1. Preparing America’s Nursing Workforce for the Future: Opportunities and Controversies Presented by: Jerry Durham, PhD, RN, FAAN Chancellor and Professor of Nursing Allen College Waterloo, Iowa Iowa Health System 2011 Leadership Symposium April 19, 2011

2. FACTS ABOUT THE RN WORKFORCE

3. Facts About the RN Workforce The number of licensed registered nurses (RNs) in the United States grew to a new high of almost 3.1 million between 2004 and 2008--an increase of 5.3% or 153,806 RNs. 2004 2008 5.3% RN Growth

4. Facts About the RN Workforce  In 2008, 2,596,599, or 84.8 percent of all RNs were employed in nursing positions—the highest rate of employment in nursing since HRSA national surveys began in 1977.  RN full-time employment has grown from 58.4 percent of RNs in 2004 to 63.2 percent in 2008--the first increase in the percent of RNs working full-time since 1996.  In 2010, 36,554 (80.5%) of Iowa’s 45,409 RNs licensed in Iowa were employed in nursing. Almost 60% were employed full time in nursing

5. Facts About the RN Workforce Between 2004 and 2008 in the U.S. Initial Educational Preparation in Nursing In 2008, 0.4 percent of RNs had entered the profession with a master’s degree in nursing and 0.03 percent had entered with a doctoral degree. 200420082010 in Iowa ADN42.9%45.4%52.0% Diploma25.6%20.4%20.0% BSN31.0%33.7%28.0%

6. Facts About the RN Workforce Percent of American RN’s achieving a baccalaureate or higher degree in nursing or a nursing-related field as their highest degree.  In Iowa in 2010, 45.2% of RNs reported the ADN as their highest degree.  In the U.S., only 21% of nurses who initially earn an ADN go on to earn a higher nursing degree 198020082010 in Iowa 27.5% 50% 32.5%

7. Facts About the RN Workforce  Nurses with advanced degrees comprised 13.2 percent of all licensed RNs in the U.S. in 2008.  There has been marked growth in the numbers of RNs with a master’s or doctoral degree in nursing or a related field.  There were an estimated 28,369 RNs (<1%) with a doctoral degree in nursing or a nursing-related field in 2008—BUT an increase of 64.4% since 2000. 2000 2008 46.9% increase RN’s with master’s or doctoral degree in nursing or related field 404,163 275,068

8. Facts About the RN Workforce In Iowa in 2010  4.9% of the Iowa’s RNs held a master’s degree in nursing as their highest degree.  2.7% held a master’s degree in another field of study as their highest degree.  379 RNs licensed in Iowa (<1%) held a doctoral degree and 66 of these lived out of state.  Only 93 RNs (.002%) licensed in Iowa held a doctorate in nursing and 27 of these lived out of state.

9. Facts About the RN Workforce  The two largest groups represented were non-Hispanic Asian (5.5 percent) and non-Hispanic Black/African- American (5.4 percent).  In 2008, 16.8 percent of nurses were Asian, Black/African- American, American Indian/Alaska Native, and/or Hispanic--an increase from 12.2 percent in 2004.

10. Facts About the RN Workforce Nearly 45 percent of RNs were 50 years of age or older in 2008, a dramatic increase. 2000 2008

11. Facts About the RN Workforce (In Iowa in 2009, there were 1,022 RNs per 100,000 population.) Estimated RNs Per 100,000 Population in the U.S. 2008 854 2004 825

12. Facts About the RN Workforce  Federal figures project that if current trends continue, a shortage of RNs will grow throughout the next 20 years because of increased demand and RN retirements.  Government analysts project that more than 581,500 new RN jobs will be created through 2018.  By 2020, more than 800,000 RN positions may go unfilled nationwide.

13. Facts About the RN Workforce  The U. S. military requires a BSN for active duty RNs.  The Veterans Administration--the largest single employer of RNs—requires a BSN degree for promotion and has provided financial support for educational advancement since 2005.  Several minority nurse associations have been committed to increasing the number of RNs at the BSN level.  Magnet hospitals place a high value on nurses with BSN and higher degrees.

