Transforming Nursing Education Creating the Nursing Workforce of the Future We are at the threshold of great opportunity in health care….and great opportunity for the nursing profession. Why is this topic of importance to our organization? Alabama’s community colleges produced 1,968 graduates in 2008-09 BSN programs produced 1,494 graduates PN programs produced761 graduates We have 67 nursing programs in the state including 25 PN programs and 27 ADN programs Linda Cater, RN, MSN Director of Health Programs – Postsecondary Education Alabama Community College System Martha G. Lavender, RN, MSN, DSN Assistant to the President – Cherokee Campus /Health Sciences Gadsden 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. The objectives for this session …..

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) In addition to our experience, values, and knowledge of the workforce needs in Alabama, this presentation will summarize data derived from the following documents: 2008 National Sample Survey of the RN Population Pat Benner’s work as the lead for the Carnegie Report: Educating Nursing – A Call for Radical Transformation and Donna Shalala’s team combining the Robert Wood Johnson Foundation and the Institute of Medicine – The Future of Nursing: Leading Change Advancing Health

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 Statistics vary: some experts predict that the US will be short more than 260,000 RNs by 2025; the Bureau of Health Professions predict 1,000,000 nurse shortage…… Iceberg Effect – which is how the shortage is often described lately due to the fact that older nurses are staying in the workforce longer due to the economic downturn in the US According to the National Student Nurses Association – market is flooded with experienced RNs who have come out of retirement, delayed retirement, or gone from part-time to full-time because of the recession. From a June 2009 survey, 44% of spring graduates were without a job. As the economy improves, workforce analysts predict a wave of retirements and a return of the effects of the nursing shortage In Arizona, about 21% of new graduates lacked nursing jobs. 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 Nursing workforce -5.3% increase since 2004 Highly employment in the history of nursing – 84.8% Sources: 2008 National Sample Survey of RNs (2010); HRSA Supply, Demand, and Use of LPN (2004)

Distribution by Initial Nursing Degree 1980-2008 The majority of nursing graduates obtained their initial nursing degree at the associate degree level…. Source: 2008 National Sample Survey of RNs (2010)

Highest Nursing or Nursing Related Degree 1980-2008 In the most recent NSS, the percentage of nursing with a baccalaureate or higher degree rose above 50% for the first time in the history of nursing. Source: 2008 National Sample Survey of RNs (2010)

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 An interesting finding….nurses who enter as an associate degree RN are less likely than those with a baccalaureate degree to advance to graduate level education. 80% of the time – associate degree nurses fail to move beyond the BSN Source: 2008 National Sample Survey of RNs (2010)

Average Age at Graduation for Initial Nursing Education by Type of Program No significant changes in average age of all RNs in the US --- - 46 More nurses less than 30 entering the profession. Average age at graduation by program type: Diploma and associate degree grads have average age of 33 years Baccalaureate grads average age is 28 Source: 2008 National Sample Survey of RNs (2010)

Actual and Inflation-Adjusted Salary Salary – and diversity/mobility of the nursing profession - are compelling incentives for choosing a career in nursing….. The average salary in the US is just below $67,000……and those practice salaries make it very difficult to recruit nurses into education (which typically has lower salaries) Also, the differences in salary for the BSN and ADN are not significant…. 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 $66,973 Diploma $65,349 Associate $60,890 Bachelor’s $66,316 Master’s/Doctoral $87,363 These data were cited from the IOM report but their actual source is the 2008 NSS Source: IOM Future of Nursing Initiative (2010). Transforming education (Chapter 4) p. 4-8.

Top 10 Nursing Salaries Nurse anesthetist $154,221 Senior Management 96,735 Nurse Practitioner 85,025 Nurse midwife 82,111 Management/administration 78,356 Consultant 76,743 Informatics nurse 75,242 Middle management 74,799 Clinical nurse specialist 72,856 First-line managers 72,006 Considering the potential for advancement, one can readily see why so many nursing students talk about anesthesia school……. Typical staff nurse salary = $61,706 As evident on the slide, typical salary of an educator = $65,844 Average salary of nurses engaged in instruction - $65,844

Employment of RNs by Age Group This graph simply depicts that we have more nurses age 50 and above in nursing today in comparison to previous NSS Source: 2008 National Sample Survey of RNs (2010)

Employment of RNs by Age Group Again, a different bar graph – with same information….. Experience and expertise is highly valued…a wave of retirements could (and will) have a significant impact on the profession and health care delivery Brain drain!

“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.” Whether we are talking about primary care, acute care, or tertiary care settings….nurses have the largest workforce in any health delivery system….. We are the heart of patient care…and for the 8th consecutive year, nursing was voted the most trusted profession by the Gallop Poll

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. In recent debates, it was clear that policy makers understand the importance of nursing care within the health delivery system Our costs may have been embedded in room charges for many years, but without nurses, we wouldn’t have patients in hospital beds…they would be taking their meds/treatments at home.

