and Wheeler, P. (2003). A challenge to meet the future: Nursing education in Oregon,
2010. Journal of Nursing Education, 42(4), 163-167.
Harder, B. N. (2010). Use of simulation in teaching and learning in health sciences: A systematic
review. Journal of Nursing Education, 49(1), 23-28, doi:10.3928/01484834-20090828-08.
He, W., Sengupta, M., Velkoff, V., and DeBarros, K. (2005). 65+ in the United States: 2005: Wash-
ington, DC: US Census Bureau.
HRSA (Health Resources and Services Administration). (2004). The Registered Nurse Popula-
tion: Findings from the 2004 National Sample Survey of Registered Nurses. http://bhpr.hrsa.
gov/health-workforce/rnsurvey04.
IOM (Institute of Medicine). (2001). Crossing the Quality Chasm: A new health system for the 21st
century. http://www.nap.edu/openbook.php?record_id=10027.
IOM. (2003). Health Professions Education: A Bridge to Quality. http://www.nap.edu/openbook.
php?isbn=0309087236.
IOM. (2008). Retooling for an aging America: Building the health care workforce. http://www.
iom.edu/Reports/2008/Retooling-for-an-Aging-America-Building-the-Health-Care-Workforce.
aspx.
Ironside, P. (2004). “Covering” content and thinking skills: Deconstructing the additive curriculum.
Journal of Nursing Education, 43, 5-12.
Ironside, P., Tagliareni, M. E., McLaughlin, B., King, E., & Mengel, A. (2010). Fostering geriatrics in
associate degree nursing education: An assessment of current curricula and clinical experiences.
Journal of Nursing Education, 49(5), 246-252.
Joint Commission on Accreditation of Healthcare Organizations. (January 2002). Health care at the
crossroads: Strategies for addressing the evolving nursing crisis. Joint Commission of Accredita-
tion of Healthcare Organizations.
http://www.nap.edu/12956
The Future of Nursing: Leading Change, Advancing Health
Copyright National Academy of Sciences. All rights reserved.
APPENDIX I �4�
Kenward, K., and Zhong, E. H. (April 2006). Transition to practice: Newly licensed registered nurse
and licensed practical/vocational nurse activities No. 22) National Council for State Boards of
Nursing. Retrieved from https://www.ncsbn.org/Vol_22_web .
Kovner, C. T., and Djukic, M. (2009). The nursing career process from application through
the first 2 years of employment. Journal of Professional Nursing, 25(4), 197-203.
doi:10.1016/j.profnurs.2009.05.002.
Kovner, C. T., Brewer, C. S., Fairchild, S., Poornima, S., Kim, H., and Djukic, M. (2007). Newly
licensed RNs’ characteristics, work attitudes, and intentions to work. American Journal of
Nursing, 107(9), 58-70.
Kowalski, K., Horner, M., Carroll, K. Center, D., Foss, K. and Jarrett, S. (2007). Nursing clinical
faculty revisited: The benefits of developing staff nurses as clinical scholars. Journal of Continu-
ing Education in Nursing, 38, 69-75.
Kreulen, G. J., Bednarz, P. K., Wehrwein, T., and Davis, J. (2008). Clinical education partnership: A
model for school district and college of nursing collaboration. The Journal of School Nursing:
The Official Publication of the National Association of School Nurses, 24(6), 360-369.
Kruger, B. J., Roush, C., Olinzock, B. J., and Bloom, K. (2010). Engaging nursing students in long-
term relationships with a home-base community. Journal of Nursing Education, 49(1), 10-16.
Krugman, M., Bretschneider, J., Horn, P., Krsek, C., Moutafis, R., and Smith, M. (2006). The national
post-baccalaureate graduate nurse residency program: A model for excellence in transition to
practice. Journal for Nurses in Staff Development, 22(4), 196-205.
Lave, J., & Wenger, E. (1991). Situated learning: Legitimate peripheral participation. Cambridge,
UK: Cambridge University Press
MacIntyre, R. C., Murray, T. A., Teel, C. S., and Karshmer, J. F. (2009). Five recommendations
for prelicensure clinical nursing education. Journal of Nursing Education, 48(8), 447-453.
doi:10.3928/01484834-20090717-03.
McNelis, A. M., and Ironside, P. M. (2009). National survey on clinical education in prelicensure
nursing education programs. In N. Ard, and T. M. Valiga (Eds.), Clinical nursing education:
Current reflections (pp. 25). New York: National League for Nursing.
Mezey, M., Mitty, E., Burger, S.G., and McCallion, P. (2008). Health Professional Training: A Com-
parison of Geriatric Competencies. Journal of the American Geriatrics Society, 56 (9), 1724-
1729, doi: 10.1111/j.1532-5415.2008.01857.x.
Moscato, S. R., Miller, J., Logsdon, K., Weinberg, S., and Chorpenning, L. (2007). Dedicated edu-
cation unit: An innovative clinical partner education model. Nursing Outlook, 55(1), 31-37.
doi:10.1016/j.outlook.2006.11.001.
National League for Nursing Accrediting Commission. (2008). NLNAC accreditation manual. Re-
trieved from www.nlnac.org/manuals/Manual2008.htm.
NCSBN (National Council of State Boards of Nursing). (2001). Report of findings from the 2001
Employers Survey (Research Brief, Vo. 3), Chicago: Author.
NCSBN. (2008). Regulatory model for transition to practice report National Council of State Boards
of Nursing. Retrieved from https://www.ncsbn.org/Final_08_reg_model .
NCSBN. (2009). Model nursing practice act and model nursing administrative rules National Council
of State Boards of Nursing. Retrieved from https://www.ncsbn.org/312.htm.
NLN (National League for Nursing). (2003). Innovation in nursing education: A call to reform. Re-
trieved from http://www.nln.org/aboutnln/PositionStatements/innovation082203 .
NLN. (2006). Nurse faculty supply continues to falls short National League for Nursing. Retrieved
from http://doh.sd.gov/Boards/Nursing/PDF/NLNNewsAug2006 .
NLN. (2008): Reflection and dialogue: Annual nursing data review documenting application, admis-
sion, enrollment, and graduation rates for 2005-2006. National League for Nursing. Retrieved
from http://www.nln.org/newsreleases/data_release_03032008.htm.
http://www.nap.edu/12956
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Copyright National Academy of Sciences. All rights reserved.
��0 THE FUTURE OF NURSING
NLN. (2009a). Reflection and dialogue: National league for nursing annual nursing data review docu-
ments, application, admission, enrollment, and graduation rates for all types of prelicensure
nursing programs National League for Nursing.
