Activity

Academic Progression in Nursing (APIN) is a program funded by the Robert Wood Johnson Foundation (RWJF) and led by the Tri-Council for Nursing (comprising the American Association of Colleges of Nursing [AACN], the American Nurses Association [ANA], the American Organization of Nurse Executives [AONE], and the National League for Nursing [NLN]). The APIN program office, located at AONE, has indicated that RWJF will have invested more than $9 million in this program by the end of 2016.¹ Nine states currently participate in APIN—California, Hawaii, Massachusetts, Montana, New Mexico, New York, North Carolina, Texas, and Washington. States were selected to receive funding in the amount of $300,000 over 2 years from 2012 to 2014 and again from 2014 to 2016 because of their efforts to make progress at the state and/or regional level on increasing the proportion of baccalaureate-prepared nurses (RWJF, 2012, 2015b). The funding is intended to be used to advance strategies on academic progression and baccalaureate-prepared nurse employment (see Box 3-2).

BOX 3-2

Academic Progression in Nursing (APIN) Models.

The New Mexico Nursing Education Consortium (NMNEC), established in 2009-2010, has created a model whereby a common curriculum has been established and adopted by all state-funded nursing programs. The idea behind this model is that “a common nursing curriculum would provide the mechanism for seamless transfer between programs and build partnerships between universities and community colleges” (Landen, 2015; Liesveld et al., 2015, p. 16). The statewide curriculum received approval from the associate's and baccalaureate state-funded schools in 2012 (Landen, 2015). Students enroll at both the community college and the university. They complete their prerequisite courses at the community college level and receive their associate's degree from the community college and their baccalaureate degree from the university concurrently (Hoffman, 2015; Landen, 2015). This model allows students to remain in their rural communities rather than incur the time and expense of moving to a large university; while attending a local community college for the majority of required courses, they can complete all additional courses and the final semester for the baccalaureate program either online or in clinical settings (Landen, 2015). Both the New Mexico Board of Nursing and RWJF, through the APIN program, have provided funding to support this model (Liesveld et al., 2015).

Overall, several APIN states have reported that they have successfully increased the percentage of baccalaureate nurses in the workforce beyond the national average increase, although programs and outcomes have varied among states (Gerardi, 2015). The Campaign is coordinating and learning from these state-level efforts with the goal of standardizing and streamlining academic progression at the national level. The Campaign convened leaders in the area of academic progression in 2015 and is developing a strategy for advancing academic progression models. The impetus for these efforts is the belief that “standardizing prerequisites and general education requirements across the nation in all nursing programs is a fundamental step in advancing nursing education and removing barriers that make it difficult for nursing students to move from an associate degree in nursing to a [baccalaureate] program” (CCNA, 2015a, p. 4). The Campaign also has provided technical assistance on academic progression to 25 state Action Coalitions and State Implementation Program grantees.

In a survey conducted by TCC Group for the Campaign, the majority of state Action Coalitions indicated that education goals were their top priority, with 59 percent focusing on the goal of increasing the number of nurses with baccalaureates to 80 percent by 2020 (TCC Group, 2013). The Campaign's most recent biannual operations report showed that 45 percent of all state Action Coalition funding had supported efforts under the education pillar (CCNA, 2015a).

The 2013 TCC Group survey revealed that state Action Coalitions believed they were making progress on this recommendation. All of the states that responded to the survey believed that availability of educational pathways had improved; all believed that nursing schools, universities, and community colleges were working better together; and 74 percent believed that there had been improvements in workplace policies that promoted nurses' educational attainment (TCC Group, 2013).

Progress

The Campaign tracks the progress on recommendation 4 from The Future of Nursing (see Box 3-2) by looking at the percentage of employed nurses with a baccalaureate degree in nursing or a higher degree, using data provided by the American Community Survey (CCNA, 2015b).² According to this data source, the percentage of baccalaureate-educated nurses rose from 49 percent in 2010 to 51 percent in 2014.

