* Titles vary by state
** Can also include advanced preparation in nursing administration or community health (no licensure or title change)

• LPN - provides bedside care, especially in acute and long term care settings; licensure maintained as LPN/LVN; often labeled "technical" nurse
  
  
• AD, diploma, BSN - all leading to licensure as "RN" or professional nurse; roles include provision of range of nursing care including bedside care; leadership; patient advocate; community health, etc.
  
  
• Master's - includes graduate education preparing nurse for advanced practice role; clinical specialist; educator; manager, and other leadership roles. No specific licensure except for advanced practice nurses who pass national certification exams which are often used by states to grant advanced practice "licensure" or recognition
  
  
• Doctorate, PhD, DNS - prepares the nurse as researcher, scholar, educator, leader and /or expert clinician

• Essence of this system has been in place for over 50 years
• Established educational system leading to each level of education
• Current licensing/testing systems are consistent with this system
• Articulation models in place
• In spite of limitation, is known and understood by delivery system

• Options for women's career choices have greatly expanded
• Dwindling enrollments in many educational programs
• Looming nursing shortage
• Lack of differentiated practice roles and compensation
• Shortage exacerbates highly stressful work environments
• Delivery system concerns that new graduates are not adequately prepared for complexity of current work environment
• Expanded need for scientific and professional content result in perception of inadequate time to teach relevant content
• Leaves nurses as least well educated of the health professionals (e.g. physical therapy at master's level, pharmacy at professional doctoral level.

Model 2 - Modification of "North Dakota" system

Notes:

• Existing job analysis and definitions of practice would be adapted to meet needs of current delivery system
  
  
• Modified testing/credentialing/licensure system could be developed for both RTN and RPN levels
  
  
• RTN = Registered Technical Nurse

- Would include graduates of A D N and/or LPN/VN programs
- Scope of practice would have technical focus
- Existing job analysis and definitions of practice would be adapted to meet needs of current delivery system
- Different testing/credentialing/licensure system would be developed

• RPN = Registered Master Nurse

- Education would be at least at the baccalaureate level
- Scope of practice would be on professional nursing practice
- Different testing/credentialing/licensure would need to be developed

• MSN, DNS, PhD - essentially unchanged
  

Pros

• Similar to current system but distinction between technical and professional nursing
• Would necessitate more clear delineation of differences in educational programs, nursing job descriptions, and roles
• Consistent with long held position of ANA
• Could potentially force the issue of differentiated salary structure

Cons

• Extensive history related to "entry into practice" and discussions about technical and professional nursing
• Would pose limited value in midst of nursing shortage
• Would require development of new technical and professional nursing titles as well as new or adapted licensing examinations for both levels of nursing practice
• Would change titles for both levels of nursing; could potentially confuse public as well as complicate structure of the current health care deliver system.
• Has not been politically feasible for the past 25 years.

Conclusion

This model offers a change from the current system -- from nursing education to licensing and titling to nursing practice. It incorporates aspects of "differentiated practice," but does not seem to offer long-term solutions to uncertainty of roles for nursing practice, the nursing shortage or increasing student enrollments in nursing education programs. The task force considered it because a similar model has been proposed for over 25 years, yet without evidence of substantial progress toward its adoption.

Model 3 - Baccalaureate degree with required residency experience (3 versions)

Model 3-A: Generalist 4 year BSN with residency:

Pros:

• Less disruptive to current system / more feasible
• Could facilitate transition of current BSN - RNs, by adding residency, then new exam and licensure

Cons:

• Requires new MN legal scope and a new licensure exam
• Leaves majority of nurses with less education than most other health professionals (student does more work and still has only baccalaureate degree)

Note: Possibility of negotiating with NOADN (and other significant groups) for support. Seek input of others in defining new MN scope in way that reduces ADN level opposition (i.e., preserves AD-RN role).