14. NURSING EDUCATION PROGRAMS

15. Approved Nursing Programs in Iowa 1 PHD 2 DNP

16. Nursing Education Programs In the 2008-2009 academic year  54% of Iowa’s RN pre-licensure students were enrolled in ADN programs.  Iowa’s ADN programs graduated more than two-thirds (67.5%) of the state’s new RNs. State’s New RN’s

17. Nursing Education Programs  More than 630 RN-to- Baccalaureate programs are available nationwide, including more than 390 programs that are offered at least partially online.  About 160 RN-to-Master’s degree programs are available which cover the baccalaureate content missing in the other entry- level programs as well as graduate level course work. 630+ RN to BSN programs available 630 RN to BSN Programs 160 RN to MSN Programs

18. WHY DOES THE BSN DEGREE MATTER?

19. Future of Nursing Project IOM, 2009  More nurses are working outside of hospitals as care shifts formally and informally into communities;  Evidence that could inform practice is growing rapidly, but is not well-integrated into either education or practice;  The need for nurses to effectively work in and lead teams is increasing; and  Numbers alone will not fill the widening gap between the supply of nurses and the growing need for their services -- additional research and new knowledge will be required.

20. Why Does the BSN Degree Matter?  Several studies support a significant association between the educational level of RNs and outcomes for patients in the acute care setting, including mortality rates.  In a widely-cited study published in JAMA in 2003, Dr. Linda Aiken identified a clear link between higher levels of nursing education and better patient outcomes.  This study found that surgical patients have a "substantial survival advantage" if treated in hospitals with higher proportions of BSN nurses. A 10% increase in the proportion of BSN nurses decreased the risk of patient death and failure to rescue by 5%.

21. Why Does the BSN Degree Matter?  In a study published in 2005, Dr. Carole Estabrooks and her colleagues found that baccalaureate prepared nurses have a positive impact on mortality rates following an examination of more than 18,000 patient outcomes at 49 Canadian hospitals.  This study confirmed the findings from Dr. Aiken’s landmark study from 2003.

22. Why Does the BSN Degree Matter?  A study reported in 2007 of 46,993 patients conducted by researchers at the University Toronto found that hospitals with higher proportions of baccalaureate-prepared nurses tended to have lower 30-day mortality rates.  The findings indicated that a 10% increase in the proportion of baccalaureate prepared nurses was associated with 9 fewer deaths for every 1,000 discharged patients.

23. Why Does the BSN Degree Matter?  In a study released in May 2008, Dr. Linda Aiken and her colleagues confirmed the findings from their landmark 2003 study which showed a strong link between RN education level and patient outcomes.  These noted nurse researchers found that every 10% increase in the proportion of BSN nurses on the hospital staff was associated with a 4% decrease in the risk of death.

24. Why Does the BSN Degree Matter?

25.  In an August 2008 article that examined the effect of nursing practice environments on outcomes of hospitalized cancer patients undergoing surgery, Dr. Christopher Friese and colleagues (University of MI) found that nursing education level was significantly associated with patient outcomes. Nurses prepared at the baccalaureate-level were linked with lower mortality and failure-to-rescue rates.  They concluded that “moving to a nurse workforce in which a higher proportion of staff nurses have at least a baccalaureate-level education would result in substantially fewer adverse outcomes for patients.”

26. Why Does the BSN Degree Matter?  In December 2009, Dr. Patricia Benner and her team at the Carnegie Foundation for the Advancement of Teaching released a new study titled Educating Nurses: A Call for Radical Transformation, which recommended preparing all entry-level registered nurses at the baccalaureate level and requiring all RNs to earn a master’s degree within 10 years of initial licensure.  The authors concluded that many of today’s new nurses are “undereducated” to meet practice demands across settings.

27. Why Does the BSN Degree Matter?  The Institute of Medicine’s report, The Future of Nursing: Leading Change, Advancing Health released in October, 2010, recommends that 80% of the nation’s RNs be baccalaureate-prepared by 2020.

28. Why Does the BSN Degree Matter?  In May 2010, the Tri-Council for Nursing, a coalition of four steering organizations for the nursing profession (AACN, ANA, AONE, and NLN), issued a consensus statement calling for all RNs to advance their education in the interest of enhancing quality and safety across healthcare settings. “Current healthcare reform initiatives call for a nursing workforce that integrates evidence-based clinical knowledge and research with effective communication and leadership skills. These competencies require increased education at all levels…Action is needed now to put in place strategies to build a stronger nursing workforce. Without a more educated nursing workforce, the nation's health will be further at risk.”

