A new trend in nursing education that is consistent with real-world practice is focused on:

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Institute of Medicine (US) Committee on the Robert Wood Johnchild Foundation Initiative on the Future of Nursing, at the Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington (DC): National Academies Press (US); 2011.


Institute of Medicine (US) Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine.

Key Article #2: Nurses have to accomplish greater levels of education and also training with an improvededucation and learning system that promotes seamless academicprogression.

Major transforms in the UNITED STATE health and wellness treatment system and exercise environments will certainly need equally prouncovered transforms in the education and learning of nurses both prior to and after they receive their licenses. Nursing education and learning at all levels needs to carry out a much better expertise of and also experience in treatment administration, top quality improvement techniques, systems-level change monitoring, and also the reconceptualized functions of nurses in a recreated health treatment system. Nursing education need to serve as a platform for ongoing lifelengthy learning and also incorporate opportunities for seammuch less transition to greater level programs. Accrmodifying, licensing, and certifying establishments must mandate demonstrated mastery of core abilities and competencies to enhance the completion of degree programs and written board examicountries. To respond to the underrepresentation of racial and ethnic minority groups and guys in the nursing workpressure, the nursing student body need to become more varied. Finally, nurses must be educated with physicians and also various other wellness professionals as students and throughout their careers.

Major alters in the U.S. health and wellness care system and also exercise environments will certainly need equally profound transforms in the education of registered nurses both prior to and also after they obtain their licenses. In Chapter 1, the committee set forth a vision of wellness care that depends on a transformation of the functions and duties of registered nurses. This chapter outlines the fundamental transformation of nurse education and learning that need to occur if this vision is to be realized.

The major purposes of nursing education remajor the same: nurses should be prepared to fulfill varied patients’ needs; feature as leaders; and also advancement science that benefits patients and the capacity of wellness professionals to provide safe, high quality patient care. At the very same time, nursing education needs to be transformed in a number of methods to prepare nursing graduates to work-related collaboratively and efficiently through other wellness experts in a facility and also evolving health treatment device in a variety of settings (watch Chapter 3). Entry-level registered nurses, for example, have to have the ability to transition smoothly from their academic preparation to a selection of practice settings, through an boosted emphasis on community and also public health settings. And progressed practice registered registered nurses (APRNs) need graduate programs that have the right to prepare them to assume their roles in main treatment, acute treatment, permanent care, and other settings, as well as specialty methods.

This chapter addresses essential message #2 collection forth in Chapter 1: Nurses should attain greater levels of education and learning and also training via an enhanced education and learning system that promotes seammuch less academic development. The chapter begins by concentrating on nurses’ undergraduate education, emphasizing the need for a greater variety of registered nurses to enter the workpressure via a baccalaureate level or to progression to this level early in their career. This area additionally outlines some of the obstacles to meeting undergraduate educational requirements. The chapter then turns to graduate nursing education and learning, stressing the should increase significantly the numbers and also preparation of nurse faculty and also researchers at the doctdental level. The 3rd area explores the must create, preserve, and expand brand-new competencies throughout a nurse’s education and learning and career. The chapter next addresses the difficulty of underrepresentation of racial and also ethnic minority groups and men in the nursing profession and suggests that meeting this difficulty will certainly need increasing the diversity of the nursing student body. The fifth section defines some creative services that have actually been devised for addressing comes to around educational capacity and also the should transform nursing curricula. The final section presents the committee’s conclusions regarding the enhancements required to transcreate nursing education.

The committee might have actually devoted this whole report to the topic of nursing education—the topic is wealthy and extensively disputed. However, the committee’s statement of task required that it research a selection of issues in the field, rather than delving deeply right into the many type of challenges involved in and services forced to advance the nursing education mechanism. Several thorough reports and analyses addressing nursing education and learning have freshly been publiburned. They encompass a 2009 report from the Carnegie Foundation that calls for a “radical transforma tion” of nursing education (Benner et al., 2009); a 2010 report from a conference sponsored by the Macy Foundation that charts a course for “life-long learning” that is assessed by the “demonstration of competency in both scholastic programs and also in proceeding education” (AACN and AAMC, 2010); 2 consensus reports from the Institute of Medicine (IOM) that speak to for higher interexperienced education of medical professionals, nurses, and also various other health and wellness professionals, and also new techniques of improving and demonstrating competency throughout one’s career (IOM, 2003b, 2009); and also various other short articles and also reports on crucial curriculum alters, faculty development, and new partnerships in education (Erickkid, 2002; Lasater and also Nielsen, 2009; Mitchell et al., 2006; Orsolini-Hain and Waters, 2009; Tanner et al., 2008). Additionally, in February 2009, the committee organized a forum on the future of nursing in Houston, Texas, that concentrated on nursing education and learning. Discussion in the time of that forum increated the committee’s deliberations and also this chapter; an introduction of that forum is consisted of on the CD-ROM in the earlier of this report.1 Finally, Appendix A highlights other current reports appropriate to the nursing profession. The committee refers readers wishing to discover the subject of nursing education and learning in higher depth to these publications.


This section starts via an introduction of existing undergraduate nursing education, consisting of educational pathmethods, the distribution of undergraduate degrees, the licensing exam, and expenses (view Appendix E for extra background indevelopment on undergraduate education). The discussion then concentrates on the require for more nurses ready at the baccalaureate level. Finally, barriers to meeting undergraduate educational requirements are reregarded.

Educational Pathways

Nursing is distinctive among the health and wellness care professions in the USA in that it has multiple educational pathmeans resulting in an entry-level license to exercise (watch the annexes to Chapter 1 and also Appendix E). For the past 4 years, nursing students have been able to seek three different educational pathmeans to become registered registered nurses (RNs): the bachelor’s of science in nursing (BSN), the associate’s level in nursing (ADN), and also the diploma in nursing. More newly, an increased, second-level bachelor’s routine for students that possess a baccalaureate degree in an additional field has become a famous option. This multiplicity of alternatives has actually fragmentised the nursing neighborhood and has actually produced confusion among the public and also various other health experts about the expectations for these educational options. However before, these pathways also provide countless avenues for womales and also men of modest implies and diverse backgrounds to accessibility careers in an economically secure area.