Model 3-B -Pre-Nursing B.S. Degree - Six Years:

Notes:

• BS graduates could move to the DNP or PhD without master's
• New role and scope of practice and licensure at conclusion of residency
• Important to determine who pays for residency, e.g. partnership between programs (only "grads" of accredited programs would be admitted and only residencies approved by an accrediting body would receive federal funds)
• Accredited residencies could be paid for with federal dollars/or tuition dollars
• Residencies should be accredited
• Could not move from BS to clinical doctorate or PhD without residency
• APRN role would be incorporated into clinical doctorate (DNP)or could be a new post residency option
• May create change in current AD and BS education models but will support their continuation.
• There is a need to promote a change in scope of practice

Pros:

• Strengthens and lengthens the clinical practice base of the Baccalaureate graduate
• Expands the education of students in arts and sciences.
• Like other pre-professional models i.e. medicine, law, etc. which have worked and may enhance the prestige of the degree.
• Focuses the scope and standards of practice on currently established curriculum models for baccalaureate education
• Provides distinction between bachelors prepared nurse and ADN/Diploma/LPN.
• Strengthens the graduate's ability to practice leadership/management and public health.
• Focuses the graduates' clinical practice on recognized scopes and standards of professional nursing practice (ANA).
• Provides for a continuing stream of nurses interested/prepared for direct care.
• Offers the potential to complete a role delineation study to show distinction between master nurse and RN--during the 2 years of residency.
• "Raises the bar" for baccalaureate education especially in preparation of students in clinical practice.
• Likely to provide greater numbers of nurses to cover 24/7 then master's entry.
• Provide new level of professional examination.
• Omits one to two years of education needed prior to doctoral degree while increasing years of education and practice at the entry level.
• Provides the APN with credentials to compete with other health care providers at their "level", i.e. MD, PharmD, etc.
• Allows for the development of "real time" partnerships between education and practice re: residencies.
• More acceptable approach to beginning freshman and transfer students who may not wish to commit to an entry level masters.
• May be able to recruit more students
• Less costly to students.
• Residency may offer students increased opportunities for employment with residency provider agency.
• Gives agencies more experienced new graduates.

Cons:

• May not be an acceptable approach to programs currently preparing BSN graduates.
• Will reduce the amount of clinical emphasis during the first four years.
• Will increase the amount of didactic nursing content to be covered in one year (senior year).
• The amount of time it will require to provide a close working relationship between education and practice to implement the 2 year residency.
• Omits the master's level completely.
• Will require a change in Scope of Practice at all levels.
• Will require partnerships between AACN, NOADN, NCSBN, and others to differentiate practice roles between levels of nursing practice.
• Does not allow equality at the entry level with other professions whose entry level is masters or doctorate.

Model 3-C - Bachelor of Science in Nursing - 5 Years

Notes:

• BSN graduates could move to the DNP or PhD without master's
• BSN could move to PhD without one year residency.
• PhD could complete 1-2 year clinical residency to refocus career and participate in clinical practice
• New role and scope of practice and licensure at conclusion of residency
• Important to determine who pays for residency, e.g. partnership between programs (only "grads" of accredited programs would be admitted and only residencies approved by an accrediting body would receive federal funds)
• Accredited residencies could be paid for with federal dollars/or tuition dollars
• Residencies should be accredited
• Could not move from BSN to clinical doctorate (DNP) without residency
• APRN role would be incorporated into clinical doctorate (DNP)or could be a new post residency option
• May change current AD and BSN education models but will support continuation of both.
• There is a need to promote a change in scope of practice

Pros:

• May be more acceptable approach to key stakeholders.
• Essentially maintain the system as is with little disruption.
• Strengthens the arts and science base in nursing
• Increases clinical practice through residency.
• Focused residency will offer opportunity for graduate to be prepared in a specialty area of practice (not as a specialist).
• Same or greater numbers of nurses available for clinical practice.
• Students able to contribute to clinical practice during residency while continuing to learn.
• Offers opportunities for "real time" education and practice partnership.
• Least costly to students.
• Strengthens leadership/management/specialty capabilities of graduates.
• Focuses Scope and Standards of practice on established models of curricula for baccalaureate education.
• Provides distinction between BSN/ADN/diploma/LPN.
• Focuses graduates' clinical practice on recognized specialty scopes and standards of practice and generalist practice (ANA).
• Provides for a continuing stream of nurses interested in being prepared for direct care.
• Offers opportunity to clearly show through role delineation the differences in levels of nursing practice.
• "Raises the bar" for BSN graduates through increased practice and specialty education.
• Likely to provide greater numbers of nurses to cover 24/7.
• Provides opportunity for new level of examination and a change in law/regulation of nurses.
• May be more acceptable approach to entering freshman considering a nursing career.
• May be able to recruit more students.
• Specialty residency may offer new graduates more options for employment than currently exists, i.e. public health, HMO, supervision, etc.
• Agencies have availability to the more experienced beginning graduates then currently exists.
• Omits one to two years of master's education prior to doctoral work while increasing years of education and practice at entry level.
• Provides a direct route to PhD, without completing the residency.
• Provides the APN with the credentials to compete with other providers at the "level, i.e. M.D., PharmD., etc.
• Since change is not dramatic will allow more time to establish relationships between key stakeholders to differentiate scopes and standards of practice at all levels.

Cons:

• Does not allow graduate equality with other professions whose entry level is masters or doctorate.
• No radical change in educational process.
• Without radical change may lose outstanding students who will choose other routes to "professional" careers.
• Omits the master's completely
• Will require a change in scope of practice at all levels.
• PhD graduates cannot enter clinical practice without completing a clinical residency.
• Some disruption in educational models as they currently exist.
• Will require close partnership between education and practice to provide appropriate residencies (per student demand).

Model 4 - Entry level master's degree

Pre-nursing baccalaureate and master's degree

* Arts & sciences with inclusion of additional or expanded work in areas such as genetics, immunology, ethics, epidemiology, arts-in-healing, etc. and pre-nursing

Notes:

• AD programs lead to licensure as RN

- Scope of practice re-evaluated
- Must be supervised by master nurse

• BSN programs would alter curriculum to expand core in arts and sciences

- Graduates would not be prepared for any legally sanctioned role
- Necessary basis for move into MSN program
- Prenursing content is introductory fundamentals - role socialization, skills, health assessment.
- BSN programs would require nursing faculty.
- Could include pharmacology and nursing theory.

• MSN (approximately 4 semesters)

- Entry into master nursing
- Different scope of practice for master nursing practice
- Different licensure

• DNS (approximately 2 additional years)

- Advanced practice credential

• PhD - research/scholar credential
  
  
• Decision would be required about whether baccalaureate degree provided exit point for practice; or served only as prerequisite to masters program
  
  
• MPrN content drawn from current AACN Baccalaureate Essentials plus a portion of Master's Essentials
  
  
• The new MPrN role may have some aspects of current CNS role
  
  
• MPrN will require new licensure mechanism & new scope of practice (to include supervision of AD-RN)
  
  
• Consortia could be formed with schools offering only BSN to establish agreements for graduates to attend regional MPrN programs
  
  
• Need to consider extent of direct patient care that would be provided by MPrN nurses
  
  
• Advanced practice education (DNP) leads to certification/licensure and scope of practice similar to current APNs
  
  
• DNP programs must be clear on content - current curricula would need to be reconfigured; also emphasis on outcomes research at the DNP level
  
  
• Important to avoid disenfranchising current practitioners; grandfathering of current practitioners would be issue

Pros:

• More reflective of the changing needs and expectations of the evolving health care environment
• Would not disenfranchise AD graduates since would retain RN title and current licensure examination
• "Raising the bar" for entry into master practice could potentially attract students seeking clear professional role in health care system
• Increased time for education would allow more comprehensive exposure to essential coursework in both core sciences and nursing
• Professional entry at masters would be consistent with other professions such as Occupational Therapy, Physical Therapy and pharmacy
• Allows for less disruption of current baccalaureate programs
• Could centralize faculty in specific institutions too provide master's level education
• DNP credential could create greater parity and clinical recognition in both academic and practice settings.
• Application of model helps address the nursing shortage by maximizing effectiveness of the continuum of nursing providers
• The model could be cost effective if each level of provider is utilized in accordance with their education and needs of the health care system, e.g. professional nurses more prepared for directing care, etc.
• Consortia could be developed to facilitate schools recruiting students into program and providing some beginning level of education
• Could strengthen focus on community health/public health and become a leader as nursing practice settings move away from acute care
• Would strengthen content in leadership and management, team building, case management, community and public health
• Graduates would have a stronger base in sciences as well as more preparation in nursing courses

Cons:

• Requires dramatic restructuring of currently existing baccalaureate programs
• Might endanger the potential for some of the existing baccalaureate programs to continue
• Requires six year education without professional doctorate
• Students will be required to expend greater sums to get education
• Costs and increased time might discourage some potential students
• Will require dramatic faculty development efforts
• Would require many educational programs to retool master's curriculum
• Could threaten programs that offer baccalaureate, but not master's programs
• Would require development of new licensure examination and professional nursing title
• Any change of this magnitude is likely to meet resistance by the established health care delivery system
• Could appear to reduce the overall number of nurses; thus raising more concern about the impact of the nursing shortage
• Issue of "exit options" at baccalaureate level would have to be decided
• Absence of existing practice models would make data on advantages of the model difficult to obtain

Model 5 - Entry level nursing doctorate (2 versions)

Model 5A - This approach provides model for "new nurse" at the professional doctorate level

Notes:

• Students with current BSN could complete a "non-traditional" program for ND
• Important to avoid disenfranchising current practitioners; grandfathering of current practitioners would be issue
• ND could move on to DNP or PhD

Pros:

• Provides parity and recognition for the entry level professional
• Provides greater differentiation from current registered nurses training
• Would increase number of years of clinical training for entry practice

Cons:

• Dramatic change in the way nursing education would be structured. Approval process might be very lengthy and difficult
• Would cost significantly more to achieve professional nursing status and require longer period of study
• Adequate arts and science education might not be possible in two years.
• Would markedly decrease the number of institutions granting professional entry-level education.
• Would require dramatic changes in faculty capabilities.

Model 5B - professional doctorate option with a residency

* Student would complete academic baccalaureate degree that would not prepare the individual for practice as a nurse. Current baccalaureate programs could transition to produce these graduates.

Notes:

• Residency controlled by academic program in partnership with a variety of specialized practice settings
• If nurses with current BSN want to become "master nurse" could do 1 year of clinical MSN program with a residency, take new licensure exam and become "Master Nurse"
• Allows schools without MSN to continue their BSN programs (for students to achieve RN licensure)

Model 6 - Combines Current BSN and Advanced Practice Nurse

Description - this model provides for various graduate degrees
as the entry point for professional nursing practice

Pros:

• Could use current structures to make it work (incorporates current BSN and MSN to become entry-level Master Nurse
• "Fail safe" model co-ops current APRN licensure and scope. No license after baccalaureate
• Direct care would be within scope, but done selectively
• Regulatory battle for APNs practice has already been negotiated and could serve as the basis for credentialing of this professional (master) nurse
• Provides educational parity with other health professions
• Allows schools/faculties option of offering master's degree or professional doctorate

Cons:

• Would require tremendous changes in the current advanced practice programs to solidify blending of NP/CNS role for entry
• Would provide dramatically different entry role (could also be a pro)
• Might not be adequate number of faculty for a large number of programs at New entry level
• Requires new licensure and scope of practice for advanced practice at DNP level
• Does not address preparation for current APRN roles; would new MSN or ND become a blend of current BSN + APRN with a variety of practice options