entry level into nursing practice. by the end of this power point presentation students will be...

Adrianne TozerFerris State UniversitySeminar Presentation

February 2014

Entry Level into Nursing Practice

By the end of this Power Point Presentation students will be able to:

1. Explain how the history of nursing has impacted the education of nurses.2. Recognize the influence hospital-based diploma programs and community

colleges have had on our current educational debate.3. List the five recommendations made by the American Nurses Association in

their position paper.4. Recognize how and why the 4 testing states failed at implementing ANAs

recommendation on BSN as the new entry level.5. Explain how the Oppression Theory relates to the nursing education dilemma.6. List supporters for increasing nursing education7. List evidence based studies relating to education level and patient outcomes.8. Understand what BSN in 10 is about and its advantages9. Recognize ways in which hospitals are currently taking control of the

educational requirements of nurses.10. Explain how the Intellectual Capital Theory relates to nursing education and

hospital profits and success

Objectives

With all the research and nursing leaders supporting a BSN as the educational preparation for entry into professional nursing practice, why has the change not occurred?

Question at Issue

1. Licensed Practical Nurse (LPN) diploma program

2. Registered Nurse (RN) diploma program

3. Associate Degree Nurse (ADN) program

4. Baccalaureate Degree (BSN) program

(Smith, 2010)

Current Routes of Entry Into the Nursing Profession

Throughout much of history caring for the sick was performed by family members based on tradition and trial and error.

During the Civil War (1861-1865) care of the sick and wounded was left to 20,000 volunteers made up of men and women (University of Pennsylvania School of Nursing, 2014).

History of Nursing Education

Training programs began developing in the United States which were based on the ideas of Florence Nightingale.

By 1900 somewhere between 400-800 schools of nursing were established.

The schools were owned/affiliated by hospitals in order to provide the student with clinical.

1. Little classroom education2. Student nurses were used for free labor3. Training took 2-3 years4. Nurses received a diploma

(University of Pennsylvania School of Nursing, 2014).


In the 1890s 2 nursing organizations were developed:

1. Nurses Associated Alumnae of the United States. This organization had two purposes which included supporting the professional and educational development of nurses and increasing the standard of nursing education (Gallagher & Sullivan, n.d.).

2. American Society of Superintendents of Training Schools for Nurses. Established rules and regulations regarding the type of training nurses should receive (Smith, 2010).


Hospitals continued to grow throughout the 1920s-1930s and patient care became more complex.

Hospital based programs continued to rely on student nurses for patient care but began to hire more nurses who had completed their education and graduated.

(University of Pennsylvania School of Nursing, 2014)


Debates began over the type of work nurses should be performing along with the proper way to educate them.

1. Stop training nurses in hospital based programs and instead placing education in institutions of higher learning.

2. Continue with hospital based programs because nurses trained in this manner provided exceptional bedside care.



The debate was never settled and a new way of nursing education began.

Community college programs started to emerge which seemed to meet somewhere in the middle of the two debates.



In 1952 Mildred Montag wrote her doctoral dissertation titled, “The Education of Nursing Technicians” (Boyd, 2011).

Her dissertation greatly impacted and advocated for ADN programs at the junior and community college level (Boyd, 2011).

The dissertation supported a shorter nursing program which would alleviate the nursing shortage (Boyd, 2011).

In 1958 the W.K. Kellogg Foundation funded seven pilot schools in 4 different states (Boyd, 2011).

The curriculum included various clinical experiences along with classroom teaching (Mahaffey, 2002)

The program was successful and the associate degree program began throughout the nation.

Mildred Montag and the Associate Degree Nursing Program

Even with the development of ADN programs the nursing shortage continued.

This lead to the 1964 enactment of the Comprehensive Nurse Training Act which supplied funds and grants to nursing schools, student loans, education grants and traineeships (Smith, 2010).

“The Nurse Training Act of 1964 is the most significant nursing legislation in the history of our country. I believe that it will enable us to attract many more of our most qualified young people to this great and noble calling” (Johnson, 1964, para 1).


American Nurses Association Study

The Comprehensive Nurse Training Act spurred the American Nurses Association (ANA) to study nursing education along with its current scope and practices.

The study focused on the increasing complexities of healthcare.

