| Introduction
In March
2000, the Board of Directors of the American Association of
Colleges of Nursing (AACN) engaged in extensive deliberations
regarding the future of the nursing profession. Central to
those discussions was the growing concern that continued declines
in nursing enrollments were symptomatic of larger systemic
professional concerns. A consensus emerged among the AACN
Board members that major, and fundamental, changes must be
made in education, practice, licensure and credentialing for
the nursing discipline to create a career destination of choice
for potential nursing applicants.
As a result
of these deliberations, the AACN Board created two task forces:
the Task Force on Education and Regulation for Professional
Nursing Practice 1 (TFER1) and the Task Force on the Hallmarks
of Professional Practice Environments. The latter task force
was charged with making recommendations regarding practice
environments that support professional nursing practice. TFER1
was given the following charge:
Develop
background information to be provided to the membership regarding
the issues and trends that prompt the need for new education
and licensure models for professional nurses in the future.
Develop
models that link professional nursing education, licensure,
and practice for the future, including rationale.
Identify
the factors/forces that would favor or inhibit implementation
of various models and the strategies for addressing implementation.
Provide
the AACN Board of Directors with recommendations regarding
preferred actions for the future.
The members
of TFER 1 conducted their work with the two following major
assumptions:
The increasing
complexity of the health care system and growing concerns
regarding the quality of patient care are evidence of the
need for a better educated nurse workforce.
The diverse
pathways to nursing must be differentiated by licensure/regulatory
frameworks that reflect legal scopes of practice, preparation
for practice, and scopes of authority based upon education.
To accomplish
its work, TFER 1 engaged in the following activities:
gathered
data regarding history of licensure and the evolution of this
process;
interviewed
multiple representatives of nursing and health care regarding
the future of nursing practice;
surveyed
the membership;
reviewed
licensure processes in other health professions;
established
assumptions to frame the future of professional nursing education,
practice, and licensure;
sought
consultation from practice and regulatory constituencies;
conducted
four membership forums at AACN meetings as of 3/02;
developed
an array of potential models for future nursing education,
practice, and licensure; and
summarized
information on the following: membership assumptions for the
future, members' views on the future of associate degree education,
and members' views on preferred scenarios for change.
As part
of its charge, the task force developed a variety of education
models that frame various approaches to nursing education
for professional practice. These models were developed based
upon the need to produce a well-qualified generalist nurse
clinician who can provide high quality, effective, and safe
nursing care in today's complex health care environment. Moreover,
TFER members concluded that a new license must be developed
to differentiate the scope practice for this professional
nurse clinician.
The TFER
understands clearly that the education models presented represent
a wide spectrum of approaches to addressing the two major
assumptions outlined above. Moreover, the TFER understands
that a broad consensus of individuals from an array of settings,
beyond education, will be needed in order to effect changes
in licensure and scope of practice.
The TFER
discussed at length the issues, assumptions, and potential
options. The attached models represent a series of options
for moving forward. The following background information provides
a description of the context within which the task force worked
and the elements that shaped the recommendations of the task
force.
Setting
the Stage: Issues that Drive the Discussion
In May
2001, the Joint Commission on Accreditation of Healthcare
Organizations (JCAHO) provided testimony to the U. S. Senate
Committee on Health, Education, Labor, and Pensions. This
testimony was given in support of Senate efforts to address
growing concerns about reported shortages of nursing personnel.
The JCAHO, however, focused on issues beyond the shortage
and highlighted in its testimony their growing concerns that
the complex care environment of today requires highly competent
nursing staff. They noted, "Issues involving educational
preparation, competency, availability, and deployment are
often identified as key contributing factors to problems in
the delivery of effective care." In their testimony,
the JCAHO notes that in 24% of reported sentinel events (serious,
unanticipated events that result in death, injury or permanent
loss of function) nursing issues are raised as a major underlying
factor. They further note their concern that nurse competency
is a key, contributing factor in care delivery problems.
The JCAHO
testimony reflects an increasing recognition by nurse executives
and leaders of patient care organizations that a more highly
educated nursing workforce may be needed to address the complex
care demands of today's health care environment. Reflecting
this concern, in 1998, the Department of Veteran's Affairs
Health Care Administration promulgated quality standards that
require nursing staff beyond the first level of entry practice
to hold at least a baccalaureate in nursing. In support of
this goal, the DVA made available $50 million to provide support
to nurses seeking to acquire the baccalaureate or higher degree
in nursing.
The University
Healthsystem Consortium Chief Nurse Officer Council engaged
in extensive collaborative efforts with AACN to achieve their
desired goal to have a much higher portion of their nursing
staff prepared at the baccalaureate level (Goode et al., 2001).
In addition, the California Association of Nurse Leaders has
disseminated a position statement on the need to discard attempts
to differentiate care responsibilities among associate degree
and baccalaureate degree educated nurses noting that today's
complex care environments require at least the baccalaureate
level nursing education to provide safe, effective nursing
care (Barter & McFarland, 2001).
Each of
these discrete expressions of concern is reflective of the
growing health system concerns about patient care quality
and errors in care delivery. The JCAHO notes that the adequacy
of nurse staffing is not just an issue of numbers but also
of appropriate education. They conclude, "The adequacy
of nursing services is among the greatest threats to the future
of quality health care. It will require multiple and very
creative solutions. The future of patient care safety is at
stake."