29. Why Does the BSN Degree Matter?  Several countries--Canada, Sweden, Portugal, Brazil, Korea, Greece, Australia, New Zealand, Philippines, Ireland, Iceland, Cuba—require a four year undergraduate degree for RN licensure  In Canada, most provinces limit licensure as an RN to individuals prepared at the baccalaureate level. None of the provinces have found that this position has decreased the number of students applying to nursing programs; in fact, applications to baccalaureate nursing program have increased.

30. Why Does the BSN Degree Matter?  For every 1000 nurses who initially graduated from a bachelor's degree program between 1974 and 1994, almost 200 eventually obtained a master's or higher degree. In contrast, only 58 of every 1000 nurses who initially graduated from an associate's degree program obtained at least a master's degree.  Twice as many nurses with an initial bachelor's degree ultimately obtained a doctorate, a finding that is relevant to the Institute of Medicine's call for a doubling of the number of doctoral level nurses by 2020.

31. Why Does the BSN Degree Matter?

32.  Of the approximately 72,000 nurses graduating from ADN programs in 2010, only about 4000 (5.5%) are likely to ever obtain a master's or higher degree — a yield that cannot produce enough faculty to replenish the RN workforce.  Had the proportions of RNs with initial education in bachelor's and associate's degree programs been reversed between 1974 and 1994, with the larger proportion being bachelor's graduates, there would probably have been 50,000 more nurses today with master's or higher degrees.

33. Why Does the BSN Degree Matter?  In 1964 the American Nurses Association adopted a motion that "ANA continue to work toward baccalaureate education as the educational foundation for professional nursing practice.“  Only one state--North Dakota--enacted such a law (1987) and then overturned the law in 2003 because various factions fought to have it removed, citing a nursing shortage.

34. Why Does the BSN Degree Matter?  Initiatives requiring a BSN degree have been introduced in the New York, New Jersey and Rhode Island legislatures over the past two years.  As many as 18 states are considering some type of initiative requiring newly graduated RNs to obtain a BSN in order to maintain their licensure.

35. Why Does the BSN Degree Matter? In 2009, a bill was introduced in the New York State Legislature to require registered professional nurses to attain a BSN degree within 10 years of their initial licensure- --called “BSN in 10.”  Grandparenting of all currently licensed RNs to exempt them from ever having to meet the requirements of the bill;  A 4-year lead-in time frame from the date of passage of the bill, to permit all students enrolled in non-BSN programs to complete their studies and be grandparented;  An RN’s license would be placed on “hold” when the baccalaureate degree is not obtained in 10 years--similar to the action taken when a licensee fails to meet continuing education requirements as a criterion for continued registration--with extensions for extenuating circumstances.

36. Why Does the BSN Degree Matter? Criticisms of the “BSN in 10” Proposal  Not all RNs want to return school and will be forced out of the workforce after ten years, further increasing an RN shortage.  BSN programs cost too much. Who will pay for RNs to complete the BSN degree?  BSN programs do not have enough capacity to accommodate all returning RNs.  Some RNs will not be academically successful in BSN programs and have to leave the nursing workforce.

37. The Need for DNP Degree  Most RNs are women and will find it difficult to juggle employee, family, and student roles.  Older RNs with only an ADN or diploma will be disenfranchised.  Employers will have to pay more for nurses with BSN degrees, further increasing healthcare costs.  Unions will resist any effort to impose a BSN requirement.  Community colleges will resist efforts to mandate the BSN for professional practice.

38. Preparation of Advanced Practice Nurses Four Types of Advanced Practice Nurses 1.Clinical Nurses Specialist 2.Nurse Practitioner 3.Certified Nurse Midwife 4.Nurse Anesthetist

39. The Nurse Practitioner Workforce Number of Nurse Practitioners in 2009: United States: 157,782 Iowa: 1,265 (0.8% of U.S. total NPs) Total Nurse Practitioners per 100,000 Population, 2009 United States:51 Iowa:42

40. Preparation of Advanced Practice Nurses Current Requirements for Initial Licensure as an Advanced Practice Nurse  Master’s degree with a major in nursing  Evidence of eligibility to take certification examination  Evidence of passing national certification examination offered by an approved organization (e.g., ANCC)

41. Proposal for Doctor of Nursing Practice Degree  In 2002 the American Association of Colleges of Nursing (AACN) convened an 11-member “Task Force on the Clinical Doctorate.”  In October of 2004 the AACN endorsed and published the Position Statement on the Practice Doctorate in Nursing.  In October 2006 the AACN member institutions voted to change the current level of preparation for advanced practice nursing from the master’s degree to the Doctor of Nursing Practice [DNP]) by the year 2015.

