More Americans with chronic illness! More elderly using healthcare services! Acutely ill people, from an array of cultures, admitted to hospitals! Expanding waistlines translating into more diabetes, heart disease and joint problems in adults and children!
Healthcare in this century will only get more complex. In addition to less healthy populations, the Affordable Care Act will require 32 million citizens to have health insurance by 2014.
Who is going to attend to all these patients?
The Institute of Medicine (IOM) and the Robert Wood Johnson Foundation (RWJF) believe nurses are more than up to the task.
"Nurses have very specific skills critical in caring for much sicker and older patients," said Susan B. Hassmiller, PhD, RN, FAAN, senior advisor for nursing at RWJF and director, The Future of Nursing: Campaign for Action.
"And we know from research, people who got an associate degree, like myself, then went on to higher degrees, know a greater feeling of competence and confidence, and will be best suited to care for those in the community and public health settings, where the need will be greatest."
Add to that the much-quoted studies of University of Pennsylvania Researcher Linda Aiken, PhD, RN, FAAN, FRCN, showing patient mortality decreases when more BSN nurses are on the job.
Making it Happen
So the number of nurses with a BSN degree must increase proposes the IOM and RWJF, among others.
To date, about 50 percent of U.S. nurses have a baccalaureate degree or higher.
The joint IOM and RWJF report, "The Future of Nursing: Leading Change, Advancing Health," calls for 80 percent of nurses to have their BSN by 2020.
It is a long-running argument that the BSN should be the entry-level requirement for nursing.
A few states, such as New Jersey, have made headway in requiring newly practicing community college- and diploma-graduated nurses to achieve a baccalaureate degree within 10 years of starting work, known as the "BSN in 10."
However, other states have been slow to jump on board.
Realizing there are many impediments to nurses achieving a baccalaureate degree and recognizing there is value in community college nursing education, the 80 percent by 2020 campaign is taking a different tack.
Aided by colleges, universities, the American Nurses Credentialing Center (ANCC), which confers Magnet recognition, in addition to grant funds and the support of numerous hospitals and health systems, the campaign is gaining momentum.
"It comes down to doing what's right for patients, regardless of the cost," said Maureen White, MBA, RN, NEA-BC, senior vice president and chief nursing executive at North Shore-LIJ Health System, with 15 hospitals and 11,000 nurses in Long Island and New York City.
White estimates it could cost North Shore anywhere from $5 million to $10 million to achieve 80 by '20. Since September 2010, when the program began at the health system, North Shore has helped about 200 newly hired RNs who didn't have a baccalaureate degree to enroll in BSN programs.
Then there is Main Line Health (MLH) with hospitals in southeastern Pennsylvania, which recognizes there are many ways nurses "can continue to grow," said Nikki Polis, PhD, RN, system director, Education, Research and Grants Management, Department of Nursing, at the five-hospital MLH, three of which have earned Magnet recognition. This growth includes attaining specialty certification, advancing on the clinical ladder, or achieving a BSN or advanced degree.
Even the ANCC Magnet program is contributing to the effort.
Effective June 1, 2013, according to the Magnet information website, (http://nursecredentialing.org/FunctionalCategory/FAQ/DEO-FAQ.aspx) a new source of evidence needed to apply for Magnet status requests applicants: "to provide an action plan and set a target, which demonstrates evidence of progress toward having 80 percent of direct-care nurses obtain a baccalaureate degree in nursing or higher by 2020."
Cohorts for Comfort
One of the most forward-thinking initiatives toward the goal began long before Aiken's study and involves a consortium of nine higher-education institutions in the Pacific Northwest, the Oregon Consortium for Nursing Education (OCNE).
OCNE sought to better prepare nurses to address changing healthcare needs and increase capacity for baccalaureate education, all on a tight budget, explained consortium member Chris Tanner, PhD, RN, FAAN, from Oregon Health & Science University, Portland.