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 Rebecca Patton, past president of ANA, provided a quick summary of the PCA at a recent national meeting….here are the highlights To address shortages in the health professions – more money for nursing education and primary care practices Incentive for new models of care delivery ---- some of not so new (e.g., nurse managed clinics) Mandate for innovation in care delivery….trying new solutions in collaboration with the patient and family APRN – National Consensus Model and multi-state approval of model regulatory language to allow for expansion of reimbursement. Wide variances in state laws make reimbursement (at the national level through CMS) almost impossible

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 From the Carnegie report, we learned that the differences in clinical and classroom education were significant. Clinical education is usually better than classroom. Benner et al., emphasized the need to integrate clinical/classroom by ongoing teamwork with classroom/clinical faculty when classroom teacher also teaches in clinical area The problem is that we tend to teach the classroom at the knowledge level (lecture, lecture, lecture) and we teach clinical at the application level. Students reported that they learned “situated cognition” in clinical because they could see and apply information. Many times they reported a disconnect with lecture content. 3 apprenticeships (refers to a metaphor for learning a practice discipline): Cognitive apprenticeship – refers to science, theory, and humanities (knowledge) Practice apprenticeship – refers to learning a practice discipline that uses knowledge in complex situation Ethical apprenticeship – learning to perceive and practice in actual situation (best practices)……emphasizes movement from socialization to formation

IOM Future of Nursing Initiative 4 Key Messages Improve nursing education. Remove scope of practice barriers. Foster interprofessional health care teams. 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 # of diploma programs in the US = XXXXX The least common route to becoming an RN is the diploma program – generally takes 3 years to complete. The number of diploma programs have decreased significantly expect in a few states: New Jersey, Ohio, and Pennsylvania

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 The most common pathway to registered nursing is the associate degree.. COST and TIME are important factors in educational program choices In most non-health care disciplines, it takes students 2 years to complete a degree. Some surveys have found it takes 3-4 years to complete an ADN - fulfill pre-requisites (misnomer----but look at our admission criteria) - lack of adequate # faculty/clinical space – leading to long waiting lists Community colleges play a key role in attracting students into the nursing pipeline. ACCESS is provided to students who may have not been able to attend a traditional university BSN program (distance, cost) ADN and BSN prepared nurses are not evenly distributed nationwide. BSN prepared RNs are found more commonly in urban areas, while many rural and medically underserved communities depend heavily on ADN nurses THIS suggests that state/community investments in nursing education may be an effective way to reduce local/regional shortages (e.g., Gadsden State Cherokee)

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 We need updated curricula – care continues to grow more complex…nurses are required to make very critical decision associated with care for sicker, frailer patients – requires analysis and synthesis….need more competencies in geriatrics, culturally relevant care, public health, and “care coordination” Benner – situated cognition, clinical reasoning, salience Quality improvement has changed: CMS Core measures, HCAPS, TJC In a reformed system, nurses must understand patient safety goals, prevention, wellness, enrollment in Medicare and Medicaid – and how to navigate those systems Rote memorization (may have worked in the past) is NO LONGE an option in nursing 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 Benner advocated by BSN in 10 IOM recommends that 80% of nurses (currently at 50%) have a BSN by 2020. Do you remember that almost 15 years ago, the National Advisory Council on Nurse Education and Practice recommended that 2/3 of RN hold a BSN or higher by 2010. Described recommendation as BOLD, ACHIEVABLE, and NECESSARY Growing body of research has related patient outcomes to educational preparation in nursing (Linda Aiken and others). Some studies have related outcomes to “experience” [- still other have found no association between BSN and patient outcomes. Some health care organizations are leading the way by requiring more BSN prepared nurses for entry-level positions…teaching and children’s hospitals tend to require 90% BSN while community hospitals (rural) are at 50% Army, Navy, and Air Force require active duty nurses to have a BSN. The VA system, the largest employer of RNs in the US, requires nurses to have a BSN to be promoted beyond entry level. The US Public Health Services required commissioned officers to hold the BSN

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 The challenges associated with prelicensure programs (faculty/clinical shortages) are less problematic for licensed RNs pursuing a BSN than for prelicensure students. RN to BSN: Much of what is needed can be taught in a classroom or online – with additional tailored clinical experiences. Fewer than 1% of nurses hold a doctorate (28,369)…..the DNP is a complement to other practice doctorates such as MD, PharmD. Doctorate in PT… DNP programs graduate clinical scholars….with the capacity to translate research. Scholars in practice, leadership, quality improvement, and health policy

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 NCLEX rates of success are often used for rating schools or for marketing to potential students…….Yet, NCLEX tests the minimum competency required to practice nursing safely – does not test desired competency levels… uses multiple choice items – no competency testing Higher level competencies in decision-making are lacking patient centered care quality improvement principles interprofessional teams evidence-based practice using health information technologies

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 Faculty shortages – real and growing problem…… Age, salary, workload, educational preparation, and diversity of faculty contribute to faculty shortages Too few faculty have formal preparation in curriculum development, instructional design, and performance assessment Faculty tend to teach the way they were taught…”covering content” IOM report called for a market-based salary adjustment for nursing faculty!

