Transforming Nursing Education

Creating the Nursing Workforce of the Future

Linda Cater, RN, MSNDirector of Health Programs – Postsecondary EducationAlabama Community College System

Martha G. Lavender, RN, MSN, DSNAssistant to the President – Cherokee Campus /Health SciencesGadsden State Community College

Today we will…

Discuss the existing nursing workforce in the United States.

Explore recommendations for the workforce of the future and the implications for nursing education.

Formulate action plans that advance nursing education in the Alabama Community College System.

•HRSA 2008 National Sample Survey (September 2010)

• Educating Nurses: A Call for Radical Transformation (December 2009)

• Institute of Medicine Future of Nursing Initiative (October 2010)

Projected Shortages of Health Care Workforce

100,000 physicians• Aging workforce, average work hours are falling,

age of the population, and advanced technology fuel demand

1,000,000 nurses• Economic conditions have led to the highest level

of employment in the workforce since 1977

250,000 public health professionals• Budget constraints, lack of qualified candidates,

lengthy process of hiring, non-competitive salaries

Source: http://bhpr.hrsa.gov/healthworkforce/

Current Nursing Workforce

• 3,063,162 licensed RNs

• 21% earned another degree before nursing

• 62.2% work in hospitals

• 83.2% are white, non-Hispanic

• 45.4% hold associate as initial RN degree

• 39% of recent graduates entered with BSN

• 596,355 licensed LPNs

84.8% employed in nursing

Sources: 2008 National Sample Survey of RNs (2010); HRSA Supply, Demand, and Use of LPN (2004)

Distribution by Initial Nursing Degree

Source: 2008 National Sample Survey of RNs (2010)

1980-2008

Highest Nursing or Nursing Related Degree

Source: 2008 National Sample Survey of RNs (2010)

1980-2008

Highest Education by Initial Nursing Education

Nurses whose initial education was the ADN averaged 7.5 years between their associate degree and completion of the baccalaureate degree

Source: 2008 National Sample Survey of RNs (2010)

Source: 2008 National Sample Survey of RNs (2010)

Average Age at Graduation for Initial Nursing Education by Type of Program

Actual and Inflation-Adjusted Salary

Source: 2008 National Sample Survey of RNs (2010)

Average earnings of a BSN-prepared nurses are not substantially higher

than those of ADN or diploma prepared nurses

Overall Average $66,973Diploma $65,349Associate $60,890Bachelor’s $66,316Master’s/Doctoral $87,363

Source: IOM Future of Nursing Initiative (2010). Transforming education (Chapter 4) p. 4-8.

Top 10 Nursing Salaries

1. Nurse anesthetist $154,2212. Senior Management 96,7353. Nurse Practitioner 85,0254. Nurse midwife 82,1115. Management/administration 78,3566. Consultant 76,7437. Informatics nurse 75,2428. Middle management 74,7999. Clinical nurse specialist 72,85610. First-line managers 72,006

Average salary of nurses engaged in instruction - $65,844

Employment of RNs by Age Group

Source: 2008 National Sample Survey of RNs (2010)

Employment of RNs by Age Group

“For health reform to succeed, and for patients to receive better care at a cost we can afford, we must change the way health care is delivered. And nursing is at the

heart of patient care.”

Health Care Reform

• Policy makers understand that without nursing, we cannot meet the mandate for higher quality, safer, and more cost effective care.

• Growing awareness that the quality of nursing care impacts not just the care outcomes but the bottom line.

Patient Protection and Affordable Care Act (2010)

• Includes support for nursing education and primary care practices (MDs, PAs, NPs)

• Includes support for new models of care delivery shaped by nurses– Community based care transitions program– Nurse managed clinics– Primary medical care home

• Includes mandate for innovation in care delivery• Includes expansion of reimbursement for APRNs

A Call for Radical Transformation

Classroom and skills lab instruction yields little correlation to practice

– Structured, rigid, prescribed

– Fragmentation of classroom, skills lab, and clinical instruction – different educators in each area

Integration of “three professional apprenticeships”

– Knowledge base (classroom)

– Skilled know-how (clinical reasoning)

– Ethical Comportment

IOM Future of Nursing Initiative4 Key Messages

1. Improve nursing education.

2. Remove scope of practice barriers.

3. Foster interprofessional health care teams.

4. Make workforce planning more effective by developing better data collection and more effective information structure.

Source: Institute of Medicine Webinar on “Leading Change and Advancing Health, October 19, 2010

Key Message #1: Improve Nursing Education

• To ensure the delivery of safe, patient-centered care across settings, an improved nursing education system is critical.

• Nurses must achieve a higher level of education and training. Education must should include opportunities for seamless transition into higher degree programs.