In enhancement to the BSN, ADN, or diploma obtained by RNs, another undergraduate-level regimen easily accessible is the licensed practical/vocational diploma in nursing. Licensed practical/vocational registered nurses (LPNs/LVNs) are particularly vital because of their contributions to treatment in irreversible care infrastructure and nursing homes.2 LPNs/LVNs receive a diploma after completion of a 12-month regime. They are not educated or licensed for independent decision making for facility treatment, yet achieve standard training in anatomy and physiology, nutrition, and also nursing methods. Some LPNs/LVNs continue their education and learning to end up being RNs; in fact, around 17.9 percent of RNs were as soon as licensed as LPNs/LVNs (HRSA, 2010b). While a lot of LPNs/LVNs have an interest in proceeding their education, a variety of barriers to their doing so have been cited, consisting of financial comes to, absence of capacity and difficulty acquiring into ADN and also BSN programs, and family commitments (HRSA, 2004). Although this chapter concentrates mostly on the education of RNs and APRNs, the committee recognizes the contributions of LPNs/LVNs in boosting the quality of health and wellness care. The committee likewise recognizes the opportunity the LPN/LVN diploma creates as a feasible pathmeans toward further education alengthy the RN and APRN tracks for the diverse individuals that hold that diploma.

Distribution of Undergraduate Degrees

At current, the many prevalent means to end up being an RN is to seek an ADN at a neighborhood college. Associate’s level programs in nursing were released in the mid-20th century in response to the nursing shortage that followed World War II (Lynaugh, 2008; Lynaugh and also Brush, 1996). The next most widespread undergraduate nursing degree is the BSN, a 4-year level generally readily available at a university. Baccalaureate nursing programs emphadimension liberal arts, progressed scientific researches, and nursing courseoccupational throughout a wider variety of settings than are addressed by ADN programs, along with formal coursework-related that emphasizes both the acquisition of management advancement and the expocertain to neighborhood and also public wellness competencies. The least common path to coming to be an RN currently is the diploma program, which is offered at a hospital-based school and primarily lasts 3 years. During the 20th century, as nursing gained a more powerful theoretical structure and various other forms of nursing programs enhanced in number, the number of diploma programs decreased remarkably except in a couple of states, such as New Jersey, Ohio, and also Pennsylvania. Figure 4-1 gives a review of trends in the distribution of nursing graduates by initial nursing level.



Trends in graduation from fundamental RN programs, by form, 2002–2008. SOURCE: NLN, 2010b.

Entry right into Practice: The Licensing Exam3

Regardless of which educational pathmethod nursing students seek, those functioning towards an RN need to inevitably pass the National Council Licensure Examicountry for Registered Nurses (NCLEX-RN), which is administered by the National Council of State Boards of Nursing (NCSBN), before they are granted a license to exercise. Rates of success on the NCLEX-RN are often offered for rating schools or for marketing to potential students. Similar to many entry-level licensing exams, but, the NCLEX-RN provides multiple-alternative, computer-based approaches to test the minimum competency required to exercise nursing safely. The exam is administered on a pass/fail basis and, although rigorous, is not intended to be a test of optimal performance. Following passage of the exam, individual state boards of nursing give nurses their license to practice.

The content of the NCLEX-RN is based upon surveys of what new nurses must recognize to start their exercise. Just like many entry-level licensing exams, the content of the NCLEX-RN directly influences the curricula supplied to educate nursing students. Currently, the exam is skewed toward acute care settings because this is wright here the majority of nurses are initially employed and also wbelow the majority of occupational throughout their careers. To store pace via the transforming demands of the health care mechanism and patient populaces, consisting of the shift toward boosting care in area settings (watch Chapter 2), the emphasis of the exam will certainly need to transition also. Greater focus should be inserted on competencies concerned community health, public health and wellness, major treatment, geriatrics, condition avoidance, wellness promotion, and various other topics past the provision of nursing care in acute care settings to encertain that registered nurses are ready to practice in an evolving health treatment device.

Costs of Nursing Education

Although a minimal variety of educational grants and also scholarships are obtainable, the majority of of people seeking nursing education have to finance their very own education at any kind of level of preparation. Costs differ based on the pathmethod selected for standard preparation and with to doctoral preparation. The LPN level is the least expensive to obtain, adhered to by the ADN, BSN (increased program), BSN, master’s of science in nursing (MSN), and PhD/medical professional of nursing practice (DNP) levels. It is no surprise that educational costs and living expenses play a major role in determining which degree is gone after and the numbers of nurses who seek advanced levels.

To much better understand also the costs of nursing education, the committee asked the Robert Wood Johnchild Foundation (RWJF) Nursing Research Network-related to estimate the miscellaneous prices linked via pursuing nursing education and learning, especially at the advanced exercise level, in compariboy via those for a medical physician (MD) or physician of osteopathy (DO). The RWJF Nursing Research Network-related produced a number of compariboy charts in an effort to convey accurately the distinctions in expenses in between alternative nursing degrees and the MD or DO degree. This task forced making assumptions about public versus private and also proprietary/for-profit education and learning choices, prerequisites for enattempt, and years required to complete each level. An location of particular difficulty emerged in assessing costs connected via obtaining an ADN degree. In the majority of non–wellness treatment techniques, the associates level takes 2 years to complete. In nursing, yet, surveys have actually discovered that it takes students 3 to 4 years to complete an ADN regimen because of the have to fulfill prerequisites essential to prepare students for entry right into degree programs and the lack of enough faculty, which cause lengthy waiting lists for many programs and also classes (Orsolini-Hain, 2008). Box 4-1 illustrates the challenges of this task by outlining the challenge of comparing the cost of coming to be a medical professional via the expense of ending up being an APRN. The job of comparing the boosting “sticker costs” of nursing and also clinical education was complex even more bereason a lot of the information necessary to compute those costs is either missing or attracted from insimilar years. In the finish, the committee decided not to incorporate thorough discussion of the costs of nursing education and learning in this report.

