1. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 1 Entry Into Practice: The Debate Rages On

2. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Entry-to-Practice Debate 1940s –Esther Lucille Brown’s Nursing for the Future 1965 –ANA Position Paper Orderly transition from hospital-based diploma programs to education in colleges/universities

3. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins ANA Position Paper Premises Education in institution of higher education BSN as minimum for professional nurse; associate’s degree as minimum for technical practice Short, intensive preservice programs in vocational educational institutions for assistants in health care occupations

4. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins ANA Position Paper (cont.) Two levels of preparation 1.Technical Junior or community college 2-year programs Associate’s degree (ADN); beginning, technical practitioner to provide care in acute-care settings under supervision of professional nurse

5. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins ANA Position Paper (cont.) Two levels of preparation 2.Professional College or university 4-year program Bachelor’s degree (BSN)

6. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins ANA Position Paper (cont.) Reaffirmed 1978 by ANA House of Delegates with BSN as entry to practice by 1985 Resolution in 2008 –BSN within 10 years of licensure for diploma- and associate-degree-educated nurses. –Individual states for mandating and implementing Issue still not settled

7. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Proliferation of ADN Education 1960s –Primarily diploma schools of nursing education –Baccalaureate enrollment increasing –Associate’s degree programs just beginning

8. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Proliferation of ADN Education (cont.) 2000s –Diploma programs virtually gone –ADN as primary model for initial nursing education –BSN education on the rise –50% of current RN workforce holding a baccalaureate or graduate degree

9. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Is the following statement true or false? During the 1960s, most nursing education was provided at the baccalaureate level.

10. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer False. Diploma nursing programs were the most common type of nursing educational program in the 1960s.

11. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Licensure and Entry Into Practice NCLEX passing rates—no significant differences Similar competencies across educational spectrum Minimum technical competencies versus performance measurement over time or test of all knowledge, skills Similar criteria for state board approval Demographic differences of BSN, ADN grads Employers’ lack of role differentiation, incentives Shorter time for ADN; cost- or time-prohibitive for BSN

12. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Educational Levels and Patient Outcomes Arguments against raising entry level –Educational degree unrelated to providing high- quality care –BSN too theoretically oriented, deficiency in basic skills mastery

13. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Educational Levels and Patient Outcomes (cont.) Research findings associated with BSN –Higher educational levels  better patient outcomes –Better care environments, best nurse staffing levels, and most highly educated nurse  lowest surgical mortality rates Institute of Medicine (IOM) report 2010 –Expectation to coordinate care with other health care professionals with higher degrees –ADN or diploma-educated nurse being set up to fail

14. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Employers’ Views and Preferences Usually no distinction in scope of practice Possible increasing awareness of differences between BSN and ADN grads –Preference for clinical placements by some employers based on higher degree programs –Nursing manager and administrator positions now requiring or preferring at least BSN Magnate hospitals required to have higher percentage of nurses at BSN level Veterans Administration: BSN as minimum for new hires, required of all non-entry-level nurses

15. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Shifting Health Care Delivery Sites and Required Competencies Hospitals  community and integrated health care settings Need for more highly educated, autonomous nurses Tri-Council for Nursing: education advancement to enhance quality and safety across health care settings IOM 2010 report –Increase from 50% to 80% of BSN nurses in workforce over next 10 years –Double population of nurses with doctorate degrees

16. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Shifting Health Care Delivery Sites and Required Competencies (cont.) Educating Nurses: A Call for Radical Transformation –BSN as entry level –Master’s degree within 10 years of initial licensure NACNEP: 2/3 of RNs with BSN or higher by 2010 Council on Physician and Nurse Supply (2007): shift in federal funding for more BSN-level programs

17. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Entry Level & Professional Status Most other professions require graduate degree for entry Growing educational gap between nursing, other health professions View by some: BSN for entry is elitist Failure of educational parity contributing to view of nurses as “second-class citizens” in health care arena Nursing as the only health care profession not requiring at least a bachelor’s or higher degree for entry into practice

18. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Is the following statement true or false? An employer will most likely pay a nurse with a BSN a larger salary than a nurse with an ADN.

19. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer False. Employers commonly provide no incentives for BSN education in terms of pay, recognition, or career mobility.

20. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Two-Year ADN Program? Argument: 2-year ADN program a myth –Minimum of 12 to 24 months of prerequisites + 2 full years of nursing education –60 semester units or 90 quarter units of coursework (or more) BSN programs: approximately 120 semester units Increased ADN time: need to prepare ADNs for more diverse environments, positions needing management skills ADN content versus BSN content

21. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Shortages and Entry-Level Requirements Short-term threat of raising entry level: exacerbation of existing nursing shortage Long-term effects –Elevation of nursing’s public image with increased recruitment –Increase in recruitment-profession with greater academic prestige –Increased retention rates—possible stabilization of workforce due to increased job satisfaction Persistence of chronic nursing shortage negates argument as excuse for postponing action to raise educational standards

22. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Professional Organizations, Unions, & Advisory Bodies Speak Out NOADN: reaffirmation of role, value of associate’s degree nursing education, practice NLN: multiple entry points for nursing; focus on lifelong learning, progression Nurse Alliance of the Service Employees International Union (SEIU): rejection of BSN as necessary for entry into or maintenance of practice –More resources to support nursing education at all levels

23. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Professional Organizations, Unions, & Advisory Bodies Speak Out (cont.) Specialty professional organizations (AACN, NANN, ANNA, AORN, AONE): position statements supporting BSN as entry level National Advisory Council on Nurse Education and Practice: 2/3 of working RNs with BSN or higher by 2010 Federal and state regulation into practice still not a reality

24. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Grandfathering Entry Levels If entry level raised, debate over how, when grandfathering applied –Some advocate for all RNs to be grandfathered –Others argue for no grandfathering –Still others suggest it be conditional (retain title for a certain time but be required to return to school to meet new entry level)

25. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Linking ADN and BSN Programs Barriers for returning to school –Cost, time, fear, lack of recognition for past education/success –Equal treatment of BSN, ADN, diploma RNs –Negative ADN or diploma school experience

26. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Linking ADN & BSN Programs (cont.) Incentives for returning to school –Being at the right time in life; working with options; achieving personal goal –BSN as credible professional identity –Encouragement from contemporaries; user-friendly RN-BSN programs

27. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Linking ADN & BSN Programs (cont.) RN to BSN programs; RN-to-Master’s degree programs Statewide articulation agreements to facilitate credit transfers Issues –Integration, standardization, or cooperation between public systems of education –Transition programs –Alternative education pathways –Funding/cost

28. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Which of the following would most likely be the major barrier to obtaining advanced nursing education? A. Fear of going back to school B. Limited time available C. Cost of the program D. Little recognition for past experience

29. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer C. Although fear, limited time, and lack of recognition for past educational and life accomplishments can be a concern for those considering continuing their education, cost is often the chief obstacle to obtaining advanced education.

30. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins International Issue Establishment/adoption of baccalaureate degree as entry level by other countries –Canada, Australia, South Africa –Wales, Scotland, N. Ireland –Italy, Norway, Spain, Ireland, Denmark –Sweden, Portugal, Brazil, Iceland, Korea, Greece, and Philippines Continued conflict even in those who have adopted or are moving toward BSN entry level

31. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins End of Presentation