NLN. (2009b). Dialogue and reflection: NLN survey on clinical education points to barriers to ef-
fective clinical education in pre-licensure nursing programs and need for continued research
Retrieved from http://www.nln.org/newsreleases/surveyofclined_082809.htm.
O’Neil, E. (2009). Four factors that guarantee health care change. Journal of Professional Nursing,
25(6), 317-321.
Orsolini-Hain, L., and Malone, R. E. (2007). Examining the gap in clinical nursing expertise. Policy,
Politics and Nursing Practice, 8(3), 158.
Schaefer, K.M., and Zygmont, D. (2003). Analyzing the teaching style of nursing faculty: Does
it promote a student-centered or teacher-centered learning environment? Nursing Education
Perspectives, 24, 238-245.
Secrest, J. A., Norwood, B. R., & Dumont, P. M. (2005). Physical assessment skills: A descrip-
tive study of what is taught and what is practiced. Journal of Professional Nursing, 21(2),
114-118.
Tanner, C. A. (2006). The next transformation: Clinical education. Journal of Nursing Education,
45(4), 99-100.
Tanner, C. A., Gubrud-Howe, P., and Shores, L. (2008). The Oregon consortium for nursing educa-
tion: A response to the nursing shortage. Policy, Politics & Nursing Practice, 9(3), 203-209,
doi:10.1177/1527154408323043.
Torangeau, A. E., Doran, D. M., McGillis-Hall, L., O’Brien-Pallas, L., Dringle, D., Tu, J. F., and
Cranley, L. A. (2007). Impact of hospital nursing care on 30-day mortality for acute medical
patients. Journal of Advanced Nursing, 57(1), 32.
Udlis, K. A. (2006). Preceptorship in undergraduate nursing education: An intergrative review. Journal
of Nursing Education, 47(1), 20-29.
Weimer, M. (2002). Learner-centered teaching: Five key changes to practice. San Francisco:
Jossey-Bass.
Williams, C.A., Goode, C. J., Krsek, C., Bednash, G. D., & Lynn, M. R. (2007). Post-baccalaureate
nurse residency 1-year outcomes. Journal of Nursing Administration, 37(7-8), 357-365.
Yonge, O. J., Anderson, M., Profetto-McGrath, J., Olson, J. K., Skillen, D. L., Boman, J., Ranson
Ratusz, A., Anderson, A., Slater, L., and Day, R. (2005). An inventory of nursing education
research. International Journal of Nursing Education Scholarship, 2(1), 11p.
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APPENDIX I ��1
THE FUTURE OF NURSING EDUCATION
Virginia Tilden, D.N.Sc., R.N., FAAN
University of Nebraska Medical Center College of Nursing
The Committee on Quality of Health Care in America of the Institute of
Medicine concluded that “the American health care delivery system is in need of
fundamental change. The current care systems cannot do the job. Trying harder
will not work. Changing systems of care will” (Committee on Quality of Health
Care in America, 2001, p. 4). Since the publication of the IOM’s quality chasm
reports, numerous organizations have called for changing not only systems of
care, but also systems of health professions education, realizing that it will be
the clinicians of the future who can most effectively change how care is deliv-
ered. Health professions education has overall seen little fundamental change in
the past 50 years and is in urgent need of new vision. New goals are needed to
improve the degree to which the practice of graduates improves the health of the
population; enhances the patient’s experience of care; and reduces or controls the
per capita cost of care.
BACKGROUND
Education in the health professions is expected to produce graduates profi-
cient in core competencies as specified by the Pew Health Professions Commis-
sions (Recreating Health Professional Practice for a New Century, Pew, 1998)
and the Institute of Medicine (Greiner and Knebel, 2003). These competencies
focus on issues of professional behavior (e.g., ethical standards, cultural com-
petence) and focus of care (e.g., prevention, primary care) with the overarch-
ing intent to (1) provide patient-centered care, (2) apply quality improvement
principles, (3) work in interprofessional teams, (4) use evidence-based practices,
and (5) use health information technologies. Although there is wide agreement
and support for these competencies, curricula have been slow to change. Faculty,
themselves educated in past eras, laden curricula with factual content delivered
in turgid lectures, often portrayed in dense PowerPoint slides. Students graduate
with ample factual knowledge but often with little sense of integration and poor
ability to function in interprofessional teams or coordinate care effectively across
the multiple care settings which most patients travel.
The Carnegie Foundation for the Advancement of Teaching (http://www.
carnegiefoundation.org/) recommends innovations in teaching in nursing and
medicine with three emphases—integration (students’ ability to connect basic,
clinical, and social science knowledge with clinical experience); systems im-
provement (student opportunities to improve the health care system); and profes-
sionalism (students’ acquisition of the qualities of professionalism including the
formation and adoption of the shared values, behaviors, and aspirations of the
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��2 THE FUTURE OF NURSING
profession). Its recent report, Educating Nurses: A Call for Radical Transforma-
tion (Benner et al., 2010), calls for teaching that invites students to develop a
sense of salience, clinical reasoning, and clinical imagination. To achieve this,
the best teachers must teach well beyond disembodied content, teaching students
instead “how to be a nurse who uses evidenced-based knowledge and cultivates
habits of thinking for clinical judgment and skilled know-how. Their (the best
teachers’) teaching is integrative and patient-centered . . . these teachers coach
their students, engaging them in experiential learning to develop situated knowl-
edge, skills, and ethical comportment” (p. 15).
The looming workforce shortages in most clinical disciplines demand that
educators prepare graduates for greater flexibility across disciplinary bound-
aries and less entrenched, siloed thinking. Many organizations speak to this.
For example, the Association of Academic Health Centers cites decentralized
decision-making in health workforce education and weak national health work-
force policy as reasons for the growing crisis in the future supply of health
professionals, and calls for urgent corrective action to improve and finance
training (Out of Order, Out of Time, 2008). The national Physicians Foundation
recommends that physicians cede much clinical management “downstream” to
nurse practitioners and physician assistants with the physician’s consultative
oversight (Physicians and Their Practices Under Health Care Reform, 2009,
www.physiciansfoundation.org/FoundationReportsDetails). These positions by
physicians indicate a greater acceptance of nursing’s key place on the team in
the care delivery enterprise.
In the past few years, enlightened nursing education has been moving from
content-based curricula taught within segregated compartments, such as care
settings isolated from each other and isolated disease-based content, to concept-
based, integrated curricula that emphasize evidence-based care and clinical deci-
sion making across settings, ages, and diagnoses. New American Association of
Colleges of Nursing (AACN) Essentials documents reflect these changes. While
encouraging, this movement is slow and falls short of radical reform.