Unfortunately,
most discussions regarding the future of nursing have focused
on preferred educational paths or the numbers of nurses available
to serve in clinical positions. Although most health policy
analysts note the dramatic changes in today's health care
delivery system, the educational process that will produce
a highly competent, and effective, nurse clinician who can
practice safely in this complex care environment remains confused.
The continuing variety of educational paths to practice as
a registered nurse also has resulted in a public view that
nursing is an unattractive career that is neither intellectually
challenging nor demanding. Nursing has experienced dramatic
declines and marked fluctuations in enrollments, and significantly
reduced interest in professional nursing as a career choice
among college-bound high school students.
The
Diminished Pipeline to Practice
For six
years (1995-2001), the nation's nursing programs reported
a continuing downward spiral in the numbers of individuals
seeking application to and actually enrolling in nursing programs.
From 1995 to 2001, the AACN reported an almost 25% decline
in entry-level baccalaureate nursing program enrollments (Berlin,
Bednash, and Stennett, 2002). Although similar data are not
available for other levels of nursing education, assessment
of the number of individuals from all types of programs taking
the National Council Licensure Examination (NCLEX®) shows
declines in all three types of entry level programs. This
year, AACN data show an increase of 3.7% in entry-level baccalaureate
nursing enrollments, the first increase in six years (Berlin,
Bednash, & Stennett, 2002). However, total enrollments
this year were 106,557 and by comparison, in 1995 (the year
enrollments began to dip) enrollments were 127,683. In addition,
this small increase must be considered in the context of enormous
efforts by schools and health care agencies to recruit students
to nursing. Moreover, this small increase falls short of meeting
the projected demand for nursing personnel.
The American
Freshman Study conducted by UCLA has surveyed college freshmen
for over thirty years, seeking data on values, career aspirations,
and political views (Astin, 1999). This longitudinal assessment
of freshman college student career choices also provides further
evidence of the declining interest in a nursing career. In
2001, only 1.8 percent of students identified nursing as the
career choice. In contrast, 8% of female freshman students
identified their goal as a degree in medicine. In fact, currently
almost half of all medical students are female, as are 75%
of veterinary medical students, 40% of dental students, and
half of all law students. These numbers are significant for
a profession that has been and continues to be predominantly
female.
A number
of efforts have been in place to expand enrollments, including
extensive efforts to develop recruitment campaigns, to partner
with K-12 educational systems, and to expand student support.
Despite these efforts, until this year, the downward trend
in enrollments has continued.
As part
of one recruitment effort-Nurses for a Healthier Tomorrow-the
J. W. Thompson Co., a major public relations firm, conducted
a series of ten national focus groups with children in grades
2-10 to assess their perceptions of the attractiveness, feasibility,
and likelihood of a future career in nursing (Sherman, 2000).
The results
of these focus groups made clear that students with a goal
to seek higher education post-high school were very unlikely
to choose a nursing career. Students in these focus groups
noted that nursing was technical work, not well rewarded,
and clearly unattractive to those seeking professional status
and upward mobility, as was reflected in the remarks of one
student who noted, "I go to private school; I think my
parents expect more of me." Moreover, these students
were aware that education for RN licensure was possible through
a variety of entry level programs and saw this inconsistency
as a sign of confusion in the discipline. Some students noted
that it seemed impossible to prepare for a profession that
dealt with life and death through a two-year program.
These
findings were similar to those of six regional forums conducted
by the Division of Nursing, DHHS, and AACN in 1999. In those
forums, educators and clinicians noted that high school counselors
were carefully steering bright and career oriented students
away from nursing, since they perceived it as a low status
field and not intellectually challenging. The diverse program
types available for entry into the field as a registered nurse
(RN) was to those students evidence that the discipline does
not value knowledge or learning as a requirement for practice
(U.S., DHHSS, 1999).
Differences
and Dilemmas
Conflicting
views of a preferred route to nursing practice have created
professional tensions throughout the past 30 plus years of
nursing's history. Much of the discussion related to nursing
education has focused on whether any particular route to professional
nursing practice is preferred or "better." In some
instances, efforts were made to require the baccalaureate
for entry to the registered nurse level or practice. In 1987,
the North Dakota State Board of Nursing instituted a regulation
requiring that all registered nurses hold a baccalaureate
degree in order to practice. Although registered nurses with
less than a baccalaureate were grandfathered into licensure
status, from that point on the baccalaureate was the required
education for professional practice. Despite strong and aggressive
opposition from hospital associations and some unions, the
state Supreme Court upheld the authority of the North Dakota
board to make this change and noted that the board was the
most appropriate group to set educational expectations for
entry into the profession. Unfortunately, no other state has
created either regulatory or statutory requirements for the
baccalaureate degree. The effects of this decision on workforce
availability, patient outcomes, etc. has not been studied
systematically.
In 1989,
the National Commission on Nursing Implementation Project
(NCNIP) sought to establish a clear framework for differentiation
of practice roles based upon education. NCNIP was led by four
major national nursing organizations - AACN, the American
Nurses Association, the American Organization of Nurse Executives
(AONE), and the National League for Nursing. The goal of NCNIP
was to establish projects throughout the nursing community
directed at differentiation of roles and clarity regarding
the educational requirements for those roles. Following the
work of NCNIP, AACN, AONE, and the National Organization for
Associate Degree Nursing (NOADN) collaborated to develop recommended
models for differentiation of education and practice (AACN,
AONE, NOADN, 1995). This was an effort to foster a consensus
and commitment to implementing differentiation among a diverse
array of organizations. A central and key element of the report
produced by this collaborative effort was the stated assumption
that both associate degree and baccalaureate nursing education
were important to the provision of high quality nursing care
but that the graduates of these two programs were prepared
for distinct and different roles.