ANA determined there was a shift in nursing practice1. Theories2. Scientific discoveries3. Advancements in technology4. Development of new treatments

(Smith, 2010)

Recommendations:

1. The education of all those who are licensed register nurses should take place in institutions of higher education (Ellis & Hartley, 2004).

2. The minimum preparation for technical nursing practice should be the associate degree in nursing (Ellis & Hartley, 2004).

3. A new license and title be created designating technical nurses as Registered Associate Nurses (RANs) (Smith, 2010).

4. The minimum preparation for professional nursing practice should be a baccalaureate degree in nursing (Ellis & Hartley, 2004).

5. Education for assistants in the health service occupation should be in vocational educational intuitions rather than on the job training programs (Ellis & Hartley, 2004).

ANA’s 1965 Position Paper Recommendations

Immediately following ANAs position paper opposition started especially on the issue of phasing out hospital-based diploma programs.

Opposition from the following:1. Physicians2. Hospital Administrators3. Diploma nurse educators4. Diploma nurse graduates

(Nelson, 2002).

Opposition

While the hospital-based diploma programs began to decline the associate degree nursing programs (ADN) began to grow at a rapid rate (Nelson, 2002).

External factors affecting the continued growth of ADN programs:

1. Shortage of nurses (Nelson, 2002)

2. Federal funding (Mahafeey, 2002)

3. Consumer concern and support (Mahafeey, 2002)

4. Professional responsibility and accountability (Mahafeey, 2002)

Associate Degree Program Growth

As the community college programs flourished the ANA still wanted to begin implementing their entry proposal on a national level.

Four testing states chosen to assist in the change1. Oregon2. Montana3. Maine4. North Dakota

(Smith, 2010)

ANAs Testing States

Oregon Opposition to the change in Oregon came from the Oregon Federation of Nurses

(OFN), Concerned Nurses of Oregon (ONO), Oregon Community College Association (OCCA) and the Oregon Council of Associate Degree Nursing Programs (OCAP).

Concerns of OFN1. Financial cost to the citizens2. Financial cost to the healthcare industry

Concerns of ONO1. Survey showed 80% of RNs opposed the change.

Concerns of OCCA and the OCAP1. Lack of evidence supporting the need for change2. Adverse effect on nursing supply3. Adverse effect on the cost of education and healthcare4. Preserving access to community college programs

(Smith, 2010)

In the end there was enough protest from organized groups that legislature halted the entry issue in Oregon.

(Smith, 2010)

Oregon

Opposition to the change in Oregon came from the Concerned Nurses of Montana (CNOM) and the Montana Hospital Association (MHA).

Concerns of CNOM1. Contribute to educational discrimination2. Simply did not feel higher education was needed.

Concerns of the MHA1. Cost concerns2. Problems in recruiting baccalaureate prepared nurses

(Smith, 2010)

Montana

In the end the opposing groups won and thebill died.

(Smith, 2010)

Oregon

Opposition groups included the Consortium of Maine Nurses, Main Health Care Association and Long-Term Care Nursing Council.

Concerns of the Consortium of Main Nurses1. Effects on the nursing shortage2. Cost to the tax payer3. Career mobility 4. Grandfather clause

Concerns of the Main Health Care Association and Long-Term Care Nursing Council

1. Lack of educational facilities2. Nursing shortage3. Costs to nurses

(Smith, 2010)

Maine

The opposing groups had enough pull and the billed died.

(Smith, 2010)

Maine

Opposing groups included the Concerned Nurses, Med-Center One Hospital and Trinity School of Nursing.

Concerns of Concerned Nurses1. Agreed a change in the educational requirements was needed but

felt they could manage it better than the North Dakota Board of Nursing (NDBM).

Concerns of Med-Center One Hospital and Trinity School of Nursing1. Felt the Board of Nursing did not have the authority to close diploma

programs.

(Smith, 2010)

North Dakota

In 1985 North Dakota adopted ANAs proposal

Lawsuit soon followed from the Med-Center One Hospital and Trinity Hospital claiming the decision was a unconstitutional delegation of legislative power.

In 1986 the lawsuit was overturned and ANAs proposal was implemented.

Between 1987-2001 a bill was introduced each year trying to over turn North Dakotas Board of Nursing decision on nursing requirements claiming the new rules were causing more of a nursing shortage.