Focus of the Paper
This paper focuses on three target areas for emphasis in nursing educa-
tion—interprofessional education, education for care coordination, and education
for health policy—each essential for a transformed health care system. In such a
system, nursing care must be recognized by the American public, policy makers,
and others on the health care team as an indispensable ingredient to quality care.
Each of these targets for curricular reform calls for pedagogy that emphasizes
integration and hands-on application well beyond factual content. This will re-
quire faculty development so that teachers engage and excite students. Each of
the targets should become fundamental content for baccalaureate, master’s, and
doctoral nursing education, with increasing levels of complexity and expectations
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APPENDIX I ��3
for application and outcome. Together the three target areas could serve as pillars
on which to structure the curriculum.
Others will likely select other targets for change, and there are many from
which to choose. Increasing requirements for admission to nursing schools, train-
ing and recruiting a more diverse faculty, funding mechanisms for programs and
students, improving mechanisms for assessing student performance, reducing and
strengthening the myriad, often confusing pathways of nursing education, dealing
with the issue of minimum education for entry into practice, and achieving new
standards for nursing education—all are topics urgently needing new vision and
bold change for the profession to receive the recognition and credit it deserves.
A major barrier of nursing education for the advancement of the profes-
sion, and specifically for embracing the three target areas of this paper, is nurs-
ing education at the community college level. Since 2006, the majority of new
nurses who sit for the NCLEX-RN licensure exam each year are graduates of
community college associate degree programs. The nursing profession’s inability
to insist that professional nursing requires a minimum of a 4-year baccalaureate
degree gravely impedes the stature of the profession. Because associate degree
students are less likely to be educated in academic health centers, they have less
proximity and exposure to students of medicine or most other health profes-
sions. Additionally, after graduation, other health professionals are disinclined to
welcome collaborative teamwork with nurses who do not hold a baccalaureate
degree. Further, the three topics of this paper vastly exceed community college
curricula. Therefore, a premise of this author is that the nursing profession must
require the BSN as minimum education for initial licensure for practice. It simply
can no longer allow infighting and special interests to dominate. Doing so has
resulted in an average lowering of education for nurses over the past 40 years,
during a time in history when other health professions have been increasing their
education requirements.
INTERPROFESSIONAL EDUCATION
Medical errors and care fragmentation are major problems that beg for
change in health professions education. Poor communication among clinicians
and resulting disparities in care priorities have been well documented. For exam-
ple, in one study of an inpatient unit, only 48 percent of physicians talked to the
RN on their team, and in only 13 percent of cases did the MD and the RN have
complete agreement on the care priorities of the day (Evanoff et al., 2005).
One outgrowth of this problem has been a move, primarily in England,
Canada, and the United States, to bring health professions students in academic
health science universities and medical centers together for periods of inter-
professional education (IPE). Defined as “occasions when two or more profes-
sions learn with, from and about each other to improve collaboration and the
quality of care” (Barr et al., 2005), such education is based on the premise that
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students’ greater familiarity with each others’ roles, competencies, nomenclatures,
and scopes of practice will result in more collaborative graduates. Graduates from
programs with IPE training will be ready to work effectively in patient-centered
teams where miscommunication and undermining behaviors are minimized or
eliminated, resulting in safer, more effective care and greater clinician and patient
satisfaction. Specifically, IPE is thought to achieve collaboration in implementing
policies and improving services, prepare students to solve problems that exceed
the capacity of any one profession, improve future job satisfaction, create a more
flexible workforce, modify negative attitudes and perceptions, and remedy fail-
ures in trust and communication (Barr, 2002).
Efforts have been made to evaluate the effectiveness of IPE in improving
outcomes, typically including increased student satisfaction, modified negative
stereotypes of other disciplines, increased collaborative behavior, and improved
patient outcomes. However, IPE’s effect is not easily verified since control group
designs are expensive, reliable measures are few, and time lapses can be long
between IPE and the behaviors of graduates. Barr and colleagues reviewed 107
evaluations of IPE in published reports, judged to be of sufficient quality for in-
clusion according to Cochrane review standards (www.cochrane.org), and found
support for three outcomes: IPE creates positive interaction among students and
faculty; encourages collaboration between professions; and improves aspects of
patient care, such as more targeted health promotion advice, higher immunization
rates, and reduced blood pressure for patients with chronic heart disease (Barr
et al., 2005). In further work, Reeves et al. (2009) reviewed six later studies that
met methodology inclusion criteria as randomized controlled trials, controlled
before-and-after studies, and interrupted time series design studies. Four of the
studies found that IPE improved aspects of how clinicians worked together, such
as an improved working culture and decreased errors in an emergency depart-
ment, improved care management for domestic violence victims, and improved
knowledge and skills of clinicians caring for mental health patients. The remain-
ing two studies found that IPE had no effect at all. Although empirical evidence
is mixed, there is widespread theoretical agreement and anecdotal evidence that
students who demonstrate teamwork skills in the simulation lab or at the bed- or
chair-side with patients will apply them beyond the walls of their academic pro-
grams, particularly if valued and reinforced by the care environments in which
they later work.
In the early days of IPE, students graduated into patient care environments in
which siloed and hierarchical systems predominated, thus creating a significant
disconnect between their college-based learning and post-graduation experi-
ence. Now, 10 years into the widespread reforms triggered by the IOM’s searing
Quality Chasm reports, the practice environments students enter tend to reinforce
rather than discourage cooperative behaviors and attitudes. This shift suggests
a readiness for IPE and fuels the momentum among health science universities
toward a growing acceptance of IPE in curricula.
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IPE goes well beyond classroom-type courses comprised largely of didactic
lectures, considered ineffective in cultivating team-based behaviors. Sitting side-
by-side in lecture halls produces little student engagement with either the faculty
or other students. From a pedagogical perspective, IPE learning comes from
conjoint reflection, problem solving, and experience. Effective IPE training pro-
duces much more than the sum of its parts, rather, it generates interprofessional
discourse that shapes collaborative thinking and behavior. IPE typically takes
one or more of three approaches: (1) clinical skills lab simulation activities using
manikins or standardized patients in case scenarios often videotaped to facilitate
review and reflection, (2) service learning projects that enhance students’ civic
engagement often with diverse communities, and (3) specific patient group clinics
such as in the care of geriatric or HIV/AIDS patients.