Unfortunately,
this agreement has not resulted in widespread practice differentiation
or in efforts to distinctly define different educational goals
for the programs. Moreover, it is troubling to note that many
individuals representing nursing practice, in addition to
some associate degree educators, have expressed the view that
differences do not exist between the graduates of the three
types of nursing programs. These perceptions raise serious
policy questions about the value placed upon education by
the practice world and about the course options available
to those students who choose the more lengthy and comprehensive
baccalaureate program. Also raised are the issues of economic
feasibility and ethical propriety of continuing baccalaureate
education in nursing if the employers do not recognize and
reward the abilities of RNs with baccalaureate degrees.
Although numerous discussions have occurred regarding the
need to differentiate roles for practice based upon the educational
preparation of the graduate, only very limited implementation
of differentiated practice has occurred. The original proposal
by Montag (1971) to develop associate degree programs in nursing
conceptualized the graduates of these programs as technical
nurse clinicians who would work under the supervision and
direction of more highly educated professional nurses. Her
seminal work on these programs was titled: Community College
Education for Nursing: An Experiment in Technical Education
for Nursing (1959). Associate degree graduates also were
to care for patients with routine, and predictable, health
care needs. Nonetheless, the national job market has tended
to place associate degree RNs in positions involving more
complex care. Simultaneously, however, an increasing number
of nurse executives are expressing a need to have a more highly
educated generalist nurse. Entire health care systems, such
as the Veteran's Affairs Health System, have taken steps to
develop a better-educated nursing workforce, and to clearly
differentiate nursing roles based on education.
Additionally,
the evolution of associate degree programs over the past 50
years and the subsequent growth in the number of these programs
occurred without a discussion on the appropriate regulation
process for graduates of different programs or the proportion
of various nurse providers needed for good patient care. Graduates
of the three very different routes to nursing practice all
sit for the same licensure exam. Moreover, many employers
cite the single licensure exam as a barrier to creation of
differentiated roles. Employers note that if nurses are each
given the same regulatory credential for practice, they must
also be given the same role responsibilities.
Conversely,
the failure to differentiate roles is often cited as a primary
factor in support of a single examination for graduates of
the three types of basic nursing programs. Representatives
of the National Council of State Boards of Nursing, the organization
responsible for development and administration of the NCLEX®,
repeatedly have expressed their view that the examination
must reflect existing practice in order to meet legal standards
for psychometric soundness. Therefore, these individuals assert
a differentiated licensure examination is only possible if
the practice sites, which employ nurses, develop and articulate
clearly different roles for graduates of different programs.
These
arguments create a circle of inaction in which each side of
the discussion-the practice community and the regulatory community-is
unwilling to change the status quo. Friss (1994) in her extensive
analysis of the history of nursing shortages noted that the
cycles of nursing shortages would not be broken without major
and systemic change in nursing education, practice, and licensure.
"This
includes licensing nurses according to their education, assigning
them according to their competencies and education, and paying
accordingly. These measures and only these, will eventually
curtail the cycles of nursing 'shortages.'" (Friss, 1994,
p. 597)
Licensure
and Roles
Currently,
the ability of prospective RNs is assessed using a licensure
mechanism that has little relevance to the different competencies
achieved in the three very different types of education programs.
Moreover, the NCLEX ® examination is developed using a
process that is retrospective, rather than futuristic in its
analysis of the nursing skills necessary for continuing high
quality practice.
The NCLEX
® examination is developed using what is termed an incumbent
job analysis. The NCSBN conducts registered nurse (RN) job
analysis studies every three years. These studies are designed
to collect empirical data from newly licensed nurses that
describe what they actually do on the job. A panel of nurse
experts, active in clinical practice, reviews and revises
a list of activities representing the full scope of current
nursing practice. [For a more detailed discussion, see the
background paper Licensure and Credentialing (Hutcherson,
2001).]
Although
the NCSBN asserts the need to develop an exam based upon descriptions
of current practice, other health disciplines in the U.S.,
and nursing bodies in other countries have used successfully
a more sophisticated and future oriented approach to assessment
of competence for practice. U.S. medical licensure exams are
more complex and are developed using a competency-based process.
In order to achieve full authority to practice independently,
physicians are required to pass three licensure exams. These
exams begin in medical school and are completed during the
second year of residency. The National Board of Medical Examiners
also is currently developing a fourth exam, which will be
required of all physicians and will test affective and interpersonal
skill levels.
A core
difference between the nursing and medical licensure exams
is the focus on evidence for practice that frames development
of the medical exams. These exams are developed through an
extensive process of data gathering regarding practice changes,
the evidence required for practice, and the knowledge necessary
to be competent into the future. The exams are created using
input from faculty, clinicians, employers, and the research
community. A model exam blueprint is created using advice
from multiple sectors and focuses beyond current expectations
for safe practice.