BOX 4-1

Costs of Health Professional Education. Depfinishing on the approach offered, the number of progressed practice registered registered nurses (APRNs) that can be trained for the price of training 1 medical professional is in between 3 and also 14. Assessing the prices of education is a multidimensional (even more...)

Why More BSN-Prepared Nurses Are Needed

The qualifications and level of education required for enattempt into the nursing profession have actually been commonly disputed by registered nurses, nursing institutions, academics, and a host of other stakeholders for more than 40 years (NLN, 2007). The causal partnership between the scholastic degree obtained by RNs and also patient outcomes is not conclusive in the study literature. However, numerous studies assistance a far-ranging association between the educational level of RNs and outcomes for patients in the acute treatment establishing, consisting of mortality rates (Aiken et al., 2003; Estabrooks et al., 2005; Friese et al., 2008; Tourangeau et al., 2007; Van den Heede et al., 2009). Other researches argue that clinical experience, qualifications prior to entering a nursing regime (e.g., SAT scores), and also the number of BSN-prepared RNs that got an earlier degree condiscovered the value included via the 4-year educational program. One research uncovered that the level of experience of registered nurses was more important than their education and learning level in mitigating medication errors in hospitals (Blegen et al., 2001). Anvarious other study perdeveloped within the Department of Veterans Affairs (VA) device discovered no significant association between the propercentage of RNs with a baccalaureate level and patient outcomes at the hospital level (Sales et al., 2008).

This controversy aside, an all-BSN workforce at the enattempt level would administer a more uniform foundation for the reconceptualized duties for registered nurses and also new models of care that are envisioned in Chapters 1 and also 2. Although a BSN education and learning is not a panacea for all that is meant of nurses in the future, it does, family member to various other educational pathmethods, present students to a broader range of competencies in such arenas as health and wellness policy and health care financing, management, high quality advancement, and also units thinking. One examine discovered that new BSN graduates reported substantially better levels of preparation in evidence-based exercise, research abilities, and also assessment of gaps in locations such as collaboration, cooperation, and exercise (Kovner et al., 2010)—various other necessary competencies for a future nursing workpressure. Moreover, as more registered nurses are being referred to as on to lead treatment coordination initiatives, they need to have actually the competencies requisite for this job, many kind of of which are contained in the American Association of Colleges of Nursing’s (AACN’s) Essentials of Baccalaureate Education for Professional Nursing Practice.4

Care within the hospital setting continues to grow even more facility, and also registered nurses need to make crucial decisions connected through treatment for sicker, frailer patients. Care in this establishing relies on sophisticated, life-conserving innovation coupled through complex indevelopment monitoring systems that call for abilities in evaluation and synthesis. Care external the hospital is ending up being even more complex as well. Nurses are being dubbed upon to coordinate care among a range of clinicians and community agencies; to assist patients manage chronic illnesses, thereby preventing acute care episodes and condition progression; and to use a range of technological tools to enhance the high quality and also performance of care. An even more educated nursing workpressure would certainly be better equipped to satisfy these needs.

An all-BSN workpressure would likewise be poised to achieve higher levels of education and learning at the master’s and doctdental levels, compelled for registered nurses to serve as main care carriers, nurse researchers, and also nurse faculty—positions presently in great demand also as debated later in this chapter. Shortperiods of nurses in these positions proceed to be a obstacle to advancing the profession and enhancing the delivery of treatment to patients.

Some wellness care organizations in the USA are already leading the means by requiring more BSN-all set registered nurses for entry-level positions. A thriving number of hospitals, especially teaching and also children’s hospitals and also those that have been recognized by the American Nurses Credentialing Center Magnet Recognition Program (view Chapter 5), favor the BSN for employment (Aiken, 2010). Depfinishing on the form of hospital, the goal for the propercentage of BSN-ready registered nurses varies; for instance, teaching hospitals aim for 90 percent, whereas neighborhood hospitals seek at leastern 50 percent (Goode et al., 2001). Absent out a nursing shortage, then, registered nurses holding a baccalaureate level are normally the preferred new-graduate hires in acute treatment settings (Cronenwett, 2010). Likewise, in a recent survey of 100 medical professional members of Sermo.com (watch Chapter 3 for even more information on this virtual community), performed by the RWJF Nursing Research Network-related, 76 percent of doctors strongly or rather agreed that registered nurses via a BSN are even more knowledgeable than those via an ADN. Seventy percent of the physicians surveyed also either strongly or rather agreed that all registered nurses who provide care in a hospital need to host a BSN, although as soon as asked about the characteristics they a lot of worth in registered nurses they occupational with, the doctors placed a significantly greater worth on compassion, performance, and also endure than on years of nursing education and also caliber of nursing institution (RWJF, 2010c).

In area and public wellness settings, the BSN has actually long been the desired minimum requirement for registered nurses, provided the competencies, understanding of community-based interventions, and skills that are needed in these settings (ACHNE, 2009; ASTDN, 2003). The U.S. military and the VA likewise are taking procedures to encertain that the nurses comprising their particular workforces are more extremely educated. The UNITED STATE Army, Navy, and Air Force require all energetic duty RNs to have actually a baccalaureate degree to practice, and the UNITED STATE Public Health Service has actually the same requirement for its Commissioned Officers. In addition, as the largest employer of RNs in the country, the VA has established a need that nurses need to have actually a BSN to be considered for promotion past entry level (AACN, 2010c). As Table 4-1 reflects, however, the average income of BSN-ready nurses are not considerably greater than those of ADN- or diploma-ready nurses.



Average Incomes of Full-Time RNs, by Highest Nursing or Nursing-Related Education and Job Title.