Barriers to IPE exist (Gilbert, 2005) but are surmountable. Jurisdictions of
faculty and professional organizations abound. Different accrediting bodies are
loath to yield control over traditional curricula and standards. Space in curricula,
with their emphasis on factual content over synthesis, integration, and coopera-
tion, is limited. Relatively rigid academic calendars control course schedules.
Other barriers pertain to motivating faculty. How to reward and give faculty credit
for IPE when the traditional reward systems such as promotion, tenure, and merit
raises are governed within, not across, professions. Resources of the various
deans to support IPE likely differ. Typically schools of nursing have smaller over-
all budgets than schools of medicine but a higher percent of funding that supports
the education mission. Medical school faculty typically are expected to generate a
larger proportion of their salaries through clinical practice and/or research. When
done well IPE can be expensive for many reasons, e.g., small groups with stability
over time to allow for reflection and the development of trust, and/or expensive
equipment for simulations. These budgetary issues can contribute to different
levels of willingness of deans to support IPE.
Recommendations
1. Students at all levels of nursing education—baccalaureate, master’s, and
doctoral—must have exposure to IPE training and demonstrate competence
in interprofessional collaboration.
2. Since academic curricula tend to resist change unless pressured by external
forces such as accreditation requirements and licensure/certifying exam con-
tent, major education and standard-setting organizations must cooperate to
bring about IPE. In addition, endorsement of IPE must come from the highest
levels within academic settings, including presidents, provosts, and deans.
3. Nursing faculty need development in IPE teaching, which requires structure
and funding. The traditional notion of “teacher as expert” urgently needs
replacement with teacher as coach and facilitator. Faculty, whose average
age nationally is in the mid-50s, need the tools to make this transition. In
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addition, since most nursing faculty are not active in practice, their own
clinical experience is often dated and sometimes based on past unsatisfying
interprofessional relationships, making them poor champions for IPE.
4. The level and timing of bringing various students together requires analysis
and pilot testing because of students’ varying educational pathways and
readiness for IPE. For example, evaluate pairing senior medical students with
graduate nursing and allied health students, in an effort to have students bring
relatively comparable amounts of university education and clinical exposure
to the experiences.
5. IPE should be structured around knowledge, skills, and competencies to in-
clude: interpersonal and listening skills; techniques for constructive dialogue
and disagreements; how “evidence” in evidence-based practice is weighted;
systems thinking and problem solving; engaging patients and families as
active participants in care; verbal and nonverbal communication within the
care team; effective data reports and displays; stereotypes and prejudices;
and appreciating alternative conceptual frameworks and points of view.
EDUCATION IN CARE COORDINATION
Both the health professions literature and the popular press note that fail-
ures in patient care coordination are widespread in the United States. Indeed,
fragmented care, lost records, hand-offs without full information, poor return of
information from specialty care after referral, unnecessary and redundant proce-
dures and services—and the attendant patient fatigue, frustration, and costs—are
the very heart of the quality chasm. This problem is particularly acute for the 125
million people with chronic illness, disability, or functional limitations, and for
the elderly whose numbers will swell in the decades ahead. Short hospital stays
have exacerbated the problem.
Historically, primary care physicians coordinated their own patients’ care
within and across settings, but this function has all but been lost for myriad
reasons, including the growth in hospitalist care, patient self-referrals to special-
ists, the breakdown in communication between primary care and specialty care,
financing constraints on physician time, and overall uncoordinated systems of in-
formation technology. Failures in care coordination also can be traced to curricula
where the competencies required are assumed to be intuitive and thus minimized
or overlooked altogether.
Serious consequences result from poor care coordination. Especially wor-
risome is the post-hospital fate of patients. One study of care transitions found
that 19 percent of patients experienced adverse events following discharge from
a U.S. teaching hospital, most of which were avoidable and typically related to
poor communication (Forster et al., 2003). In another survey, 48 percent of newly
discharged patients reported not receiving information about side effects of new
prescriptions ordered at discharge (Schoen et al., 2005). In a study of urgent care
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patients, in 33 percent of cases information such as medical history and labora-
tory results was absent. In half the cases, the information was essential to patient
care (Gandhi, 2005).
As defined by the National Quality Forum (2006), care coordination should
meet patients’ needs and preferences for information and services across settings
over time. This facilitates beneficial, efficient, safe, and high-quality patient ex-
periences and improved health care outcomes. Qualities and principles of care
coordination include an enduring patient relationship and an established and
up-to-date care plan that anticipates routine needs, manages acute, episodic,
and chronic care needs and tracks progress toward goals that are jointly set by the
health care team and the patient/family. Care coordination ensures information
flow to and from referrals to specialty care or community services; ensures that
all team members, including the patient, are apprised of tests and services with
results readily available; reconciles medication orders and educates patients and
families about side effects and medication management; and reduces opportuni-
ties for error. Care coordination requires linguistically and culturally competent
communication with the patient and family, and seeks and responds to patient/
family questions and feedback.
Yawning gaps in care coordination are rallying many health professions or-
ganizations to search for solutions. For example, the American Board of Internal
Medicine Foundation structured its annual Forum on this topic in 2007, and later
spearheaded a consortium, referred to as the SUTTP Alliance (Stepping Up to
the Plate for Managing Transitions in Care) comprised of 10 medical specialty
societies, including the American College of Physicians, the American Academy
of Family Physicians, and the Society of Hospital Medicine. Nurses are the logi-
cal and ideal clinicians to fill the role of care coordinator, yet a similar alliance
among nursing organizations is absent. Germane to this paper, curricula in care
coordination in nursing education are underdeveloped.
Nursing research has produced important findings about advance practice
nurses as care coordinators. Brooten’s early work on care of low-birth-weight
infants (Brooten et al., 1986) showed significant cost and quality improvement
for early discharge and follow up home care by advance practice nurses (APNs).
Naylor and colleague’s (1999, 2004) studies of a transitional care model by
APNs for older cardiac patients post-hospitalization also demonstrated positive
effects of nurse-managed transitional care. In these models, APNs tailored post-
discharge services to each patient’s situation and followed patients by telephone
and home visits. The intervention emphasized patients’ and caregivers’ goals,
individualized plans of care developed and implemented in collaboration with
patients’ physicians, educational and behavioral strategies to address needs,
and coordination and continuity of care across settings. Overall outcomes were
positive across a series of studies, showing lower rehospitalization rates, fewer
hospital days when readmitted, substantial cost savings, and greater patient
satisfaction with care.