In Canada,
a competency-based examination development process is used
to develop the licensure exam for registered nurses. In 1993,
a national panel was created to develop a set of competencies
for the professional registered nurse. (Canadian Nurses Association,
1999) The final report of that competency project was published
in 1997 and 183 competencies were identified that reflect
the competent RN capable of giving safe and high quality generalist
care. These competencies served as the primary framework for
the content domain of the Canadian licensure examination.
ather than a focus on current expectations for safe practice
upon graduation, the Canadian model sought a mechanism for
a broader and more expansive assessment of the competencies
that must be held by the professional nurse. As a result of
this extensive process, widespread agreement has emerged among
the Canadian nursing community that a uniform and higher level
of education is necessary to develop a graduate with the explicit
competencies to be tested by the RN exam. Educators have come
to agreement that this should be the baccalaureate degree.
A central
part of the Canadian discussion was growing concerns about
the complex health care system and the need to have highly
competent professional nurses in these settings. Recently,
awareness of the need for nurses who are seen as peers in
an interprofessional environment was made very apparent during
what has been termed the Manitoba Pediatric Surgery Inquest
(Reeder, 2001c). This inquest was a result of a series of
medical care failures in which a number of pediatric cardiac
patients died during or immediately after cardiac surgery
by a single physician. Concerns expressed by nursing staff
were not given full credence due to the medical community's
failure to recognize nurses about this surgeon's practice
as partners in assessment of the quality of care. The final
report of the inquest notes that nurses must be seen as equal
partners in a team of providers and that structures should
be created to make that possible. Unfortunately, in most instances
in Canada and the U.S., the limited education of nurses in
the RN role makes this peer acknowledgement unlikely, given
the much higher level of education and training that is required
for most other health professionals.
Competency-Based
Education and Practice: Quality in a Complex Health Care Arena
Increasingly,
other health professions have recognized that the complexities
of the current health care system require a more highly educated
clinician. Pharmacy, physical therapy, occupational therapy,
and even acupuncture practice, now require a graduate degree.
Yet, it is nurses who are least educated, who hold the most
critical responsibilities for good patient care outcomes in
a number of settings. Currently almost 60% of the nursing
workforce have less than a baccalaureate degree in nursing.
Additionally, less than 16% of nursing personnel who enter
nursing with less than a baccalaureate degree acquire additional
education in nursing during their careers.
A particularly
troubling trend is the decline in the educational preparation
of senior nurse administrators over the last four years. In
1996, 26% of nursing administrators in the U.S. held an associate
degree in nursing as their highest level of education. In
2000, that number had increased to 31%. (Spratley et al.,
2002) The result is a situation where those in practice leadership
roles are unable to develop and foster differentiated practice
roles based on education because they themselves do not have
the educational preparation or perspective necessary to do
so.
Although
the percentage of nurses with baccalaureate degrees has increased
over the last four years, the rate of increase has been approximately
0.5% per year. At this rate of growth, recommendations from
the Department of Health and Human Services that 60% of U.S.
nurses hold the baccalaureate degree will not be met until
2080. At the same time, a number of other countries, including
Canada and the Philippines, already have developed standards
for general nursing practice that require the baccalaureate
degree as the minimal level of education.
In 1987,
AACN published The Essentials of Education for Professional
Nursing Practice, a consensus-based document created to
guide baccalaureate educators in the preparation of professional
nurses. In 1999, a revised set of competencies, The Essentials
of Baccalaureate Nursing Education, was released. This
revised document was created using an extensive process of
data gathering and consensus setting from educators, clinicians,
employers, representatives of higher education and consumer
groups, regulators, specialty nursing bodies, and the public.
At a series of regional forums conducted by AACN, this diverse
community provided direction to the AACN regarding the competencies
necessary for highly effective, safe, and high quality nursing
practice. Currently, these standards set the benchmark for
development of the nursing curriculum and clinical training
in baccalaureate nursing programs. Moreover, the process used
for development and the content of this document hold many
similarities to the Canadian experience.
Associate
degree nursing (ADN) education has undergone significant change
in its 50-year history. The changing nature of health care
has apparently caused a general lengthening of the ADN program
of study. As a result, the traditional 60-credit requirement
for an associate degree is exceeded in most associate degree
nursing programs which require an average of 75-80 credits.
Many associate degree nursing programs explicitly note in
their written materials that the AD in nursing requires at
least three years of full time study. The addition of required
credits, and the common requirement that students in these
programs study for three years, implies that these programs
cannot address the required learning in two years. This must
also be contrasted against the clear message contained in
the final report of the task force that created the Essentials,
in which the authors note their belief that it may not be
possible to achieve this complex set of competencies, and
their corresponding knowledge requirements, skills, and role
expectations, in a traditional four year baccalaureate program.
The unanswered question, therefore, is what type or length
of program is necessary to achieve this level of competent
practice?
For several
decades, nursing professionals have debated the value of an
entry-level professional nursing education program that is
graduate level. Most often this has focused upon the nursing
doctorate as the entry level degree and four U.S. institutions
continue to offer this degree although the number of individuals
completing these programs of study has not grown significantly.
Critique of entry-level graduate education for professional
nursing practice has been directed at the following concerns:
the potential
costs to the health care system that would employ a more educated
nursing professional,
the potential
that adequate numbers of these individuals would not be produced
to meet the needs of a health care system that requires a
large nursing workforce, and
the concern
that requiring graduate education for entry into the professional
nursing roles would decrease the numbers of students from
diverse communities who could acquire a nursing degree.