Decades of “blue ribbon panels” and also reports to Congress on the wellness treatment workforce have actually discovered that there is a far-ranging shortage of registered nurses through baccalaureate and also higher degrees to respond to the nation’s health and wellness needs (Aiken, 2010). Ala lot of 15 years ago, the National Advisory Council on Nurse Education and also Practice, which advises Congress and the secretary of Health and also Person Services on locations appropriate to nursing, referred to as for the advance of policy actions that would encertain a minimum of 66 percent of RNs that job-related as nurses would have a BSN or higher degree by 2010 (Aiken et al., 2009). The outcome of plan initiatives of the previous decade has actually been a workpressure in which approximately 50 percent of RNs host a BSN level or higher, a number that consists of ADN- and also diploma-educated RNs who have actually gone on to achieve a BSN (HRSA, 2010b). Of significant note, the Tri-Council for Nursing, which is composed of the Amerihave the right to Nurses Association, Amerihave the right to Organization of Nurse Executives, National Organization for Nursing (NLN), and AACN, freshly released a consensus plan statement calling for a more extremely educated nursing workforce, citing the should rise the variety of BSN-prepared nurses to supply safer and also more effective treatment (AACN, 2010a).

In amount, an increase in the percent of nurses with a BSN is imperative as the scope of what the public demands from nurses grows, expectations bordering top quality heighten, and the settings where registered nurses are needed prolifeprice and come to be more facility. The formal education associated via obtaining the BSN is preferable for a variety of factors, including ensuring that the following generation of nurses will grasp more than fundamental expertise of patient treatment, offering a more powerful structure for the expansion of nursing scientific research, and also imparting the tools registered nurses need to be efficient change agents and also to adapt to evolving models of care. As disputed later on in this chapter, the committee’s reference for a much more highly educated nursing workforce need to be paired with overall enhancements to the education system and should encompass competencies in such areas as leadership, basic wellness plan, evidence-based care, top quality advancement, and systems reasoning. Additionally, also as the breadth and also depth of content rise within prelicensure curricula, the caring significance and humale connectedness registered nurses bring to patient care should be preserved. Nurses must proceed to carry out holistic, patient-focused care that goes beyond physical health requirements to identify and also respond to the social, psychological, and spiroutine demands of patients and also their households. Other fundamental facets of nursing education and learning, such as principles and integrity, need to remajor intact also.

The Goal and a Plan for Achieving It

In the committee’s watch, raising the percentage of the present nursing workpressure holding a BSN from 50 to 100 percent in the near term is neither useful nor achievable. Setting a goal of boosting the percentage to 80 percent by 2020 is, however, bold, achievable, and also essential to move the nursing workpressure to an increased collection of competencies, specifically in the domains of area and also public wellness, management, units advancement and also adjust, research, and wellness policy.

The committee believes achieving the goal of 80 percent of the nursing workpressure having a BSN is possible in part because a lot of the educational capacity needed to satisfy this goal exists. RNs with an ADN or diploma level have actually a variety of choices for completing the BSN, as presented below. The combination of these choices and also others yet to be occurred will be required to accomplish the 80 percent goal—no one strategy will administer a global solution. Technologies, such as the use of simulation and also distance discovering via digital courses, will need to play an essential function as well. Above all, what is essential to accomplish this goal is the will of nurses to return to greater education, assistance from nursing employers and also others to aid fund nursing education and learning, the elevation of educational requirements, an education system that recognizes the experience and also previous finding out of returning students, and local collaboratives of schools of nursing and employers to share financial and human sources.

While there are challenges connected via shorteras of nurse faculty and also clinical education and learning sites (disputed below), these difficulties are much less problematic for licensed RNs pursuing a BSN than for prelicencertain students, that call for more intense oversight and also security by faculty. Furthermore, the majority of of what ADN-prepared nurses have to move on to a baccalaureate level have the right to be taught in a classroom or digital, via extra tailored clinical endure. Online education and learning creates adaptability and provides a secondary ability set to students who will certainly use modern technology right into the future to retrieve and also manage indevelopment.

Over the course of its deliberations and also during the forum on education held in Houston, the committee learned about several pathmeans that are accessible to attain the goal of 80 percent of the nursing workpressure having actually a BSN (added inventions debated at the forum on education and learning deserve to be uncovered in the forum summary on the CD-ROM in the earlier of this report). For RNs returning to achieve their BSN, a number of choices are feasible, including typical RN-to-BSN programs. Many hospitals likewise have actually joint arrangements with local colleges and also colleges to market onsite classes. Hospitals mainly provide stipends to employees as an incentive to proceed their education and learning. Online education programs make courses obtainable to all students regardless of wright here they live. For prospective nursing students, tbelow are conventional 4-year BSN programs at a university, but tright here are likewise neighborhood colleges currently providing 4-year baccalaureate degrees in some claims (check out the following section). Educational collaboratives in between colleges and neighborhood colleges, such as the Oregon Consortium for Nursing Education (described in Box 4-2), enable for automatic and also seamless transition from an ADN to a BSN regime, through all colleges sharing curriculum, simulation framework, and also faculty. As explained listed below, this type of model is goes beyond the traditional articulation agreement in between neighborhood colleges and colleges. Beyond standard nursing colleges, brand-new companies of nursing education are entering the industry, such as proprietary/for-profit schools. These programs are providing new models and choices for delivering curriculum and also reaching RNs and prospective students, although each of these schools need to be evaluated for its capacity to meet nursing accreditation criteria, including the provision of clinical experiences required to advancement the profession.

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BOX 4-2

Case Study: The Oregon Consortium for Nursing Education (OCNE). Sharing Resources to Prepare the Next Generation of Nurses In 2006, as soon as Basilia Container, BSN, RN, entered nursing institution at Mount Hood Community College in Gresham, Oregon, near Portland, (more...)

Two various other vital programs designed to facilitate academic progression to better levels of education and learning are the LPN-to-BSN and also ADN-to-MSN programs. The ADN-to-MSN regimen, in specific, is developing a far-reaching pathmethod to advanced practice and faculty positions, particularly at the area college level. Financial support to help build capacity for these programs will certainly be important, including resources for grants and also scholarships for registered nurses wishing to seek these pathways. By the very same token, the committee believes that diploma programs need to be phased out over the following 10 years and must consolidate their sources with those of community college or preferably university programs offering the baccalaureate degree. Furthermore, there are federal resources presently being provided to assistance diploma schools that could better be supplied to expand also baccalaureate and better education programs.