Source: Institute of Medicine Webinar on “Leading Change and Advancing Health, October 19, 2010

Role of LPN/LVN

• Not educated or licensed for independent decision-making for complex care

• Approximately 17.9% of RNs were once licensed as LPNs/LVNs

• Barriers to academic progression:– Financial concerns

– Lack of capacity and difficulty getting into ADN /BSN programs

– Family commitments

Future of Diploma Programs

• IOM Committee recommends a phase-out over the next 10 years

• Consolidation of resources with those of a community college or preferably a university program offering the baccalaureate degree

– Redirect federal funding of diploma education to baccalaureate and higher degree programs

Associate Degree in Nursing

• 45.4 % of nurses obtain basic degree at a community college

• 21% progress to the baccalaureate or higher degree

• Nursing students typically take 3-4 years to complete the associate degree

• To meet prerequisite course requirements

• Competitive applicants pools and/or long waiting lists

• Predominate educational provider in rural and medically underserved areas of the nation

Future professional nurses need…

• Better experience in care management

• Understanding of quality improvement methods

• Systems-level change management

• Reconceptualized roles of nurses in a reformed health care system

• Commitment to lifelong learning

Source: Institute of Medicine Webinar on “Leading Change and Advancing Health, October 19, 2010

80% BSN by 2020

• Wider range of competencies in arenas e.g.,– Health policy– Health care financing– Leadership– Quality improvement– Systems thinking

• Growing number of agencies are requiring the BSN– Teaching Hospitals– Children’s Hospitals– U.S. Military and VA Hospitals

Create Seamless Academic Progression• Both ADN and BSN graduates seek an additional degree at about the same

rate– RN-BSN programs, community college baccalaureates– RN-MSN programs

• Greatest number of master’s and doctorally-prepared nurses received a BSN as their initial degree– Aiken concluded that since 2/3 of current RNs received the ADN as their initial

degree that it is mathematically improbable that we can produce enough faculty (and advanced degree nurses)

• Double the number of nurses with a doctorate by 2020.– DNP: Clinical Doctorate

• Opportunity for PSE: Reconsider admission criteria for LPN – RN mobility program

NCLEX vs. Competency Assessments

Exam is skewed toward acute care settings because it is where the majority of nurses are first employed and where most work throughout their careers

Regulatory agencies, the public, and other use NCLEX outcomes to rate educational programs

Alabama – 80% first-time pass rate

Faculty Shortages

• Faculty Workloads– Address differences in workload: credit hours versus

contact hours

• Professional Development for Faculty– Clinical reasoning teaching strategies

– Fostering continued development regarding classroom civility, disruptive students (or colleagues)

• Create innovative partnerships– Shared faculty resources

Age Distribution of Nursing Faculty

Source: http://bhpr.hrsa.gov/healthworkforce/

Nurse Faculty Intern Program

North Dakota (2004)• “Grow your own”

• NFI allows BSN-RNs with at least two years of clinical experience to teach in nursing schools while pursuing graduate degrees

– Requires a faculty mentor– Requires a consulting PhD-level educator

Innovations in Clinical Education

• Number of required clinical hours• Productive learning environments necessary to

acquire clinical reasoning skills• Other clinical options – DEUs, community and

public health settings, long-term care

Limited clinical settings

Faculty report spending time supervising students in hands-on procedures, leaving little time for clinical scenarios, questioning, and fostering salience

Curricular InnovationsSimulation Technology Survey

• Scant evidence that simulation expands faculty capacity

• No data exist to define what portion of clinical experience simulation can replace

• NCSBN Simulation Study: Survey of Clinical Time and Simulation Use in Prelicensure Programs (in progress)

Preliminary Data for Alabama

• 23/40 programs responded (57.5%)

• 15 associate degree programs, 7 bachelor’s, 1 diploma, and 1 master’s

• Clinical hours per course ranged from 90 to 924 hours (X = 624 hours)

• 17/23 (74%) used simulation models

• Med/Surg course most frequently substitutes simulation for direct clinical hours (3-12% of hours)

Simulation Possibilities

• Simulation Centers (strategically located across the state)

• NLN –Simulation Innovation Resource Center (SIRC) http://sirc.nln.org/

• Simulation scenarios resource pool

• Create policy on the percentage of time allowed for lab/clinical/simulations

“Selected Best Practices”

Oregon - Consortium for Nursing Education (OCNE)Partnership with eight community colleges. Developed common admission standards and curriculum to allow for a seamless to the BSN.

MassachusettsNew Nurse Competencies developed to serve as educational standards and creates common expected outcomes

Hawaii Innovative technology applications to address faculty shortages and lack of classroom space. Creating a sim center to link campuses and hospital sim labs statewide.

MississippiDeveloped the Mississippi Student Navigator which directs students to information financial, health insurance, transportation assistance, child care, stress management, and academic preparation.

IOM Recommendations

• Address underrepresentation of racial and ethnic minority groups and men (7%)– Harlem Headstart Project– RAIN Project

• Develop interdisciplinary models of education with other health care professionals

• Implement nurse residency programs.• Ensure that nurses engage in lifelong learning.

Pay for Performance

Method of evaluating a professor’s worth using:– Amount of research money

– Tuition money generated from teaching

– Salary (plus fringe benefits)

$75,000 +

300 CHPs X $180 =54,000 -

$85,000 + 27,200 (32%)

Net Worth:

$16,800Texas A&M Model

Source: National Education Association Advocate (October, 2010), 28 (1), p.9.

Questions??For a copy of these slides, please visit

the ACCS extranet:

http://www.accs.cc