Overview
The Veterans Health Administration (VHA) is a recognized leader
in adopting best practices and setting the standard for quality health care in
the United States. The administration's commitment to improving patient care and
reducing medical errors serves as a model for other health care providers to follow.
As the nation's largest integrated health care system, with almost 36,000 registered
nurses (RNs), the VHA is the nation's single largest employer of RNs and, as such,
plays a lead role in setting the professional standards for nursing practice.
The
VHA's commitment to providing the best possible care to our nation's veterans
extends to preparing a well-educated nursing workforce. The VHA employs nurses
in roles consistent with their educational preparation and provides them with
the education necessary to develop new clinical skills and move forward in their
nursing careers. The VHA's support for the Bachelor of Science in Nursing (BSN)
for positions beyond the entry-level is consistent with other progressive health
care facilities that place a high value on learning and are also recognized for
their nursing excellence. Nurse executives, federal agencies, the military, national
nursing organizations, health care foundations, Magnet Hospitals, and minority
nurse advocacy groups all recognize the unique value that baccalaureate-prepared
nurses bring to the practice setting. In the same vein, the VHA's Nursing Qualification
Standards creates a model career ladder program for the profession that is essential
to maintaining patient safety and diversifying the nursing workforce.
The
American Association of Colleges of Nursing (AACN) is the national voice of baccalaureate
and graduate nursing education representing more than 570 senior colleges and
universities that educate over 150,000 students each year and employ 9,300 nursing
faculty. AACN member schools work in collaboration with the VHA to provide the
necessary education to develop the VHA nursing workforce. VHA employees are attending
300 different educational institutions at almost 400 locations throughout the
United States. Many nursing education programs are offered on-site at VHA facilities
and many of these facilities provide clinical placement opportunities essential
to educating new nurses and assisting in the transition from academia to the clinical
setting.
Nurse
Qualification Standards
The Nurse Qualification Standards create a framework
for appointment and advancement of RNs based on education and practice requirements
within the veterans health care system. They establish the baccalaureate degree
as the level of educational preparation that VHA registered nurses must have to
move beyond entry level.
Though
the VHA has moved to strengthen its educational requirements, the administration
remains committed to hiring RNs prepared at the diploma and associate degree (AD)
levels. From 1995-2001, 40% of newly hired RNs were prepared at the AD/diploma
level while 60% were prepared at the BSN or higher degree levels. These standards
ensure that RNs are educated to provide the highest quality health care to veterans,
but are flexible enough to recognize and reward performance and advanced education.
National
Nursing Education Initiative
The VHA provides significant financial support for academic achievement through
the National Nursing Education Initiative (NNEI). This program ensures that the
VHA workforce can meet the challenges of an intense, complex, and changing work
environment. The NNEI program awards tuition support to nurses to obtain baccalaureate
or post-graduate degrees and training. The average awardees receive $11,000 in
tuition assistance. In support of this effort, the VHA has partnered with schools
of nursing to provide educational opportunities to its employees on-site at VHA
hospitals, via the Internet, and through other alternate arrangements.
The
latest NNEI program statistics indicate that there are 2,702 total participants
with 61% enrolled in baccalaureate programs. A total of 454 participants have
already completed a BSN degree. Additionally, the program supports and generates
potential nurse faculty with 995 master's and 55 doctoral program enrollees. The
NNEI program includes a service obligation that ensures graduates will remain
with the VHA for as long as three years after completion of an academic program.
This staff development and nurse retention effort has effectively improved the
career horizon and enhanced the earning potential for hundreds of licensed practical
nurses (LPNs), nursing assistants (NAs), and RNs with only minimal nursing preparation.
Through this program 173 LPNs and 23 NAs will become RNs and move forward in their
careers.