Cost and
number issues are inherently related. However, these concerns
are based upon current views of how nursing care is delivered
and organized. Currently, the model of diversely educated
RNs overextends the competency of some RNs, while underutilizing
the competence of others. Roles are homogenized, and nurses
are not utilized based on differentiated, complementary roles.
A model of nursing care based upon differentiated role capabilities
and responsibilities would use teams of nurses, varying in
number and type, based on patient care needs. In this model
of care delivery, a core of skilled associate degree nurses
is utilized as a part of the delivery of the full range of
nursing care required. This is true differentiation of practice
and would implement the recommendations of the AACN/AONE/NOADN
report that explicitly stated the need to have an array of
nursing clinicians with different and complimentary
skills. Teams of nurses composed of individuals with differentiated
roles and scopes of practice are configured based on patient
care needs, thus allowing for the delivery of cost-effective,
but high quality care. This differentiation of practice roles
would require validation through a differentiated licensure
process designed to assess the discrete role competencies.
Attracting
Future Student Pools
A recent
report of the Council of Graduate Schools and the University
Continuing Education Association entitled Postbaccalaureate
Future provides evidence that fully half of all students
entering four-year colleges and universities report that they
will continue their education beyond the baccalaureate to
acquire at least a master's degree (Kohl & LaPidus, 2000).
This is based on their views that success in the complex and
challenging work environments require this level of education.
The growing trend by students enrolled in senior colleges
and universities to seek professions that demand advanced
education as a mechanism for career advancement and status
makes nursing an even less attractive career because considerably
less education is required in comparison with other health
professions. Moreover, this trend seems to indicate that potential
students will seek preferentially those careers that provide
clear evidence that additional education is a valuable asset.
The desire
for baccalaureate or graduate education has often been seen
as a goal of the traditional majority population. However,
conversations with representatives of multiple organizations
representing ethnically or racially diverse communities provide
evidence that the student populations they represent will
find nursing more attractive if the profession provides clear
access to careers seen as academically challenging and professionally
rewarding. The Hispanic Association of Colleges and Universities
and the National Association of Hispanic Nurses entered into
a Memorandum of Understanding with the AACN with the explicit
goal that efforts be made to expand the pool of Hispanic students
in graduate education preparing for faculty and research roles.
The National Black Nurses Association also advocates baccalaureate
education as a preferred entry route to a nursing career.
In fact, recent data from the Division of Nursing of the Department
of Health and Human Services indicate that a larger portion
of Hispanics, Asians, and African-Americans have acquired
either a baccalaureate or graduate degree than have white
nursing professionals.
Despite
clear evidence that minority populations have clearly sought
higher levels of education in nursing, efforts to expand the
pool of baccalaureate or higher degree educated nurses are
often critiqued as a clear obstacle to minority populations
seeking a nursing career. However, data from the AACN indicate
that enrollments of ethnically and racially diverse groups
in baccalaureate programs have increased steadily over the
last six years. Moreover, data from the Division of Nursing
also indicate that baccalaureate nursing programs are more
successful with retention of students from these populations.
The strong support voiced by ethnically and racially diverse
communities for enhanced access to baccalaureate or graduate
education conflicts with the view expressed by some that community
college education is a preferred route to a nursing career
for minority students.
In March
2001, the AACN brought together an advisory body comprised
of noted leaders in higher education, health care, philanthropy,
organizational design, and nursing to seek guidance on the
issues to which this organization should devote energies and
resources. The AACN Community Advisory Commission was uniformly
supportive of the need for a general commitment in nursing
to "raising the bar" and increasing the educational
requirements to practice as a professional nurse. They particularly
noted the recent and dramatic advance in bio medical sciences
and in health care. They questioned the safety of a U.S. health
care system that is dependent upon an undereducated nursing
work force
Summary
The task
force began its work with a focus on licensure and regulation
and the need to develop a differentiated regulatory process
that would distinguish the scope of practice of a baccalaureate-educated
nursing professional. This beginning led to an extensive discussion
of the educational process, the continued resistance to differentiation,
the policy and emotional issues that surround discussions
regarding the educational characteristics of the nursing workforce,
and the nature of knowledge evolution in all health professions.
This is reflected in the models developed by the task force.
A strong
consensus exists regarding the competencies that should be
acquired in an entry-level professional nursing program as
described in AACN's The Essentials of Baccalaureate Nursing
Education. Although a number of draft and proposed educational
models have been developed to advance the TFER's view that
a better educated entry-level generalist nurse is a vital
necessity in today's health care environment, the TFER has
not yet determined their recommendations for the future.
Recommendations/Final
Report to Membership from AACN Education & Regulation
Task Force
1. Continue
the Education and Regulation work with a new task force.
2. Consider
broader task force membership from outside AACN (e.g., AONE,
ANCC, AD Nursing, NCSBN).
3. Develop
a plan/blueprint for nursing education and regulation that
will allow us to:
A. Effectively
meet patient care needs of the future - recognizing the
dramatically increasing complexity of health care.
B. Advance
the profession.
The issue is not the historic "entry into practice"
issue, nor has there been a decision to have generic master's
as a sole route to professional practice.
4. The
new Task Force's blueprint/plan should address:
A. How
all AACN members can participate in the plan, in
various ways with differing timeframes.
B. How
graduates of all nursing education programs can fit into
the plan.
C. Guidelines/models
for new nursing education programs - and revise guidelines
for existing programs as needed (e.g., revise Essentials
documents).