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Another superlative example of care coordination is On Lok Senior Health
Services for older adults living in San Francisco. For over 30 years, On Lok
has used multidisciplinary teams, electronic medical records, capitated pay-
ment, and a full range of services (including transportation, housing, meals,
adult day health services, and geriatric aides who make frequent home visits) to
provide seamless transitions for nursing home-eligible frail elders at lower cost
than usual care. On Lok became the model for similar institutions around the
Unitd States through the Program of All-Inclusive Care for the Elderly (PACE)
(Bodenheimer, 1999).
Another care coordination model is Tom Bodenheimer’s “teamlet”
(Bodenheimer and Laing, 2007), dyads that are a subset of the larger health
care team and comprised of a physician and, ideally, an experienced nurse or an
APN. Patients enter “an expanded encounter,” in which pre-, post-, and between-
visit care is continually monitored and coordinated by the nurse. Ingredients for
success include making sure the patient understands advice and direction and
agrees with the plan of care; communicating and interpreting laboratory and
other diagnostic tests, and continually looping information between the patient
and family, the physician, other care providers such as clinical pharmacists
and allied health. Bodenheimer notes that ideally the coach would be an RN or
an advanced practice nurse, but in their absence, a medical assistant could be
trained for the role.
Thus, the role of care coordinator as patient advocate, communicator, as-
sessor, and intervener, ideally suited to what nurses do best, presents a huge
opportunity for nursing education. But, as implied by Bodenheimer, the nursing
profession will be bypassed if nurses fail to seize the opportunity. To do so, how-
ever, requires that nursing school curricula incorporate not just the knowledge
underlying the competencies of the role but convey the importance of the role to
students by threading the concept and competencies of care coordination through-
out the curricula. As already mentioned, most nursing curricula currently teach
compartmentally, not across systems. Courses, particularly in the baccalaureate
program where attitudes about nursing and nursing care are first formed, focus
on content and skills in specific discrete clinical settings. Faculty generally teach
within, not across, settings of care. Often the master’s level Clinical Nurse Spe-
cialist program is the only track with a course or parts of courses that address
care transitions and care coordination, and this content may be confused with case
management, the latter being a more limited concept usually applied to contain-
ing costs within reimbursement systems.
Interprofessional education discussed above will by itself, improve gradu-
ates’ competence in care coordination because many of the competencies students
learn in IPE are relevant. However, there is a body of knowledge and sets of skills,
attitudes, and role-related behaviors specific to care coordination that should be
integrated throughout the levels of nursing education rather than confined to
episodic IPE training.
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Recommendations
1. BSN students should be placed for clinical training in new models of inte-
grated care that require care coordination, such as accountable care organiza-
tions within universities or medical homes.
2. MSN students should study the research cited above that shows the effective-
ness of APN transitional care. Components of MSN clinical training should
include the care coordination role.
3. Across education levels of nursing education, care coordination should be
structured around knowledge, skills and competencies to include: advanced
assessment skills appropriate for senior baccalaureate and master’s/DNP
students; interpersonal and communication skills necessary for the ability
to communicate with patients and families with a high degree of sensitiv-
ity and cultural competence, as well as the science-based skills necessary
to communicate effectively with physicians and others on the health care
team; competencies in care planning that integrate the biological, social, and
psychological needs of patients; understanding of and ability to seek and ap-
ply evidence-based protocols and national standards for patient conditions;
and payment and social services systems to better address the full range of
patients’ and families’ needs.
HEALTH POLICY EDUCATION
In large measure nursing education must remain patient focused. This makes
sense for an applied discipline whose goal is the prevention or amelioration of
illness and the improvement in the wellbeing of patients, families, and communi-
ties. However, a major lesson of the past 20 years is the degree to which health
systems and policy shape the health both of populations and individual patients.
Yet nursing students gain only a glimmer that health policy at multiple levels,
from the hospital unit to the federal government, affects not only their practice
but ultimately the fate of patients. Few educational programs include more than
a token course on health policy, typically only at the graduate level. Since nurs-
ing education curricula generally treat health policy as extra rather than core, the
naiveté of graduates, is no surprise. With few exceptions, nurses generally view
themselves as being shaped by, not shaping, policy.
Since nurses largely take a back seat to policy processes, the profession’s in-
put has been relatively invisible, certainly compared to that of medicine (Mechanic
and Reinhard, 2002). Few nurses, when asked “What is nursing?” include health
policy as a component of what nurses do (Gebbie et al., 2000). Missed opportu-
nities for nursing to shape legislation or wade into legislative debates are all too
common. One example is the recent Centers for Medicare and Medicaid Services
(CMS) rule that restricts reimbursement for such “never events” as pressure
ulcers, certain catheter-related infections and injuries, and certain surgical site
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infections. The majority of these conditions can be prevented by excellent nursing
care, yet the nursing profession has not effectively convinced the Congress or the
American public that nursing care is the key ingredient safeguarding the public
from these problems (Leavitt, 2009).
Another example is the “killing grandma” and “death panel” controversy,
sparked by wording in the August 2009 congressional health care reform bills.
Thousands of nurses across the country have daily, intimate contact with patients
and families in the throes of decision making about DNR orders, advance direc-
tives, and other end-of-life issues. Nurses have close personal knowledge about
how they and other clinicians facilitate discussions and considerations about palli-
ative care and life-extending treatments. Despite this, nurses were largely silent in
the face of widespread public misunderstanding and resulting acrimonious outcry
over what is intended in counseling patients facing such decisions. This silence is
surely an outgrowth of the inattention of nursing curricula to health policy.
The Healthy People Curriculum Task Force, convened by the Association of
Academic Health Centers and the Association of Teachers of Preventive Medi-
cine, with representatives from medicine, nursing, pharmacy, and physician as-
sistants, as well as their educational associations recommended the following
four domains fundamental to health professions curricula on health policy (http://
www.atpm.org/CPPH_Framework/index.html):
• Organization of clinical and public health systems (connecting the pieces
of the system; connecting clinical care to public health structures)
• Health services financing (underlying determinants of cost and options
for payment and cost containment; comparison to health systems of
other countries)
• Health workforce (understanding the roles and responsibilities of other
health professionals)
• Health policy process (introduction to the impact of policy on health
and clinical care, the processes involved in developing policies, and
opportunities to participate in those processes, whether within a local
institution or state or federal legislation)
Medicine has advocated the inclusion of these domains in all medical school
curricula (Riegelman, 2006). Nursing curricula should do no less.