The committee anticipates that it will take a few years to construct the educational capacity necessary to achieve the goal of 80 percent of the nursing workpressure being BSN-all set by 2020, but also emphasizes that existing BSN completion programs have capacity that is much from exhausted. Regional networks of institutions functioning together, along with health treatment institutions, might ideal facilitate getting to this goal. Moreover, the committee believes this plainly characterized goal will certainly stimulate stakeholders to take activity. Examples of such action include scholastic and health and wellness care organizations/employers partnering to achieve strategic alignment around workpressure development; federal government and structures presenting capital avenues for scholarships to develop faculty and carry out tuition relief; state boards of nursing raising the use of earmarks on licencertain fees to balance out the price of education; and also states emerging statewide policy agendas and also political activity plans with identified leaders in nursing, government, and company to adopt measures to satisfy the goal.

The Role of Community Colleges

Community colleges play a vital function in attracting students to the nursing education and learning pipeline. Specifically, they carry out an possibility for students who may not have access to conventional university baccalaureate programs bereason of those programs’ absence of enrollment capacity, distance, or cost.

Community colleges have actually an important role to play in ensuring that even more BSN-prepared registered nurses are obtainable in all areas of the United States and also that nursing education and learning at the associate level is high quality and affordable and also prepares ADN registered nurses to move on to greater levels of education. Currently, ADN- and BSN-ready nurses are not evenly spread nationwide. BSN-prepared RNs are uncovered even more typically in urban areas, while many type of rural and various other medically underoffered neighborhoods depend heavily on nurses with associate’s levels to staff their hospitals, clinics, and also permanent care framework (Cronenwett, 2010). Figure 4-2 shows the highest possible nursing or nursing-associated education by urban/rural residence. According to a research by the Urban Institute, “clinical personnel, including registered nurses, tend to work close to wright here they were trained” (Bovjberg, 2009; watch Figure 4-3). This suggests that state and community investments in nursing education (e.g., structure nursing institution capacity, structure facilities to assistance that capacity, resources the purchase of modern technology, and also offering scholarships) may be an efficient means to alleviate neighborhood and also regional shortperiods. Community colleges are the predominant educational organizations in rural and medically underserved areas. As such, they need to either join educational collaboratives or build innovative and conveniently accessible programs that seamlessly affix students to institutions offering the BSN and also greater levels, or they must build their very own BSN programs (if feasible within state legislations and regulations). Community colleges need to foster a culture that promotes and also values academic progression and should encourage their students to continue their education through tactics that incorporate making them mindful of the full range of educational pathmethods and also opportunities obtainable to them (e.g., ADN-to-MSN and online RN-to-BSN programs). Box 4-3 describes a neighborhood college in Florida wright here nursing students can take advantage of lower prices and also virtual classes to receive a BSN degree.


Highest nursing or nursing-related education by urban/rural residence. SOURCE: Calculations perdeveloped using the information and documentation for the 2004 National Sample of Registered Nurses, easily accessible from the Health Reresources and Services Administration’s (more...)

Barriers to Meeting Undergraduate Educational Needs

Although the committee believes the capacity required to ensure a nursing workpressure that is 80 percent BSN-ready by 2020 deserve to be attained utilizing the viewpoints outlined over, acquiring tright here will certainly not be straightforward. Nursing colleges throughout the United States collectively turn amethod 10s of countless qualified applicants annually bereason of a lack of capacity (Kovner and Djukic, 2009)—a case that renders filling projected demands for even more and also different forms of nurses challenging. Figure 4-4 reflects the breakdown of numbers of qualified applicants who are turned amethod from ADN and BSN programs.

An examination of the root causes of the education and learning system’s insufficient capacity to meet undergraduate educational demands reveals four significant barriers: (1) the aging and also shortage of nursing faculty; (2) insufficient clinical placement methods of the ideal kind or duration for prelicencertain nurses to learn their profession; (3) nursing education and learning curricula that fail to impart relevant competencies essential to accomplish the future needs of patients and also to prepare nurses adequately for scholastic progression to greater degrees; and also (4) poor workforce planning, which stems from a lack of the communications, data resources, and information units needed to align educational capacity through sector requirements. This final root cause—inadequate workpressure planning—affects all levels of nursing education and is the subject of Chapter 6.

Aging and Shortage of Nursing Faculty

Tright here are not sufficient nursing faculty to teach the current variety of nursing students, let alone the number of qualified applicants that wish to go after nursing. The exact same forces that are bring about deficits in the numbers and competencies of bedside registered nurses impact the capacity of nursing faculty also (Allan and also Aldebron, 2008). According to a survey by the NLN, 84 percent of U.S. nursing institutions tried to hire brand-new faculty in the 2007–2008 academic year; of those, four out of 5 discovered it “difficult”5 to recruit faculty, and also one out of three discovered it “incredibly challenging.” The major challenges included “not enough qualified candidates” (cited by 46 percent) and the incapacity to sell competitive salaries (cited by 38 percent). The survey concluded that “post-licencertain programs were much more most likely to mention a shortage of faculty, whereas pre-licencertain programs reported that absence of clinical placement settings were the biggest impediment to admitting more students. Specifically, nearly two thirds (64 percent) of doctdental programs and also one half of RN-BSN and master’s programs figured out an inenough faculty pool to attract from as the significant constraint to expansion, in contrast to one third of prelicencertain programs” (NLN, 2010a).