"Before OCNE developed a common curriculum taught at all 13 campuses, there were many impediments to people advancing their education," Tanner told ADVANCE.
"First, nursing coursework in baccalaureate programs was duplicative of what nurses had already studied in an associate degree program. Second and third: work schedules, financial obligations and no access to financial aid created additional barriers.
"Half or more students in community colleges live below the poverty level, so financial considerations to continue education are considerable," Tanner stressed.
Another issue: many associate degree nurses in the Beaver State were required "to go back and take prerequisites, like prechemistry and algebra, before starting a BSN program," Tanner continued. "Then they had to fill out a separate application for each and every school."
OCNE even examined what might be considered minor details with significant impact. "We considered a cohort model because it would be more enjoyable for students at community college campuses to continue their education as a group in their home community."
OCNE's 13 partnering campuses eliminated other educational barriers.
"Through work with financial aid officers, students may have seamless aid as they transition to the university for their final year of coursework," Tanner explained. "We agreed on some prerequisite courses on all campuses to avoid duplication. We standardized admission applications and requirements."
Achieving the Goal
Tanner points out the goal is not to make BSN a requirement to enter nursing. "Making this all about the degree is a problem because it throws us back into the argument about BSN as entry-level," she said. Also education institutions don't have the capacity to accommodate all students who might seek a BSN because of faculty shortages, another OCNE concern.
Hassmiller agreed in a RWJF communication: "We must all stand together as a profession to make healthcare better, not quibble about whether the ADN or the BSN degree is better." She later told ADVANCE, "in rural areas there may not be a university for many miles. Community college may be the only option."
RWJF and IOM got involved in this issue, Hassmiller said, because it affects the heart of the healthcare system.
"Nursing is a critical component of the RWJF mission, to improve health and healthcare for all Americans," she explained. "Nursing, as the largest healthcare profession, the one closest to the patient, is essential to making this work."
The commitment to this goal is high. For example, 36 states are part of RWJF's Action Coalitions in its Future of Nursing Campaign for Action www.thefutureofnursing.org. "Each state chooses whichever of the 43 IOM recommendations they want to work on," Hassmiller said. "In almost every state, the one they have chosen is 80 percent BSN by 2020."
What They Are Doing
North Shore and MLH each approaches the problem of education unique to their needs.
"Main Line has not definitely decided on adopting the 80 percent by 2020," said Martha Lyman, MSN, MPH, RN, system director for nursing systems for MLH. "However, the health system is committed to ensuring nurses have every opportunity to advance education and clinical expertise."
For external new nurse graduates MLH will only interview and hire BSN-prepared nurses at this point.
"Given the complexity of care today, we do seek a BSN for new graduates. For all our nurses we provide multiple resources to help them advance their skills including generous tuition reimbursement - $6,000 annually. We support nurses becoming certified, advancing in the clinical ladder and pursuing other opportunities that will enhance their clinical expertise."
That support goes further. "In January and February at each of our five sites, we've invited 10-plus of our education partners to a college fair," Polis explained. "Nurses want to know the options for programs such as entrance requirements, format, [i.e.], are they online only, a blend of online and classroom or only classroom."
MLH has negotiated tuition reductions or deferral of payment for courses and two MLH facilities have onsite education programs for nurses.
Even though, as of Sept. 1, 2010, North Shore required new hires to hold a BSN, they will consider RNs who agree to continue their education. "We give them up to 5 years to achieve that, understanding they would need to enroll in a program within 2 years of hire," White explained. Tuition is paid upfront.
North Shore also offers the chance for ancillary staff to become nurses through diploma or community college programs with the expectation they will go for a BSN degree later. "We were struck by the number of employees who said they always wanted to be a nurse," White said.
New York State is considering a bill to require a BSN in 10 years, but White said: "We looked at that legislation in hopes it would pass but thought, "Why wait? If it's the right thing to do, let's do it now.'"
Gail O. Guterl is a frequent contributor to ADVANCE.