As emphasized above, health policy curricula are needed at the baccalaure-
ate, master’s, and doctoral levels of nursing education, with increasing scope and
complexity as the student advances. Political competence requires continuing
skill development that begins early in students’ education, thus setting the course
toward the graduate’s life-long engagement.
Baccalaureate students need to understand the role of policies at the unit
level that shape the environment in which they will eventually work. Workplace
policies (e.g., mandatory overtime, nurses’ authority to close beds to new admis-
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APPENDIX I ��1
sions based on professional judgment of adequate staffing, school nurses’ author-
ity to teach reproductive information) lend themselves for students’ analysis and
can help students clarify their own biases and potential ethical conflicts.
Another example of the type of policy work ideal for analysis by baccalau-
reate, and even graduate, nursing students pertains to the Robert Wood Johnson
Foundation and the Institute for Healthcare Improvement project, Transforming
Care at the Bedside (www.ihi.org/IHI/Programs/TransformingCareAtTheBed-
side/). TCAB is an excellent teaching–learning vehicle for students to gain un-
derstanding of local policy and how it is shaped. Originally designed as a way to
improve hospital work environments so that more nurses would seek (and stay)
in positions on medical–surgical units, TCAB also addresses care improvement
processes, such as rapid PDSA (plan-do-study-act) cycles for gathering data to
influence patient care policies. Faculty should engage baccalaureate students in
this TCAB literature, with application in clinical assignments and an emphasis
on policy implications and processes. In addition, baccalaureate students need an
understanding of the important role that nursing organizations can play so as to
encourage their involvement both as students and as graduates.
Graduate education in nursing, both at the master’s and doctoral levels,
should be infused with multiple learning experiences in health policy, including
both explication and hands-on experience. Building on the foundation from the
health policy curriculum at the baccalaureate level, APN students need to be ac-
tively involved in political processes that affect the care they will deliver in the
future. At this stage of their education, they should be expected to understand the
link between evidence and policy, i.e., the role that data can play in illuminating
problems and capturing the attention of policy makers. IPE can provide collab-
orative efficiencies so that interprofessional student groups engage together in
policy projects.
AACN’s DNP Essentials (www.aacn.nche/DNP/pdf/Essentials ) includes
“Health Care Policy for Advocacy in Health Care” (Essential V), which expects
DNP graduates to engage in the health policy process, whether through institu-
tional decision-making, influencing organizational standards, or governmental
actions. It is expected that students will be oriented to the principles of social
justice, particularly in advocating for the underserved. Examples of hands-on
assignments include preparing and presenting a policy brief analyzing a state
or national health policy issue or problem related to access, utilization, cost, or
quality; writing a letter (not to be sent) to an editor or an elected official on a
health issue; and educating the lay public through speaking at local Rotary or
other civic organization.
At the PhD level, student understanding of how to impact health policy
moves specifically to the role of research. The focus at this level should be on
advanced knowledge of political processes within the state and federal govern-
ment and on the competencies needed to articulate research findings persuasively.
Students should understand how to plan their doctoral studies and related work,
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such as scholarly projects and the dissertation, toward the end goal of becom-
ing influential. Many authorities (e.g., McBride et al., 2008) urge researchers to
engage end users when framing research since those in position to make policy
frequently complain that the research they need is rarely available. A useful ex-
ercise for PhD students early in their program is to meet with a state or federal
elected member to discuss topics of mutual interest in improving health or health
care and determining what evidence may be useful in future policy agenda.
Linking research findings to health policy formulation requires a set of
specific skills which should be core to PhD education. These range from the con-
crete, for example, selecting a title for a policy brief or media report that reflects
the key take-away message (since busy policy makers will overlook material
that does not draw them in quickly), to the more conceptual, e.g., learning the
separate perspectives of legislators who make policy and researchers who study
health problems, which Hinshaw refers to as “moving between two cultures”
(Hinshaw, 2008).
Recommendations
1. In addition to health policy courses at baccalaureate, master’s, and doctoral
levels, health policy objectives should be threaded throughout the curricu-
lum, ideally embedded in every course and reflected in course assignments.
Using probing questions that invite student reflection, synthesis, integration,
and deduction, faculty should lead students to articulate the policy implica-
tions in everything they study.
2. Accreditation and licensure/certifying examinations must ramp up their ex-
pectations for student competencies related to health policy.
3. Health policy education should be structured around knowledge, skills and
competencies to include: policy-related relationship building skills; tech-
niques for crafting testimony and writing effective white papers and posi-
tion statements; effective use of numeric and narrative data to emphasize
evidence-based information; working with the media; critiquing the ethical
aspects of health policy in terms of vulnerable populations; mastering health
policy terminology; understanding legislators’ perspectives; techniques for
policy analysis; legislative processes in policy development; roles of stake-
holders and special interest groups; and advocacy and strategies to influence
policy.
EPILOGUE
The RWJF/IOM Initiative on the Future of Nursing will yield transforma-
tional recommendations for the nursing profession at a critical time in history for
nursing and for America’s health care system. There is much to reform in nursing
education, from agreement about the minimum degree for entry into practice to
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APPENDIX I ��3
producing graduates with the requisite knowledge, skills, and interprofessional
competencies they will need. This paper has reviewed the rationale for and cur-
ricular implications of three target areas—interprofessional education, education
for care coordination, and education for health policy—around which to restruc-
ture education at the baccalaureate, master’s, and doctoral levels. The author ac-
knowledges the difficulties in changing entrenched curricula and habits of faculty
educated in past eras. But one remains optimistic, given the many examples of
progress already made (Benner et al., 2010) that an enlightened profession with a
will for change can bring about a refreshing new future for nursing education.
REFERENCES
Barr, H. (2002). Interprofessional education today, yesterday and tomorrow: A review, LTSN Hs&P,
London, England.
Barr, H., Koppel, I., Reeves, S., Hammick, M. and Freeth, D. (2005). Effective interprofessional
education: Argument, assumption & evidence. Blackwell Publishing Ltd., Oxford, England.
Benner, P., Sutphen, M., Leonard, V., and Day, L. (2010). Educating nurses: A call for radical
transformation. The Carnegie Foundation for the Advancement of Teaching, Jossey-Bass, San
Francisco.
Bodenheimer, T. (1999). Long-term care for frail elderly people—the On Lok model. New England
Journal of Medicine, 341, 1324-1328.
Bodenheimer, T., and Laing, B.Y. (2007). The “teamlet” model of primary care. Annals of Family
Medicine, 5, 457-461.