D. Working
with institutional members to:
- Develop
partnerships/strategies for development of new licensures
and scopes of practice, as needed.
- Help
member institutions develop plans and resources to transition
to new education programs, as they are ready to do so
in the context of their institutional cultures and communities
of interest.
When the
Task Force began this work we were enthusiastic and excited
about developing new models of nursing education and regulation
to address patient care needs for the future. We have come
to realize that:
1. This
is difficult and yet we are still convinced, it is
critically important.
2. The
task force is convinced, also, that while background papers,
survey, models, and data are very important, most important
will be our ability to work together, to embrace change, develop
collaborative will, and empower every AACN member to understand
how his/her institution can participate in building what we
need for the future of patient care.
This task
force has completed Phase One. We look forward to continued
work with you on exploring and resolving this critically important
issue.
Task Force on Education and Regulation
for Professional Nursing Practice #1
Kathleen A. Long, PhD, APRN, FAAN, Chair
University of Florida
Eileen Breslin, PhD, RN
University of Massachusetts-Amherst
Dorothy Detlor, PhD, RN
Washington State University
Mary Fenton, DrPH, RN
University of Texas-Galveston
Elizabeth Parato, PhD, RN
Marian College of Fond du Lac
Dorothy Powell, EdD, RN, FAAN
Howard University
Marcia Stanhope, DSN, RN, FAAN, Faculty Representative
Carolyn Hutcherson, MS, RN, Consultant
AACN Education and Regulation Annotated Bibliography
AACN
Issue Bulletin (April 1999). Faculty shortages intensify
nation's nursing deficit. Washington, DC: American Association
of Colleges of Nursing.
As a component of the escalating nursing shortage, faculty
shortages are expected to intensity, hampering the ability
of nursing education programs to increase school enrollments.
In addition to noting a variety of recruitment and retention
strategies, the efforts of one state to resolve this issue
are highlighted.
AACN
Issue Bulletin (February 2000). Nursing school enrollments
decline as demand for RNs continues to climb. Washington,
DC: American Association of Colleges of Nursing.
This document reports changes in enrollment and graduation
for baccalaureate and graduate programs and contrasts the
fifth consecutive drop in baccalaureate enrollments with the
escalating nursing shortage. Factors contributing to the decline
in enrollments are noted with citations to strategies utilized
in the health care system to combat this growing dilemma.
American
Association of Colleges of Nursing (1999). The Essentials
of Baccalaureate Education for Professional Nursing Practice.
Washington, DC: American Association of Colleges of Nursing.
Revised standards for baccalaureate nursing education programs.
Consensus-based standards developed to shape the expectations
for competency based practice by professional nurses.
American
Association of Colleges of Nursing, American Organization
of Nurse Executives, national organization for Associate Degree
Nursing (1995). A Model for Differentiated Nursing Practice.
Washington, DC: American Association of Colleges of Nursing.
Report of collaboratiave effort by three major national nursing
organizations to describe the unique differences that should
be facilitated in education and practice for nurses from associate
degree and baccalaureate degree programs.
Anderson,
C. A. (2000). The time is now. Nursing Outlook 48,
257-258.
An editorial by a recognized nursing education leader, emphasizing
the troubling outcomes of not differentiating nursing roles
on the basis of education. The large number of college-bound
women who are opting for majors and careers not in nursing
is highlighted. Recommendation is made for past-baccalaureate
education for professional nursing.
Astin,
L. Cooperative Institutional Research Program & Higher
Education Research Institute (December 1999). The American
freshman: National norms for fall 1999. Los Angeles, CA:
Author.
The 34th annual report of the American Council on Education
and the Graduate School at UCLA, providing a narrative profile
of the American freshman population. The marked decline in
interest in nursing among women entering college in 1999 is
documented.
Barter,
M., McFarland, P. L. (2001). BSN by 2010: A California initiative.
Journal of Nursing Administration, 31, 141-144.
Report on the initiative by the Association of California
Nurse Leaders to move to the baccalaureate for RN entry as
of 2010. Nurses' lack of education in comparison to other
health professionals is noted. An action plan to move toward
baccalaureate entry is outlined.
Bednash,
G. (2000) The Decreasing Supply of Registered Nurses. Journal
of the American Medical Association, Vol 283, No. 22.
2985 - 2987.
Presents data about the decreasing enrollments in nursing
education programs and poses challenges of the increasing
demands of the health care delivery system for qualified nursing
personnel. In addition to analysis of the issues, efforts
of several groups to address the problems are highlighted.
Berlin,
L., Bednash, G., & Stennett, J. (2001) 2000-2001 Enrollments
and Graduations in Baccalaureate and Graduate Programs in
Nursing. American Association of Colleges of Nursing.
Annual report on enrollments and graduations detailing five-year
trends in enrollments.
Berlin,
L., Bednash, G., & Stennett, J. (2002) 2001-2002 Enrollments
and Graduations in Baccalaureate and Graduate Programs in
Nursing. American Association of Colleges of Nursing.
Annual report on enrollments and graduations detailing five
year trends in enrollments.
Boyce,
C. A., Evans, D. A., Symonds, D., et al. (2001). End the debate
entry level into practice should be the master's degree. Journal
of Nursing Administration, 31, 166-168.
Graduate students in nursing make a strong case for moving
to master's degree preparation for entry into professional
practice.