Era is also a contributing element to faculty shortperiods. Nursing faculty tfinish to be older than clinical nurses because they should accomplish needs for an progressed degree in order to teach. Figure 4-5 shows that the average age of nurses who work as faculty as their principal nursing position—the position in which a nurse spends the majority of his or her working hours6—is 50 to 54. By comparison, the median age of the full RN workpressure is 46. More than 19 percent of RNs whose primary place is faculty are aged 60 or older, while just 8.7 percent of nurses that have actually a secondary position as faculty—those who hold a nonfaculty (e.g., clinical) primary position—are aged 60 or older. Nurses who work-related as faculty as their second place tfinish to be younger; among nurses under age 50, more job-related as faculty as their second than as their principal place (HRSA, 2010b). Moreover, the average retirement age for nursing faculty is 62.5 (Berlin and also Sechrist, 2002); as an outcome, many type of full time faculty will certainly be prepared to retire quickly. Given the landscape of the health treatment mechanism and also the fragmentized nursing education and learning system, the current pipeline cannot quickly replenish this loss, let alone meet the potential demand for even more educators. In enhancement to the innovative tactics of the Veterans Affairs Nursing Academy (VANA) and also Gulf Coast Health Services Steering Committee for responding to faculty shortperiods (disputed later in this chapter), a potential chance to relieve faculty shorteras can involve the development of programs that would certainly allow MSN, DNP, and also PhD students to teach as nursing faculty interns, via mentoring by permanent faculty. Box 4-4 presents a nurse profile of one assistant professor and also her experience relocating right into an academic career.

Effects of the first level at entry into the profession Nurses that enter the profession via an associate’s level are much less likely than those who enter through a bachelor’s degree to development to the graduate level over the course of their career (Cleary et al., 2009). Figure 4-6 provides an introduction of the highest educational level obtained by woguys and also males who hold the RN license. It contains RNs that are working as nurses and those who have reworn down, have actually readjusted professions, or are no longer working. According to an analysis by Aiken and also colleagues (2009), registered nurses whose initial level is the ADN are just as most likely as BSN-all set registered nurses to look for one more degree. Approximately 80 percent of the moment, yet, ADN graduates fail to relocate past a BSN. Because of this, the biggest variety of registered nurses via a master’s or doctorate, a prerequiwebsite for serving as faculty, obtained a BSN as their initial level. Since two-thirds of present RNs received the ADN as their initial degree, Aiken’s evaluation argues that currently “having sufficient faculty (and also various other master’s ready nurses) to enable nursing colleges to expand also enrollment is a mathematical improbability” (Aiken et al., 2009). A sepaprice analysis of North Carolina registered nurses resulted in a similar conclusion (Bevill et al., 2007). Table 4-2 shows the size of time it takes those registered nurses that perform relocate on to greater levels of education and learning to progress from completing initial nursing education and learning to completing the greatest nursing level accomplished.


Distribution of the registered nurse populace by highest nursing or nursing-associated educational preparation, 1980–2008 NOTES: The totals in each bar might not equal the estimated numbers for RNs in each survey year because of incomplete indevelopment (more...)

Salary disparities Another aspect that contributes to the existing nursing faculty shortage is salary disparities between nurses working in education and also those working in clinical company (Gilliss, 2010). As presented in Table 4-3, the average annual income of registered nurses who work-related permanent as faculty (most with either a master’s or doctdental degree) total $63,949. By contrast, nurse practitioners (NPs) (through either a master’s or doctdental degree) average just over $85,000 (check out Table 4-4). Section 5311 of the Affordable Care Act (ACA) uses an incentive designed to offset lower faculty salaries by providing as much as $35,000 in loan repayments and scholarships for eligible nurses that complete an advanced nursing level and also serve “as a full time member of the faculty of an accredited school of nursing, for a full duration, in the aggregate, of at leastern 4 years.”7 However, the ACA does not provide incentives for registered nurses to construct the specific educational and clinical competencies required to teach.


Mean Annual Wages of Nurses Who Work Full Time as Faculty in Their Principal Nursing Position, 2008.

Projections of future faculty demand To create a much better expertise of future needs, the committee asked the RWJF Nursing Research Netjob-related to proj ect faculty demand also for the next 15 years. After reviewing information from the AACN8 and the NLN (Kovner et al., 2006), the netjob-related estimated that between 5,000 and also 5,500 faculty positions will certainly remajor unfilled in associate’s, baccalaureate, and also greater level programs. This projection is based on historic nurse faculty retirement rates and also on graduation patterns in research-concentrated nursing PhD programs. Although a doctoral degree is frequently compelled or preferred for all current faculty vacancies, some of these positions deserve to be filled through faculty holding DNP or master’s degrees.

If faculty retirement prices decrease and/or brand-new faculty positions are produced to satisfy future demands (resulting, for instance, from provisions for loan repayment in the ACA), these factors will affect the shortage estimates. Furthermore, the faculty supply may be impacted positively by flourishing numbers of graduates with a DNP level (discussed later in this chapter) who, as noted above, may be eligible for faculty positions in some scholastic establishments.

Inadequate Clinical Placement Opportunities

As nursing education has actually moved out of hospital-based programs and right into mainstream colleges and also colleges, integrating methods for clinical endure right into coursejob-related has come to be more tough (Cronenwett, 2010). Nursing leaders proceed to face difficulties associated via the separation of the scholastic and practice worlds in ensuring that nursing students construct the competencies compelled to enter the workpressure and also attribute properly in wellness care settings (Cronenwett and also Redman, 2003; Fagin, 1986). While efforts are being made to expand also placements in the area and more care is being yielded in area settings, the mass of clinical education for students still occurs in acute care settings.

The compelled number of clinical hours varies commonly from one routine to another, and also many state boards of nursing execute not specify a minimum number of clinical hrs in prelicensure programs (NCSBN, 2008). It is most likely, moreover, that many type of of the clinical hours fail to result in abundant learning. Students spfinish a lot of their clinical time perdeveloping routine care tasks continuously, which might not contribute considerably to raised learning. Faculty report spfinishing the majority of of their time supervising students in hand-operated steps, leaving little time concentrated on cultivating the development of clinical thinking abilities (McNelis and Ironside, 2009).9

Some developments in clinical education and learning have actually been made with solid academic–service partnerships. An example of such partnerships in community settings is nurse-controlled wellness centers (questioned in Chapter 3), which serve a twin role as safety net practices and also clinical education sites. Another, frequently provided design is having actually professional and experienced practitioners in the field overwatch student clinical experiences. According to a recent integrative evaluation, using these skilled practitioners, called preceptors, in a clinical setting is at least as efficient as traditional ideologies while conserving scarce faculty resources (Udlis, 2006). A range of other clinical partnerships have been designed to rise capacity in the face of nursing faculty shorteras (Baxter, 2007; DeLunas and also Rooda, 2009; Kowalski et al., 2007; Kreulen et al., 2008; Kruger et al., 2010).