Age Distribution of Nursing Faculty Age is a contributing factor ….. Faculty tend to be older than clinical nurses because they must meet requirements for advanced degrees in order to teach. Average age of faculty 50-54. Average retirement age for faculty is 62.5 years – many will soon be ready to retire. 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 As said before, another factor is salary Average earning for a faculty with MSN or Doctorate is $63,949 – nurse practitioners average salary is $85,000. RWJF Nursing Research Network project faculty demand in ADN and BSN programs over the next 15 years – estimated between 5,000 and 5,5000 positions unfilled. In Alabama, the 2008-09 annual reports revealed that 52 faculty positions were unfilled (down from 97 in 2007-08 year)

Innovations in Clinical Education Limited clinical settings Faculty report spending time supervising students in hands-on procedures, leaving little time for clinical scenarios, questioning, and fostering salience 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 Required clinical hours vary from program to program and most BON do NOT specify a minimum # hours in prelicensure program. More likely that many of clinical hours fail to result in productive learning. Faculty report spending most of time supervising hands-on procedures, leaving little time focused on fostering development of clinical reasoning skills DEU – viable alternative for expanding clinical capacity. Health care unit are dedicated to instruction of students from one program..staff who want to serve as clinical faculty are prepared to do so – faculty used to support development and their comfort in the role. DEUs were started in Australia – University of Portland. Students have 2 six-week rotations per semester – each staff nurse instructor teaches no more than two students at a time. University faculty oversee instructor. Benefit to hospital – hire graduates ready to work!

Curricular Innovations Simulation 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) High fidelity simulation offers a potential solution to the problem of limited opportunities for clinical experiences However, little evidence that simulation expands faculty capacity no data to define what portion of clinical it can replace (NCSBN National Study

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 NLN has established an online community SIRC where faculty learn how to design, implement, and evaluate the use of simulation in their curricula In the future, we’ll probably see some guidelines if not specific regulatory language about the percentage of time allowed for 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. Massachusetts New 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. Mississippi Developed the Mississippi Student Navigator which directs students to information financial, health insurance, transportation assistance, child care, stress management, and academic preparation. OCNE – Oregon Health and Science University – Christine Tanner – shared curriculum (similar to the common curriculum in PSE) shared simulation facility shared faculty

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. Underrepresentation of racial and ethnic minorities is greatest in pathways associated with higher education (less accessible, less affordable) Men in nursing – stereotypes, academic acceptance, and role support is needed for men…yet distribution by degree is: 28.2% - ADN, 23.6% BSN, 24.4%, MSN, and 20.3% Doctoral Compared to medical school (traditionally male) ½ of all grads were female in 2009 Harlem Project RAIN – Recruitment and Retention of American Indians into Nursing – created an atmosphere of “total support” in a “home away from home” 8 day immersion orientation academic mentors help with child care free taxi services cash assistance for emergencies Shared learning environments Residencies to offer transition to practice = reinforce competencies in real world setting that are safe and monitored No linkage between continuing education and continuing competence – need to build capacity for life-long learning (continuing competence and advanced degrees)

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: $16,800 Pay-for-Performance Plan: In 2009, Texas was facing an immediate nursing shortage of 22,000; it was projected to increase to 70,000 by 2019. The Texas Workforce Shortage Coalition determined the need to double graduates by 2013…they enlisted the support of the Texas Association of Business (TAB) who demanded that additional funding be based on pay-for-performance with a defined accountability system. They looked at graduation rates and found a wide variance: 22 to 98%. They divided the programs into high grad producers (70% or more) and low producers (less than 70%). A request for $60 million was made with most of the money targeted for high producers. Schools in both groups that failed to meet the set target percentages would have to return state money on a pro rata basis. Final outcome: 49.7 million in new and capacity building funds were appropriated. High-producing schools received $20.5 million over two years in new money and 9.5 million to low producers. ($5 million for a sim lab (UT Arlington) and almost $15 million targeted for schools that show increase between 2008 and 2009) Texas A&M Model Source: National Education Association Advocate (October, 2010), 28 (1), p.9.

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