Eventually the laws were changed and the multi-level education system was

once again in place. (Smith, 2010)

North Dakota

Some of the groups opposing ANAs proposal only came together for a short time in order to defeat the proposal and then the groups dissolved.

1. Nursing Homes2. Hospitals3. Community Colleges4. Nurses

These groups have a agenda in order to serve their own cause or economic interests.

The groups influence state government decisions due to their economic power and political lobbying strengths. Public officials are often dependent on them due to their financial backing.

Decisions to implement the change began at the top of the hierarchy and filtered down to lower levels which generates a feeling of force. This leads to suspicion and resentment.

(Smith, 2010)

Why the Failure ?

Has the oppression of nurses caused the educational divide throughout the profession?

In 1983 Susan Jo Roberts applied Paulo Freire’s model of oppression to the nursing profession.

Roberts states, “The view of nurses as oppressed is supported by the fact that nurses lack autonomy, accountability and control over the nursing profession”.

Roberts States- “The nurse is to be bold, share initiative and be responsible for making significant recommendations while at the same time, she must appear passive”.

(Roberts, 1983)

Theory of Oppression

Roberts Theory-Oppression occurs when a group of people have been controlled by outside forces who have greater power, status and prestige.

Nursing Implications-In he early 1900s many schools of nursing opened and were controlled by hospitals and physicians.

Roberts Theory- Oppression causes internal conflict and tension within the group.

“This tendency toward internal conflict is often given as proof that oppressed persons are unable to organize, be civilized and govern themselves” (Roberts, 1983, p. 23). In turn growth and change are impeded.

Nursing Implications-We see this played out as members of the nursing profession have argued amongst themselves for years; getting very little accomplished.

(Roberts, 1983)

Oppression Theory

Roberts Theory- Oppressed groups have been forced to become dependent and submissive as a means of dealing with the dominant group.

Nursing Implications-Nurses have remained quiet on what we thought was best for the profession. Instead we have let others dictate what should be done.

Roberts Theory-The dominant group often uses education as a means of control. “If the education is controlled by the powerful and limited to curricula that support their values, little conflict occurs” (Roberts, 1983, p. 28).

Nursing Implications-This occurred by way of hospitals, physicians and ADN programs telling the nursing profession what should be done in regards to education.

(Roberts, 1983)

Oppression Theory

A growing body of research suggests improved patient outcomes are connected with baccalaureate prepared nurses.

1. 2013 Ann Kutney Lee and colleagues found a increase in the percentages of nurses holding a BSN within a hospital was associated with a reduction in deaths.

2. 2013 Mary Blegan and colleagues found that hospitals with higher rates of BSN or higher degrees had lower CHF mortality, decubitus ulcers, failure to rescue, postoperative DVTs and shorter lengths of stay.

3. 2012 researchers for the University of Pennsylvania found Magnet hospitals had a lower rate of surgical deaths and failure-to-rescue rates than patients who were cared for in non-Magnet hospitals.

(American Association of Colleges of Nursing, 2014)

Evidence Based Research

A growing body of research suggests improved patient outcomes are connected with baccalaureate prepared nurses.

1. 1995-1998 a study of RN to BSN graduates showed a higher level of expertise in nursing practice, communication, leadership, professional integration and research.

2. 2003 Linda Aiken and colleagues performed an extensive study which found surgical patients have a higher survival advantage if treated in hospitals which have a greater number of baccalaureate prepared nurses or higher.

3. 2003 Dr. Betty Rambur and colleagues conducted a study which found BSN prepared nurses are essential to stabilizing the nursing workforce because they have higher levels of job satisfaction.


Evidence Based Research

Supporters include:1. Federal government2. Military3. Nurse executives4. Healthcare foundations5. Nursing organizations


Supporters for BSN Prepared Nurses

The National Advisory Council on Nurse Education and Practice (NACNEP)

recommends at least two-thirds of the nursing workforce hold a baccalaureate degree or higher but is currently at 55%.

The US Army, Navy, and Air Force require all active duty nurses to hold a BSN.

The National Black Nurses Association, Hispanic Association of Colleges and Universities and National Association of Hispanic Nurses have announced their commitment to increasing the amount of BSN prepared nurse among minority nurses.

A Harris poll conducted in 1999 found that 76% of the public believed nurses should hold a BSN degree or higher in order to practice.