Buerhaus,
P. I. (October 2000). Demographics of the RN workforce:
Trouble now, big trouble ahead. Paper presented at the
meeting of the American Association of Colleges of Nursing,
Washington, DC.
A compelling review of the confluence of variables resulting
in a serious current and long-term shortage of nurses. The
effects of nursing shortage on patient outcomes is documented.
Changes in the work environment infrastructure in order to
support the work of nurses is proposed as a major strategy
for encouraging recruitment and retention of nurses.
Christensen,
C. M., Bohmer, R., & Kenagy, J. (2000). Will disruptive
innovations cure health care? Harvard Business Review
78, 102-111.
A compelling review of the forces at work in health care to
prevent needed changed and reform. The importance of disruption,
i.e., powerful change to move entrenched systems is discussed.
The consequences of political and economic forces that limit
and constrain nursing are considered.
Goode,
C. J., Pinkerton, S., McCausland, M. P. et al. (2001). Documenting
chief nursing officer's preference for BSN-prepared nurses.
Journal of Nursing Administration, 31, 55-59.
Begins with a good review of previous studies showing differences
in the performance of BSN and ADN nurses, as well preferences
for BSN nurses among nursing executives. Provides a report
of a survey of chief nursing officers in the University HealthSystem
Consortium (UHC). Results show a preference for a nursing
staff that is 71% BSN-prepared. Some salary and practice differentiation
was found to exist for BSN nurses currently practicing in
UHC hospitals, but such differentiation was not significant
in most facilities
Friss,
L. (1994). Nursing studies laid end to end form a circle.
Journal of Health Politics, Policy and Law, 19, 597-631.
An analysis of workforce issues in the early 90's, emphasizing
that stop-gap approaches focused on image enhancement and
salary increases do not work in the long run. The author points
out the need for fundamental changes in the workplace as well
as clarification of the entry paths for professional practice.
Kohl,
K., & LaPidus, J. (2000) Postbaccalaureate Futures:
New markets, resources, credentials. Washington, DC: American
Council on Education.
Report on student career opportunities and career expectations.
Discusses trends in educational expectations of students.
Nona,
D. A. (2000). A brief history of the present as told by accreditation
standards for pharmaceutical education. Supplement to the
Journal of the American Pharmaceutical Association, 40,
519-524.
An historical review of the education, accreditation and credentialing
process in pharmacy, highlighting the process that culminated
in the requirement of a professional doctorate for pharmacy
practice.
Safriet,
B. (1992). Health care dollars and regulatory sense: The role
of advanced practice nursing. Yale Journal of Regulation,
9, 417-487.
A thorough summary of the data supporting the cost-effectiveness
and quality of health care provided by nurse practitioners.
A classic piece demonstrating that data alone are not sufficient
to cause change in the health care delivery system where powerful
forces are at work to "protect professional turf"
and maintain the status quo.
Sherman
G. (2000). Memo to nurses for a healthier tomorrow coalition
members. (Healthcare Group of J. Walter Thompson, August
28, 2000.)
Summary of research to determine perceptions of nursing by
a national sample of students in grades 2 through 10, done
in preparation for the STTI "Nurses for a Healthier Tomorrow"
campaign. The results indicate that elementary and middle
school children have markedly negative perceptions of nursing,
which is viewed as unpleasant, frightening and unrewarding
work. Nursing is generally not seen as a career requiring
a 4-year college degree, and nurses are not seen as significant
decision-makers or knowledge workers.
Spratley,
E., Johnson, A., Sochalski, J., Fritz, M., & Spencer,
W. (2002). The Registered Nurse Population: Findings from
the National Sample Survey of Registered Nurses- March 2000.
Washington, DC: US DHHS, HRSA, Division of Nursing.
Quadrennial report on characteristics of the US registered
nurse population.
Staiger,
D. O., Auerbach, D. I., & Buerhaus, P. I. (2000). Expanding
career opportunities for women and the declining interest
in nursing as a career. Nursing Economic$, 18, 230-236.
A review of the various factors contributing to the current
nursing shortage: aging workforce, increasing demand based
on health technology advances, and the selection of other
health-related careers by college-bound women.
Credentialing
and Testing
Schoon,
C. G., & Smith, I. L. (2000). The Licensure and Certification
Mission: Legal, Social, and Political Foundations. New
York, NY: Professional Education Services.
Presents an array of discussions about licensure and certification
organizations and explores the role of credentialing in today's
policy world. Five sections are included: 1) Purpose, Governance,
and Resources 2) Responsibilities to Stakeholders 3) Assessment
Instruments 4) Recertification and 5) Maintaining Accreditation.
The
American Educational Resource Association (AERA), The American
Psychological Association (APA), the National Council on Measurement
in Education (NCME) (1999) Standards for Educational and
Psychological Testing. Washington, DC: AERA Publications.
Provides an invaluable resource with comprehensive information
about test construction, evaluation and documentation; fairness
in testing and testing applications. It addresses vital issues
for educators as well as professional and technical experts
involved with testing and credentialing.
Background
Advisory
Committee on Student Financial Assistance (2001, February).
Access Denied: Restoring the Nation's Commitment to Equal
Educational Opportunity: Executive Summary. Washington,
DC: Author.
Discusses impact of college education on earning potential
over life of a career. Focus on need to have better access
to baccalaureate and graduate education for minority populations
as a mechanism for greater earning potential equity and the
need to strengthen student financial interest to achieve this.