Brooten, D., Kumar, S., Brown, L. P., Butts, P., Finkler, S. A., Bakewell-Sachs, S., Gibbons, A., and
Delivoria-Papadopoulos, M. (1986). A randomized clinical trial of early hospital discharge and
home follow-up of very-low-birth-weight infants. New England Journal of Medicine, 315(15),
934-939.
Committee on Quality of Health Care in America. (2001). Crossing the quality chasm. Institute of
Medicine, National Academy Press, Washington, DC.
Evanoff, B., Potter, P., Wolf, L., Grayson, D., Dunagan, C., and Boxerman, S. (2005). Can we talk?
Priorities for patient care differed among health care providers. Advances in Patient Safety,
Volume 1. Rockville, MD, AHRQ.
Forster, A., Murff, H. J., Peterson, J. F., Gandhi, T. K., and Bastes, D. W. (2003). The incidence and
severity of adverse events affecting patients after discharge from the hospital. Annals of Internal
Medicine, 138, 161-167.
Gandhi, T. K. (2005). Fumbled handoffs: One dropped ball after another. Annals of Internal Medicine,
142, 352-358.
Gebbie, K. M., Wakefield, M., and Kerfoot, K. (2000). Nursing and health policy. Journal of Nursing
Scholarship, 32(3), 307-315.
Gilbert, J. H. V. (2005). Interprofessional learning and higher education structural barriers. Journal
of Interprofessional Care, Supplement 1, 87-106.
Greiner, A. C., and Knebel, E. (2003). Health professions education: A bridge to quality. Institute of
Medicine, the National Academies Press, Washington, DC.
Hinshaw, A. S. (2008) Nursing research shaping health policy. Paper presented at the University of
Nebraska Medical Center College of Nursing, March 25, 2008.
Leavitt, J. K. (2009). Leaders in health policy: A critical role for nursing. Nursing Outlook, 57,
3-77.
http://www.nap.edu/12956
The Future of Nursing: Leading Change, Advancing Health
Copyright National Academy of Sciences. All rights reserved.
��4 THE FUTURE OF NURSING
McBride, T., Coburn, A., MacKinney, C., Mueller, K., Slifkin, R., and Wakefield, M. (2008). Bridg-
ing health research and policy: Effective dissemination strategies. Journal of Public Health
Management Practice, 14(2), 150-154.
Mechanic, D., and Reinhard, S.C. (2002). Contributions of nurses to health policy: Challenges and
opportunities. Nursing and Health Policy Review, 1(1), 7-15.
National Quality Forum. 2009. “NQF-Endorsed Definition and Framework for Measuring Care Co-
ordination,” http://www.qualityforum.org/projects/care_coordination.aspx (accessed 7 January
2011).
Naylor, M. D., Brooten, D., Campbell, R. Jacobsen, B. S., Mezey, M. D., Pauly, M. V., and Schwartz,
J. S. (1999). Comprehensive discharge planning and home follow-up of hospitalized elders: A
randomized clinical trial. Journal of the American Medical Association, 281(7), 613-620.
Naylor, M. D., Brooten, D., Campbell, R. L., Maislin, G., McCauley, K. M., and Schwartz, J. S.
(2004). Journal of the American Geriatrics Society, 52(5), 675-684.
Out of Order, Out of Time: The State of the Nation’s Health Workforce. (2008). The Association of
Academic Health Centers, Washington, DC.
Physicians and Their Practices Under Health Care Reform, The Physicians Foundation, 2009.
Recreating Health Professional Practice for a New Century. The Fourth Report of the Pew Health
Professions Commission, December, 1998.
Reeves, S., Zwarenstein, M., Goldman, J., Barr, H., Freeth, D., Hammick, M., and Koppel, I.
(2009). Interprofessional education: Effects on professional practice and health care outcomes.
Cochrane Database of Systematic Reviews, Issue 4, The Cochrane Collaboration, John Wiley
& Sons, Ltd., West Sussex, England.
Riegelman, R. (2006). Health systems and health policy: A curriculum for all medical students.
Academic Medicine, 81(4), 391-392.
Schoen, C., Osborn, R., Huynh, P. T., Doty, M., Zapert, K., Peugh, J., and Davis, K. (2005). Taking
the pulse of health care systems: Experiences of patients with health problems in six countries.
Health Affairs Web Exclusive, W5-509-525.
http://www.nap.edu/12956
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Leidy Morey
TheImportanceofNursingEducation.edited x
Summary
1401 Words
Running head: THE IMPORTANCE OF NURSING EDUCATION 1
THE IMPORTANCE OF NURSING EDUCATION 2
Student: Submitted to Grand Canyon University
Unpaired braces, brackets, quotation m…: (
The Importance of Nursing Education
Student Name
Instructor Name
Course
Date
Higher Education in Nursing
After getting licensure, nurses, especially the APRNS (advanced practice registered
nurses, are needed to pursue continuing education (CE) coursework in their entire career life.
http://www.nurse.credentialing.org/Accreditation/
http://online.stmary.edu/rn-
bsn/resources/higher-nursing-education-impact-on-patient-safety
http://online.stmary.edu/rn-bsn/resources/higher-nursing-education-impact-on-patient-safety
THE IMPORTANCE OF NURSING EDUCATION 3
a bachelor’s degree to satisfy the competency level needed for delivery for high-quality care and
the growing complexity of patient requirements. The AACN (American Association of Colleges
of Nursing) dictates that Bachelor of Science in Nursing (BSN) be the primary nursing graduate
suitable for one to serve in the healthcare environment offering ambulatory care, critical care,
mental health, and public health (Ulrich, 2015). Therefore, BSN enjoys the most significant
employment options.
Review the IOM Future of Nursing Recommendations for achieving higher levels of
education. Describe what professional certification and advanced degrees (MSN,
DNP, etc.) you want to pursue and explain your reasons for wanting to attain the
education. Discuss your timeline for accomplishing these goals.
The profession certification and advanced degrees I want to pursue after graduating with
BSN are the Doctor of Nursing Practice (DNP). The primary reason I want to pursue DNP is that
the DNP program offers extra training in disciplines like healthcare policy, health information
systems, systems leadership, evidence-based approaches, and interprofessional collaboration.