In addition to academic–business partnerships and preceptor models, the use of high-fidelity simulation uses a potential solution to the problem of limited methods for clinical experience, via early researches arguing the performance of this method (Harder, 2010). The NLN, for instance, has establimelted an digital area referred to as the Simulation Innovation Resource Center, wright here nurse faculty deserve to learn just how to “style, implement, and also evaluate the usage of simulation” in their curriculum.10 However before, tbelow is little proof that simulation increases faculty capacity, and also no data exist to specify what percent of clinical endure it deserve to replace. To establish unidevelop guidelines for educators, accreditation needs should be evaluated and also revised to enable simulation to satisfy the requirement for a traditional variety of clinical hrs. The usage of simulation in partnership to the promotion of interprofessional education and learning is questioned below.

Increased attention is being focused on the dedicated education unit (DEU) as a viable alternative for broadening clinical education and learning capacity (Moscato et al., 2007). In this model, health and wellness care systems are dedicated to the instruction of students from one regime. Staff registered nurses who want to serve as clinical instructors are ready to carry out so, and faculty specialization is used to assistance their development and comfort in this function. DEUs were arisen in Australia and also launched in the USA at the College of Portland in Oregon in 2003. Since then, the University of Portland also has actually assisted at leastern a dozen other U.S. nursing schools create DEUs. In programs that market DEUs, students perform two 6-week rotations per semester, each instructor/staff nurse teaches no even more than 2 students at a time, and also a university faculty member oversees the instruction. Early results suggest the DEU can dramatically increase capacity and also have a positive effect on satisfaction among students and also nursing staff. A multiwebsite research funded by RWJF is currently under means to evaluate outcomes of the DEU design.

DEUs market benefits for the nursing colleges, the hospitals, the faculty, and also the students. Since the hospital employs the clinical instructors, the nursing school can increase its enrollment without boosting costs. The hospital benefits by training students it deserve to hire after their graduation and also licensure. Students advantage by having continuous clinical instructors each day, somepoint not guaranteed under the standard preceptorship model. As the case research in Box 4-5 shows, the benefits of DEUs extfinish beyond the scholastic environment to the practice setting as well.

BOX 4-5

Case Study: The Dedicated Education Unit. A New Model of Education to Increase Enrollment Without Raising Costs Jamie Sharp, a 21-year-old University of Portland (UP) nursing student that has percreated clinical rotations in a selection of systems, remembers (more...)

Need for Updated and Adaptive Curricula

A look at the method nursing students are educated at the prelicencertain level11 mirrors that the majority of schools are not offering sufficient nurses with the compelled competencies in such locations as geriatrics and also culturally relevant treatment to meet the changing health and wellness requirements of the UNITED STATE populace (as outlined in Chapter 2) (AACN and also Hartford, 2000). The majority of nursing institutions still educate students generally for acute care fairly than community settings, including public health and wellness and also long-term care. Most curricula are arranged roughly traditional medical specialties (e.g., maternal–kid, pediatrics, medical–surgical, or adult health) (McNelis and also Ironside, 2009). The intricacies of care coordination are not adequately addressed in most prelicencertain programs. Nursing students may gain exposure to leading health and wellness treatment self-controls and understand somepoint about standard health and wellness plan and available wellness and also social service programs, such as Medicaid. However before, their education and learning frequently does not promote the abilities necessary to negotiate through the health and wellness care team, navigate the regulatory and accessibility stipulations that identify patients’ eligibility for enrollment in health and wellness and social business programs, or understand how these programs and also health and wellness policies influence wellness outcomes. Nursing curricula should be reexamined and updated. They need to be adaptive enough to undergo constant testimonial and also development based upon brand-new proof and also a changing scientific research base, alters and also advances in innovation, and changes in the demands of patients and the wellness treatment device.

Many kind of nursing colleges have actually encountered the fast growth of health study and understanding by including layers of content that call for more instruction (Ironside, 2004). A wide variety of brand-new competencies also are being integrated right into requirements for accreditation (CCNE, 2009; NLNAC, 2008). For example, brand-new competencies have actually been promulgated to resolve quality and patient safety goals (Cronenwett et al., 2007; IOM, 2003a). Greater emphasis on prevention, wellness, and also boosted health outcomes has actually led to brand-new competency needs too (Allan et al., 2005). New models of treatment being promulgated as an outcome of health and wellness treatment recreate will certainly should be presented into students’ experiences and will require competencies in such areas as care coordination. These models, many of which could be focused in alternative settings such as schools and worklocations, will certainly produce brand-new student placement choices that will should be tested for scalability and compared for efficiency with more conventional treatment settings. (See likewise the conversation of competencies later on in the chapter.)

The explosion of understanding and decision-scientific research technology additionally is changing the way health specialists access, process, and also usage information. No longer is rote memorization an alternative. Tbelow sindicate are not sufficient hrs in the day or years in an undergraduate regimen to proceed compushing all obtainable information right into the curriculum. New approaches have to be developed for evaluating curricula and presenting standard principles that can be used in many various instances fairly than requiring students to memorize various lists of facts and indevelopment for each case.

Just as curricula must be assessed and rethought, so, as well, need to teaching–discovering strategies. Many nurse faculty initially learned to be registered nurses with extremely structured curricula that were laden through content (NLN Board of Governors, 2003), and also also few have received progressed formal preparation in curriculum breakthrough, instructional architecture, or performance assessment. Faculty, tending to teach as they were taught, emphasis on extending content (Benner et al., 2009; Duchscher, 2003). They likewise view curriculum-connected requirements as a obstacle to the production of discovering settings that are both engaging and student-focused (Schaefer and Zygmont, 2003; Tanner, 2007).