Public and Private Supporters

Policymakers and Practice Leaders who support raising the bar on nursing education:

1. Robert Wood Johnson Foundation (RWJF)2. Institute of Medicine3. Council on Physician and Nurse Supply4. American Organization of Nurse Executives

(AONE)


Policymakers and Practice Leaders Support

Countries which require a BSN as entry into practice:1. Canada2. Sweden3. Portugal4. Brazil5. Iceland6. Korea7. Philippines


Global Level

Even with all the support and evidence not one state currently requires a BSN as the entry level into nursing, however, several states are attempting to pass a law which would require RNs to obtain their BSN within 10 years of licensure.

1. New York2. New Jersey3. Rhode Island

(National League for Nursing, 2012)

BSN in Ten

The BSN in Ten Bill is not about changing the entry level into nursing.

If a BSN was not obtained within the ten year period the nurse’s license would go on hold until the degree is completed.

If the bill is passed all current licensed RNs would be exempt from meeting the new requirements (grandfathered).

(American Association of Colleges of Nurses, 2012)

BSN in Ten

Advantages1. Provide future nursing instructors2. Improve patient care3. Respond to need of critical thinking skills4. Give credibility to the profession

(American Association of Colleges of Nurses, 2012)

Reasons for BSN in Ten

Opposition is coming from the Healthcare Association of New York

Concerns:1. Lack of nursing faculty to teach

(National League for Nursing, 2012)

Opposition for BSN in Ten

More than 600 schools throughout the nation have opened RN to BSN programs

Many community college programs have partnered with four-year schools to make transitions streamlined

About 90,000 students are currently attending bachelor's degree nursing programs, up from 30,000 about ten years ago.

(The Advisory Board Company, 2012)

BSN DemandWhat is being Done?

Want to remain competitive More hospitals seeking Magnet status Hospitals aware of improved patient outcomes More than 5000 hospitals in the last 5 years

now have policies requiring nurses to obtain their bachelors within a specific time frame.

(The Advisory Board Company, 2012)

Hospitals Want BSNs

Since BSNs are in demand hospitals are offering incentives

1. Tuition Reimbursement2. Wage Increases3. Promotions4. Paid time off to attend classes

Hospital Incentives

If hospitals do not reward advanced education here is why they should:

Intellectual Capital Theory

Hospital Incentives

What is it?1. The intellectual capital theory is using the

knowledge of employees in order to improve the business and profits.

How does it apply to nursing?1. Applying this theory to nursing explains how

nursing knowledge relates to patient and organizational outcomes.

(Covell & Sidani, 2013)


When an organization promotes and values education for nurses by allowing time off for education, wage increases and tuition reimbursement the organization, in turn, builds an intellectual asset which will positively benefit business performance and the future outlook.



Example1. Hospitals supporting nurses who return to school

for a BSN will reap the benefits of improved patient outcomes.

Benefits1. Improved patient outcomes 2. Positive reputation 3. Increase profits4. Decrease spending



What circumstances both past and future have impacted the advancement of nursing education.

1. Oppression2. Nursing Shortage3. Hospital-Diploma Programs4. Community Colleges5. Hospitals6. Nurses

Conclusion

What steps are currently being taken to positively influence the advancement of nursing education?

1. BSN in 102. Hospitals mandating BSNs3. Employer incentives4. Increase in RN-BSN programs5. Smoother transitions from community colleges to

Universities6. Increased studies showing improved patient

outcomes7. Increased support form leaders and nursing

organizations

Conclusion

The Advisory Board Company. (2012). More nurses attending RN to BSN programs for job security. Retrieved from Advisory.com Web site: http:/ / www.advisory.com/ daily-briefing/ 2012/ 06/ 26/ more-nurse-attending-rn-to-bsn-programs

American Association of Colleges of Nurses. (2012). Advancement of nursing education BS in 10 bill [PowerPoint Slides]. Retrieved from http:/ / www.aacn.org/ wd/ chapters/ chaptersdocs/ 00382581/ websites/ doc/ %20%20%20%20%20%20%20%20%20%20%29%20%20%20%20%20%20%20%20%20%20%20%20Advancement%20of%20Nursing%20Education%20BS%20in%2010%20Bill%20Mary%20Ellen%20Plass.ppt

American Association of Colleges of Nursing. (2014). The impact of education on nursing practice. Retrieved from http:/ / www.aacn.nche.edu/ media-relations/ fact-sheets/ impact-of-education