Information
collected from a 2002 Nursing Personnel Exit Survey indicates strong support
for the NNEI and the Nursing Qualification Standards. Among the 2,428 RNs who
left the VHA system, primarily through retirement, 64% said that the BSN requirement
in the VHA standards will either "attract higher quality candidates or enhance
the nursing profession" and 86% acknowledged the VHA's "support to nurses
to pursue their educational goals." None of the departing nurses listed the
change in educational requirements as a reason for leaving. In addition, the VHA's
nursing turnover rate in 2000 was 9.5%, substantially less than the national average
of 15%.
Education
Makes a Difference in Nursing Practice
The VHA recognizes that a highly
educated nursing workforce is good for patient care. The administration understands
the role education plays in enhancing patient safety and managing an increasingly
complex system of care. Already the standard for nursing practice in the military,
a bachelor's degree is essential to ensuring that educational preparation for
nurses is commensurate with the other health disciplines. The additional education
provided by a BSN enhances clinical decision-making and critical thinking skills,
and includes preparation in community health, patient education, and nursing management
and leadership. Support for raising the educational level of the nursing workforce
is growing as evidenced by the following:
- The
National Advisory Council on Nurse Education and Practice (NACNEP), policy advisors
to Congress and the Secretary of Health and Human Services on nursing issues,
has urged that at least two-thirds of the nurse workforce hold baccalaureate or
higher degrees in nursing by 2010. NACNEP found that nursing's role for the future
calls for registered nurses to manage care along a continuum, to work as peers
in interdisciplinary teams, and to integrate clinical expertise with knowledge
of community resources.
- The
Pew Health Professions Commission in a 1998 report called for a more concentrated
production of baccalaureate and higher degree nurses. This commission, an interdisciplinary
group of health care leaders, legislators, academics, corporate leaders, and consumer
advocates, was created to help policy-makers and educators produce health care
professionals able to meet the changing needs of the American health care system.
- Chief
Nurse Officers in university hospitals prefer to hire nurses who have baccalaureate
degrees, and nurse administrators recognize distinct differences in competencies
based on education. In a 2001 survey, 72% of these directors identified differences
in practice between BSN-prepared nurses and those who have an associate degree
or hospital diploma, citing stronger critical thinking and leadership skills.
Model
Career Ladder Program
The VHA employs nurses in roles congruent with their
educational preparation. In essence, the VHA has created a 'career ladder' program
for its nursing workforce based on different educational preparation. Beginning
in 2005, the administration will require an AD or diploma for Nurse I positions,
a BSN degree for Nurse II positions, and a Master of Science in Nursing (MSN)
degree for Nurse III positions. Similar practice models have been implemented
in acute care operating rooms, inpatient settings, rural community nursing centers,
and acute care operating rooms. Evidence indicates that these practice models
foster positive outcomes related to job satisfaction, staffing costs, nurse turnover
rates, adverse events, nursing roles, and patient interventions. National support
for nursing career ladder programs as a nurse retention and career progression
mechanism is increasing. Recent developments include the following:
- The Nurse
Reinvestment Act (P.L. 107-205), signed by President Bush on August 1, 2002,
establishes a career ladder grant program to promote career advancement for nurses
and encourage partnerships between health care providers and nursing schools for
advanced training.
- On
August 7, 2002, the Joint Commission on Accreditation of Healthcare Organizations
(JCAHO) released a landmark report on the nursing shortage that provides a public
policy action plan to address this evolving health care crisis. One of the primary
strategies promoted by the expert panel centered on the creation of a career ladder
commensurate with education level and experience. The report states that: "Nurses
enter the workforce with a variety of educational experiences, although these
different skill and competency levels are not necessarily recognized - through
compensation and role differentials - in the work setting. This serves as a disincentive
for nurses to raise their level of education."
- In
an article in the July 29, 2002 issue of the Health Care Policy Report,
Labor Secretary Elaine Chao stated that the Departments of Labor, Health and Human
Services, and Education are developing a nursing career ladder pilot program.