42. The Need for DNP Degree  The changing demands of this nation's complex healthcare environment require the highest level of scientific knowledge and practice expertise to assure quality patient outcomes.  The rapid expansion of knowledge underlying practice; increased complexity of patient care; national concerns about the quality 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 healthcare team.

43. The Need for DNP Degree  In a 2005 report titled Advancing the Nation's Health Needs: NIH Research Training Programs, the National Academy of Sciences called for nursing to develop a non-research clinical doctorate to prepare expert practitioners who can also serve as clinical faculty.  Nursing is moving in the direction of other health professions in the transition to the DNP. Medicine (MD), Dentistry (DDS), Pharmacy (PharmD), Psychology (PsyD), Physical Therapy (DPT), and Audiology (AudD) all offer practice doctorates.

44. Seven “Essentials” that Guide DNP Programs 1.Science underpinning advanced practice 2.Leadership for quality improvement 3.Clinical scholarship for evidence-based practice 4.Information systems/technology for improvement of health care 5.Health care policy for advocacy in health care 6.Interprofessional collaboration for improving care outcomes 7.Clinical prevention and population health to improve the nation’s health 8.Advanced nursing practice

45. Support for DNP Degree American Association of Nurse Anesthetists (AANA) Council on Accreditation will not accredit new master’s programs for nurse anesthesia after 2015. Mandates that all CRNA programs transition to the practice doctorate (“Doctor of Nurse Anesthesia Practice”) by 2022. All new CRNA graduates must hold a practice doctorate by 2025 to be eligible for certification.

46. Support for DNP Degree The Nurse Practitioner Coalition Statement Seven nurse practitioner organizations (AANP, ACNP, AFPNP, NCGNP, NONPF, NPWH, NPNP) support the DNP: “the DNP degree more accurately reflects current clinical competencies and includes preparation for the changing healthcare system.”

47. Support for DNP Degree National Organization of Nurse Practitioner Faculties Endorsed the DNP and developed competencies for NP practice at the doctoral level. National Association of Clinical Nurse Specialists Neutral position on the DNP; has developed DNP level competencies for CNS graduates. American College of Nurse Midwives Recognizes the DNP as an option for some midwifery programs.

48. Challenges in Starting a DNP Program  Insufficient numbers and type of faculty  Limited financial resources  State and accreditation regulations  Lack of faculty support  Lack of interest by students (especially post-MSN programs)  Insufficient preceptors/mentors for students

49. About DNP Programs  72% of schools with ARNP programs (388 schools) are either offering (120) or planning (161) a DNP program.  62% of schools either offering or planning a DNP program are planning to offer a post ‐ baccalaureate entry option.  CCNE has accredited 55 DNP programs  Many additional DNP programs are pursuing CCNE accreditation

50. About DNP Programs DNP programs are now available in at least 36 states plus the District of Columbia. States with the most programs (5 or more) include Florida, Minnesota, New York, Pennsylvania, and Texas. In Iowa  The University of Iowa offers a post-BSN/post- master’s DNP program.  Allen College plans to open a post-master’s DNP program in fall 2011.  Clarke University has been approved to start a DNP program in fall 2011.

51. DNP Questions  How do schools of nursing transition their MSN programs to DNP programs?  What credentials do faculty need to teach in DNP programs?  Will moving to a DNP program reduce the number of ARNPs in my school and state?  Will employers prefer to hire DNP graduates over MSN graduates?  Will the increased cost of completing a DNP be offset by higher salaries for those with the DNP?  Can DNP graduates earn tenure in the faculty role?

52. DNP Questions  Will health care systems have the personnel and time to supervise students in additional clinical and independent project activities?  Will MSN-prepared ARNPs be grandfathered if the DNP becomes the required degree for ARNP certification?  How will other practitioners and the public view and understand the DNP-prepared ARNP?  Will patients be confused when the NP is called “Doctor”?  What new roles will DNP graduates play in a reformed healthcare system?  Will the DNP cause a ↓ in PhD program enrollments?

53. Questions and Comments