American Association of Community Colleges. (n.d.). Get the facts about registered nurses [Fact Sheet]. Retrieved from http:/ / www.aacc.nche.edu/ Resources/ aaccprograms/health/ hpat/ Documents/ RN_F3_magnet.pdf

Boyd, T. (2011). Mildred Montag envisions AD nursing education. Retrieved from http,/ / new.nurse.com/ article/ 20110502/ NY02/ 105020072

Covell, C. L., & Sidani, S. (2013). Nursing intellectual capital theory: implications for research and practice. OJIN: The Online Journal of Issues in Nursing, 18(2). doi:10.3912/ OJIN.Vol18No02Man02

Ellis, J., & Hartley, C. L. (2004). Nursing in today's world: trends, issues & management (8th ed.). Retrieved from books.google.com/ books?isbn=0781741084

References

Gallagher, R. M., & Sullivan, K. (n.d.). Compendium of ANA education positions, position statements, and documents. Retrieved from http:/ / nursingworld.org/ MainMenuCategories/ Policy-Advocacy/ State/ Legislative-Agenda-Reports/ NursingEducation/ NursingEducationCompendium.pdf

Johnson, L. B. (1964). Remarks upon signing the nurse training act of 1964. Retrieved from The American Presidency Project Web site: http:/ / www.presidency.ucsb.edu/ ws/ pid=26484

Mahaffey, E. H. (2002). The relevance of associate degree nursing education: past, present, future. OJIN: The Online Journal of Issues in Nursing, 7(2). Retrieved from www.nursingworld.org/ ojin/ MainMenuCategories/ ANAMarketplace/ ANAPeriodicals/ OJIN/ Tableof contents/ Volume72002/ No2May2002/ RelevanceofAssociateDegree.aspx

National League for Nursing. (2012). NY "BSN in 10" initiative. Nursing Education Policy Newsletter, 9(1). Retrieved from http:/ / www.nln.org/ publicpolicy/ newsletter/ vol9_issue_1_blast.htm

Nelson, M. A. (2002). Education for professional nursing practice: looking backward into the future. OJIN: The Online Journal of Issues in Nursing, 7(3). Retrieved from www.nursingworld.org/ MainMenuCategories/ ANAMarketplace/ ANAPeriodicals/ OJIN/ TableofContents/ Volume72002/ No2May2002/ Education- ProfessionalNursingPractice.aspx

Roberts, S. J. (1983). Oppressed group behavior: implications for nursing. Advances in Nursing Science, 5(4). Retrieved from http:/ / journals.lww.com/ advancesinnursing/ Citation/ 1983/ 07000/ Opprssed_group_behaviors_implicaiton_for_nursing.6.aspx

References

National League for Nursing. (2012). NY "BSN in 10" initiative. Nursing Education Policy Newsletter, 9(1). Retrieved from http:/ / www.nln.org/ publicpolicy/ newsletter/ vol9_issue_1_blast.htm

Nelson, M. A. (2002). Education for professional nursing practice: looking backward into the future. OJIN: The Online Journal of Issues in Nursing, 7(3). Retrieved from www.nursingworld.org/ MainMenuCategories/ ANAMarketplace/ ANAPeriodicals/ OJIN/ TableofContents/

Volume72002/ No2May2002/ Education- ProfessionalNursingPractice.aspx

Roberts, S. J. (1983). Oppressed group behavior: implications for nursing. Advances in Nursing Science, 5(4). Retrieved from http:/ / journals.lww.com/ advancesinnursing/ Citation/ 1983/ 07000/ Opprssed_group_behaviors_implicaiton_for_nursing.6.aspx

Shipman, D., Roa, M., & Hooten, J. (2011). Healthcare organizations benefit by promoting BSN education. Nurse Education Today, 31, 309-310. doi:10.1016/ j.nedt.2010.10.003

Smith, T. G. (2010). A policy perspective on the entry into practice issue. OJIN: T he Online Journal of Issues in Nursing, 15(1). doi:10.3912/ OJIN.Vol15No01PPT01

University of Pennsylvania School of Nursing. (2014). American nursing: an introduction to the past. Retrieved from www.nursing.upenn.edu/ nhhc/ Welcome%20Page%20Content/ American%20Nursing.pdf

References

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