Additionally, I will want to enroll in the DNP program as it entails training and coursework
aimed at building on the skills and knowledge as well as preparing students for the highest level
of activities in their specialization. And since I would prefer specializing in administration in
clinical nursing, DNP will sufficiently suit my future goals. I purpose to attain a degree in the
Spelling mistake: CEs Yes
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CEs are essential for nurses as they help them sharpen up of necessary skills, keep up with new
technological transitions, and study new healthcare processes. Registered nurses (RNs), as well
as other healthcare leaders, should enroll for lifelong studies as an integral element of healthcare
education. A compelling survey conducted by IOM (Institute of Medicine) under-performed on
the need for adequately educated nurses in the United States of America. The research called on
nurses to prioritize advancing patient care and profession. Branson et al. (2016) note that the
approaches used to teach nurses in the 20th century is significantly different and perhaps
obsolete for addressing healthcare realities in the 21st century. Since the patient requirements
and care settings have become more sophisticated, nurses should earn requisite competence to
enhance high-quality care. In its findings, the IOM reported that the hope of nursing; focuses on
continued education.
Discuss your options in the job market based on your educational level.
Nursing is a fascinating, ever-changing, and, an extremely indulging career. As per the
Bureau of Labor Statistics, the need for qualified nurses will grow, with a projected increase of
12 percent through in the near future, extra faster compared to any average profession globally.
A landmark research demonstrates that an emerging delivery framework with a concentration on
controlling health conditions as well as forbidding acute health problems will lead to increased
demand for nurses. Furthermore, the demand for nurses will be influenced by the increasing rate
of aging Baby Boomers and global population growth. Being an undergraduate, I have reduced
options in the job market since IOM’s preferences are that at least 80 percent of RNs should own
DNP program seven years after my BSN graduation since I will want to work and get the money
to sponsor my advanced studies. Additionally, I will want to gain real experience in the field of
nursing to know what lies ahead of me, even as I advance my education.
Discuss how increasing your level of education would affect how your
competitiveness in the current job market and your role in the future of nursing.
THE IMPORTANCE OF NURSING EDUCATION 4
THE IMPORTANCE OF NURSING EDUCATION 5
Statistically detect wr…: accessed assessed
sufficient (enough): sufficient enough
as per (as, in ac…: as per in accordance wi…
currently: Currently Now
Passive voice: is considered to be
Student: Submitted to Grand Canyon University
Advancing my education level would increase the competitiveness of my nursing
profession in the present job market since. By advancing to DNP, I will increase my
competitiveness since it will be easy to qualify for various roles that cannot be accessed by
nurses who are limited to ADN (Associate Degree in Nursing) and BSN degrees. As I stated
earlier, I have immense interest in pursuing an administrative role in clinical medicine, and
according to IOM, a doctorate is sufficient to equip me with the necessary knowledge and
expertise needed to fulfill this nursing role. Additionally, academically advanced nurses can
change to new roles such as clinical documentation, community care, nursing informatics,
ambulatory care, infectious diseases, and case management as the profession is shifting to a
framework aimed at boosting outcomes and building a continuum of care (Branson et al., 2016).
Discuss the relationship of continuing nursing education to competency, attitudes,
knowledge, and the ANA Scope and Standards for Practice and Code of Ethics.
Advancing education is considerably related to becoming competitive in the nursing
field, growing positive attitude towards patient management, a better understanding of various
roles of a nurse as well as delivering as per the ANA Scope and Standards for Practice and Code
of Ethics. Currently, nursing is considered to be competent when there is a robust education
continuation, unlike in the past, when all needed was a license. According to the University of
Saint Mary (2017), the continuation of education is a fundamental tool in determining the level
of competency in nursing due to the ever-changing nursing field where the use of modern
technology has taken over the critical roles in the clinical premises. Higher education creates a
significant difference in providing effective and safe care to patients, and nurses earn skills
required to address medication issues with minimal errors safely.
The advantage of continuing higher education in nursing is that it boosts knowledge and
quality of care delivered as well as enhancing the ability of the nurse to compete favorably in the
job market. Higher education is directly related to ANA standards and scope of practice as it
ensures top-quality care and knowledge expansion and career advancement. The range of
training is based on the “who, when, why, what, where, and how” of the nursing profession.
Nursing practices need specialized skills, knowledge, and independent minds for decision
THE IMPORTANCE OF NURSING EDUCATION 6
that nurses gain proficiency upon the utilization of modern technologies since advanced
education courses explore up to date technology. Moreover, with continued education, nurses are
knowledgeable about the latest trends in clinical medicine with transforming patient
requirements. Higher education enables nurses to proficiently and effectively coordinate care for
patients by communicating and partnering with other healthcare professionals, share knowledge
via networking. Finally, nurses enjoy exposure to seminars where they interact with proficient
providers in the field.
assist, assistance (help): assists help
Hyphenation p…: decision maki… decision-maki…
Spelling mistake: reedifying re edifying
formulation. Every nurse is expected to have robust experience and modern evidence-based
approaches if he or she must provide the best care desired by the patients. With the attainment of
higher education, nurses can embrace superior leadership roles.
Leadership roles play a significant role in changing the healthcare and for private and
governmental healthcare policymakers to involve representation from the board of nurses. As
dictated by ANA, nurses owe similar responsibilities to themselves as they do others. This
includes duties to observe equal and fair treatment, be competent, safe patient care, create trust,
extend positive influence, assists guide in better decision making, integrity, increase career
knowledge and skills, advance personally and professionally, and be educated to offer the best
care. This can only be attained by continuing education to foster these codes of ethics.
Discuss whether continuing nursing education should be mandatory. Provide
support for your response.
Continued nursing education should be made compulsory since higher nursing education
is reedifying nurses to create a difference during service delivery by providing adequate and safe
care to patients. Additionally, through higher education, nurses earn requisite skills for safe
administration of drugs while cutting down on errors, assessing, and monitoring the patient
reaction to the administered medication. American Nurses Credentialing Center (2018) posits
THE IMPORTANCE OF NURSING EDUCATION 7
References
American Nurses Credentialing Center. (2018). The Importance of Evaluating the Impact of
Continuing Nursing Education on Outcomes: Professional Nursing Practice and Patient
Care. Retrieved March 15, 2020, from http://www.nurse.credentialing.org/Accreditation/
Branson, S., Boss, L., & Fowler, D. L. (2016). Team-based learning: Application in
undergraduate baccalaureate nursing education. Journal of Nursing Education and
Practice, 6(4), 59.
Ulrich, B. (2015). Progress on the 2010 IOM future of nursing report and future needs.
Nephrology Nursing Journal, 42(6), 527-529.
The University of Saint Mary. (2017) Higher Nursing Education and its Impact on Patient
Safety. Retrieved on March 15, 2020, from http://online.stmary.edu/rn-
bsn/resources/higher-nursing-education-impact-on-patient-safety