Enhancing
Patient Safety
The VHA is a leader in providing quality care, supporting
nursing research, and advocating for advanced nursing education. The administration
recognizes the role education plays in enhancing patient safety and managing an
increasingly complex system of care. The VHA uses innovative approaches to improve
quality care, and recently established a new Deputy Undersecretary for Health
Policy Coordination to support this effort. The purpose of this position is to
improve performance measures and quality through coordination with the U.S. Department
of Health and Human Services on a wide range of issues including healthcare quality,
patient safety, and information technology.
The
VHA system is an innovator in setting new standards in health care and has been
recognized for its efforts to ensure quality care and patient safety. In 2002,
the Institute of Medicine released a report entitled Leadership by Example,
which praised the VHA's efforts to improve quality care as "one of the best
in the nation." The report cited the use of performance measures to improve
quality in clinical disciplines, ambulatory, hospital, and long-term care as keys
to their success. For example, VHA interventions are reflected in the data that
show post-operative death rates decreased by 27% from 1991 to 2000. During the
same year the VHA's National Center for Patient Safety received the John E. Eisenberg
Award for Patient Safety for Systems Innovation. The Eisenberg Awards are given
by the Joint Commission on the Accreditation of Healthcare Organizations and the
National Forum for Healthcare Quality and Reporting.
Promoting
Diversity
The VHA has demonstrated a strong commitment to increasing diversity
among its RNs and other health professionals. Nurse leaders recognize the connection
between a culturally diverse nursing workforce and the ability to provide quality
patient care. The VHA has developed comprehensive strategies to ensure that enhancing
diversity remains a top priority.
Internally,
the Office of Diversity Management and Equal Employment Opportunity maintains
numerous diversity initiatives and programs that promote diversity. The office
encourages executives, managers, supervisors, and staff to participate in diversity
training and development programs. Annually this office organizes an awards ceremony,
where the Secretary of Veterans Affairs honors select employees for their contributions
to promoting diversity. The Equal Employment Opportunity Awards are given to individuals
who have contributed to the awareness and importance of diversity through related
initiatives.
A
culturally diverse nursing workforce is vital to meeting the changing health care
needs of the nation. Minority populations are increasing substantially, but they
also have higher rates of certain diseases, lower rates of successful treatment,
and in some cases, shorter life expectancies than the majority population. The
nursing community understands the importance of cultural sensitivity and diversity
in providing quality patient care and is taking action to address this issue.
Efforts
to diversify nursing are working. Though minority representation within the nursing
workforce is only 12.3% according to the latest National Sample Survey of Registered
Nurses, minority students currently enrolled in baccalaureate nursing programs
make up 21.5% of the student population. In fact, minority representation in baccalaureate
nursing programs has risen steadily over the past ten years from 17.1% in 1990
to 21.5% in 2002.
The
NNEI initiative is an important step to ensuring a diverse nursing workforce.
Data from the sample survey show that minority nurses are much more likely to
pursue the BSN degree than their white counterparts. By removing the financial
barriers to an education, the VHA will further facilitate efforts to diversify
the nursing profession and provide career advancement opportunities to nurses
from underrepresented groups. Minority nurse organizations, including the National
Black Nurses Association, Hispanic Association of Colleges and Universities, and
National Association of Hispanic Nurses, are all committed to increasing the number
of minority nurses with baccalaureate and higher degrees.
Conclusion
AACN fully supports the VHA's commitment to expand opportunities for nurses to
obtain baccalaureate and advanced degrees in nursing through the NNEI initiative.
In addition, the VHA Nurse Qualification Standards establish a system-wide framework
that recognizes educational preparation and awards performance in advancing through
the nursing career ladder. AACN recognizes the pivotal role of the National Commission
on VA Nursing in assessing the future of the nursing profession in the VHA. The
legislative and organizational policy recommendations of the Commission will have
an important and lasting impact. AACN and its member schools will continue to
work with the VHA to bring innovative educational programs to their nursing workforce
with the goal of providing the best patient care to the nation's veterans.