Even missing passage of the ACA, the require for APRNs, nurse faculty, and also nurse researchers would certainly have actually increased dramatically under any scenario (Cronenwett, 2010). Not only must schools of nursing build their capacity to prepare even more students at the graduate level, yet they need to do so in a method that fosters a unified, competency-based technique through the greatest feasible requirements. Because of this, building the scientific research of nursing education research, or just how best to teach students, is a crucial focus for the area of nursing education and learning. For APRNs, graduate education need to ensure that they have the right to add to major care and also aid respond to shortperiods, particularly for those populaces who are the majority of underoffered. For nurse researchers, a focus on fundamental renovations in the distribution of nursing care to enhance patient safety and security and high quality is key.

Numbers and Distribution of Graduate-Level Nurses

As of 2008, more than 375,000 womales and men in the workpressure had actually received a master’s level in nursing or a nursing-connected area, and more than 28,000 had actually gone on to obtain either a doctorate in nursing or a nursing-connected doctdental level in a area such as public health and wellness, public management, sociology, or education12 (view Table 4-5) (HRSA, 2010b). Master’s levels prepare RNs for functions in nursing administration and clinical management or for work in progressed exercise duties (questioned below) (AARP, 2010 ). Many nursing faculty, particularly clinical instructors, are prepared at the master’s level. Doctoral levels encompass the DNP and PhD. A PhD in nursing is a research-oriented degree designed to educate nurses in a vast selection of scientific areas that may include clinical scientific research, social science, plan, and also education and learning. Traditionally, PhD-educated registered nurses teach in university settings and conduct research to expand also understanding and also boost treatment, although they have the right to additionally job-related in clinical settings and assume leadership and governmental functions in health and wellness care devices and academic settings.


Estimated Distribution of Master’s and also Doctoral Degrees as Highest Nursing or Nursing-Related Educational Preparation, 2000–200.

The DNP is the match to other practice doctoprices, such as the MD, PharmD, doctorate of physical treatment, and others that need highly rigorous clinical training. Nurses through DNPs are clinical scholars who have actually the capacity to analyze research, form systems of care, potentiate individual treatment right into treatment necessary to serve populations, and also ask the clinical inquiries that affect organizational-level research to enhance performance utilizing informatics and top quality improvement models. The DNP is a reasonably brand-new level that uses nurses an opportunity to come to be practice scholars in such locations as clinical practice, leadership, quality innovation, and health policy. The core curriculum for DNPs is guided by the AACN’s Essentials of Doctdental Education for Cutting edge Nursing Practice.13

Schools of nursing have actually been occurring DNP programs considering that 2002, but just in the last 5 years have actually the numbers of graduates approached a considerable level (Raines, 2010). Between 2004 and 2008 the variety of programs offering the degree increased by nearly 40 percent, as is shown in Figure 4-7. At this suggest, even more proof is needed to study the impact DNP registered nurses will have actually on patient outcomes, expenses, high quality of treatment, and also access in clinical settings. It is also hard to discern just how DNP registered nurses might impact the provision of nursing education and also whether they will play a far-ranging role in easing faculty shortages. While the DNP provides a promising chance to breakthrough the nursing profession, and also some nursing institutions are cultivating this level as the following step for APRNs, the committee cannot comment directly on the potential duty of DNP registered nurses bereason of the current lack of proof on outcomes.


Growth fads in various nursing programs. NOTE: BSN = bachelor’s of scientific research in nursing; DNP = medical professional of nursing exercise.

Although 13 percent of registered nurses host a graduate level, fewer than 1 percent (28,369 nurses) have actually a doctdental level in nursing or a nursing-associated area, the qualification required to conduct independent research study (HRSA, 2010b). In reality, just 555 students graduated via a PhD in nursing in 2009, a number that has actually remained constant for the previous decade (AACN, 2009a). As detailed, essential roles for PhD nurses include teaching future generations of nurses and conducting study that becomes the basis for renovations in nursing practice. As the require for nursing education and study and for registered nurses to engage with interexpert study teams has actually grvery own, the numbers of registered nurses via a PhD in nursing or a connected field have not preserved pace (view Figure 4-7 for patterns in the assorted nursing programs). The major reasons for this lag are (1) an poor pool of nurses with progressed nursing levels to attract upon, (2) faculty salaries and benefits that are not equivalent to those of nurses via progressed nursing levels working in clinical settings, and (3) a society that promotes obtaining clinical experience before continuing graduate education.

Preparation of Advanced Practice Registered Nurses

Nurses ready at the graduate level to administer advanced practice services incorporate those with master’s and also doctoral degrees. APRNs serve as NPs, certified nurse midwives (CNMs), clinical nurse professionals (CNSs), and also certified registered nurse anesthetists (CRNAs). To get certification in among these advanced exercise locations, nurses need to take specialized courses in enhancement to a basic core curriculum. Credit demands vary from regime to routine and also from specialty to specialty, yet typically selection from a minimum of 40 credits for a master’s to more than 80 credits for a DNP. Upon completion of forced coursework and clinical hours, students should take a certification exam that is administered by a credentialing company relevant to the particular field of expertise, such as the American Nursing Credentialing Center (for NPs and CNSs), the American Midwifery Certification Board (for CNMs), or the National Board on Certification and also Recertification of Nurse Anesthetists (for CRNAs).

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Nurses that receive certification, including those serving in all advanced exercise functions, provide included assurance to the public that they have got the specialized experienced advancement, training, and competencies required to administer safe, top quality care for certain patient populaces. For instance, NPs and CNSs might qualify for certification after completing a master’s level, post-master’s coursework-related, or doctdental level with an acattributed nursing regimen, through specific progressed coursejob-related in areas such as health and wellness assessment, pharmacology, and also pathophysiology; additional content in wellness proactivity, condition prevention, differential diagnosis, and also illness management; and also at leastern 500 hrs of faculty-looked after clinical training within a routine of study (ANCC, 2010a, 2010c).

Certification is time-restricted, and maintenance of certification requires recurring acquisition of both knowledge and experience in exercise. For instance, the majority of advanced practice certification need to be renewed eexceptionally 5 years (NPs, CNSs); demands incorporate a minimum of 1,000 practice hours in the certain certification function and also population/specialty. These demands have to be