American
Nurses Association (1993). Licensure and Regulation of
Nursing Profession. Washington, DC: Author.
This legal opinion was prepared for the American Nurses Association
in response to a request for an analysis on the apportionment
of police powers under state and federal constitutions and
how these concurrent powers relate to licensure and regulation
of nursing practice.
Bridgman,
M. (1953). Collegiate Education for Nursing. Philadelphia,
PA: William F. Fell Co.
Seminal critique of nursing education and the need to prepare
a better educated nursing staff for the dynamic world of practice.
Focuses on need to move nursing education from hospitals to
a higher education system that would prepare nurses with a
broader skill set.
Canadian
Nurses Association (April 1999). Blueprint for the Canadian
Registered Nurse Examination. Ottawa, Ontario: Author.
Describes competency based process for creating the Canadian
licensure examination for registered nurses. Lists critical
competencies for professional nursing practice.
Department
of Health Regulatory Boards (1983). Commonwealth of Virginia
Policy Review: The regulation of the health profession.
Richmond, VA: Author.
Provides a valuable resource in articulating the criteria
for determination of levels of regulation necessary for any
unregulated activity. It is frequently cited in state reviews
analyzing the need for proposed additional regulation of a
profession or occupation.
Massaro,
T. M. (1984). Legal opinion on advanced practice. (Unpublished)
Used widely by nursing regulators, this legal opinion provides
an overview of the legal foundations and jurisdictional authority
for the regulation of nursing.
Montag,
M. L. (1971). The Education of Nursing Technicians.
New York: Wiley & Sons, Inc.
Describes early experiments in community colleges to create
a nursing technician that would assist with delivery of nursing
care. Update of original 1951 report with comprehensive discussion
of the evolution of the concept.
Montag,
M. L. (1959). Community College Education for Nursing.
New York: McGraw-Hill Book Company, Inc.
Final report on the co-operative project to develop technical
nurses in junior and community colleges. Describes project
conceptualization, implementation, and implications.
National
Council of State Boards of Nursing. (2001). Test Plan for
the National Council Licensure Examination for Registered
Nurses. Chicago, IL: Author
The test plan is developed from the results of the periodic
job analysis study. It identifies the categories and distribution
of content to be tested on the registered nursing licensure
examination. The percentage of questions in each categories
is identified.
Reeder,
J. M. (2001). Patient safety: Cultural changes, ethical imperatives.
Healthcare Papers, 2, 48-54.
Discusses need to create a culture of quality and interdisciplinary
collaboration to assure accountability in practice.
Reeder,
J.M. (April 2001). Improving patient safety in surgical settings.
School Science and Mathematics, 7, 49-53.
Discusses goals of IOM report on quality and relationship
to standards of Joint Commission on Accreditation of Healthcare
Organizations.
Reeder,
J.M. (October 2001). Being there: Supporting health professionals
involved in medical errors. School Science and Mathematics,
7, 40-44.
Discusses need for rquality focused interventions in medical
error to assure change rather than to create blame focused
accountability.
Review
and Implementation Committee. (May 2001). Report of the
Review and Implementation Committee for the report of the
Manitoba pediatric cardiac surgery inquest. Manitoba,
Canada: Manitoba Health Publications.
Report of the committee charged with investigating high numbers
of pediatric cardiac deaths and relationship of hospital policies,
interprofessional tensions, and clinician incompetency in
this situation. Provides directives regarding need to have
strong nurse and physician relationships and need to share
reporting and assessment responsibilities with nursing staff.
Sibbald,
B. (November 1997). A right to be heard. Canadian Nurse,
98, 22-30.
Provides report on results of nurse presence in Canadian Manitoba
inquest. First time nursing was given authority in a practice
inquest.
Styles,
M. M. (1986). Report on the Regulation of Nursing.
Geneva, Switzerland, International Council of Nurses.
The result of a very extensive study by Dr. Margretta Styles
to assist ICN to develop its position on the future of regulation
in nursing. The project analyzes structures, processes, and
standards that regulate nursing education and practice around
the world. Recommendations are included for the ICN position
on nursing regulation.
Suche,
C. (March 2001). Case closed? A summary of the report on the
Health Sciences Centre Pediatric Cardiac inquest, Nurscene,
24-29.
Discusses testimony of nursing personnel in Canadian pediatric
inquest.
Weisenbeck,
S. M., & Calico, P.A. Licensure and Related Issues in
Nursing. In G. L. Deloughery, Issues and Trends in Nursing,
243 - 295. St. Louis, MO: Mosby.
This chapter provides a comprehensive discussion of a wide
range of nursing regulatory issues. Background and theoretical
foundations serve as the backdrop for analysis of relevant
issues and identification of future trends and issues in regulation.
A thorough discussion of the premised underlying the current
regulatory scheme in the United States forms the perspective
for many of the current and future issues facing nursing regulation.
Yocom,
C., Chornick, N. & Jacobson, J. (1995). Role delineation
study: Nursing activities performed by nurse aides, licensed
practical/vocational nurses, registered nurses and advanced
practice registered nurses. Chicago: National Council
of State Boards of Nursing, Inc.
In 1998, the National Council of State Boards of Nursing initiated
research to delineate the similarities and differences in
the practice characteristics of four levels of nursing personnel:
nurse aides, licensed practical/vocational nurses (LPN/VNs),
registered nurses (RNs) and advanced practice registered nurses
(APRNs).
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