Significant growth has occurred in the number of nursing programs over the past decade. Between 2002 and 2012, more growth was observed among 4-year college programs (from 882 in 2002 to 1,413 in 2012, a 60 percent increase) than among 2-year college programs (from 729 to 857 programs, an 18 percent increase) (Buerhaus et al., 2014). The numbers of baccalaureate nursing programs, enrollees, and graduates—including both prelicensure (entry-level and accelerated baccalaureates) and postlicensure (baccalaureate completion) (see Box 3-3)—have increased over the past 15 years (see Figures 3-1, 3-2, and 3-3, respectively).

BOX 3-3

Educational Pathways to Achieving a Baccalaureate Degree in Nursing.

FIGURE 3-1

Number of baccalaureate nursing programs, 2000-2014. SOURCE: Data received from the American Association of Colleges of Nursing (AACN), August 28, 2015.

FIGURE 3-2

Enrollees in baccalaureate nursing programs 2000-2014. NOTE: Number of enrollees is calculated from responses to American Association of Colleges of Nursing (AACN) surveying. Not all programs in the United States replied with enrollment data. SOURCE: (more...)

FIGURE 3-3

Graduates of baccalaureate nursing programs, 2000-2014. NOTE: Number of graduates is calculated from responses to American Association of Colleges of Nursing (AACN) surveying. Not all programs in the United States replied with graduate data. SOURCE: Data (more...)

Postlicensure Baccalaureate

From 2010 to 2014, the number of baccalaureate completion programs increased steadily (see Figure 3-1), and enrollment in these programs increased by 69 percent, from 77,259 to 130,345 students (see Figure 3-2).⁴ Schools have expanded capacity in baccalaureate completion programs accordingly. Given the tremendous increases in enrollment in and graduation from these programs (see Figure 3-3) and the modest increase in the number of programs in recent years, further exploration is warranted to determine how capacity has been increased, possibly through the use of innovative education delivery approaches, such as partially or fully online programs and programs offered at health care facilities (AACN, 2015a).

In addition to increased capacity in baccalaureate completion programs, some state legislatures have undertaken efforts to require nurses to obtain a baccalaureate within 10 years of entry into practice (known colloquially as “BSN-in-10”) (Larson, 2012). In 2008, ANA's House of Delegates passed a BSN-in-10 resolution that voices support for initiatives that require nurses to obtain a baccalaureate degree within 10 years after receiving their initial nursing license (Edwards, 2012; Larson, 2012; Trossman, 2008). Since 2005, legislation requiring a baccalaureate within 10 years of initial licensure has been introduced in three states—New Jersey,⁵ New York,⁶ and Rhode Island (ANA, 2013). In New York, for example, “North Shore–LIJ Health System has required all RNs hired after September 1, 2010, to either have a baccalaureate degree or enroll in an accredited baccalaureate program within 24 months of hire in order to earn the degree within five years” (Hendren, 2010; North Shore–LIJ, 2015).

Despite the increases in numbers of baccalaureate nursing programs, enrollees, and graduates, there were until 2012 more nurses graduating with associate's than baccalaureate degrees (Buerhaus et al., 2014). In 2012, however, the number of nurses with baccalaureate degrees (including those obtained through entry-level, accelerated, and baccalaureate completion programs) surpassed the number with associate's degrees, increasing to 53 percent of the nursing workforce (see Figure 3-4). The increase in first-time takers of the NCLEX-RN with a baccalaureate degree continues, while the growth of first-time takers with an associate's degree has slowed (Salsberg, 2015).

FIGURE 3-4

Number of nursing baccalaureate and associate's degree graduates, 1984-2012. NOTE: Baccalaureate degrees encompass entry-level, accelerated, and baccalaureate completion programs. Data source: Integrated Postsecondary Education Data System (IPEDS). SOURCE: (more...)

Funding for Nursing Education

The Future of Nursing calls on the Health Resources and Services Administration (HRSA) and other federal agencies to “expand loans and grants for second-degree nursing students.” However, HRSA funding for nursing education programs has been relatively flat over the past decade, except for increased investments in the Nurse Corps Loan Repayment and Scholarship Program (formerly called the Nursing Education Loan Repayment Program) and the Nurse Faculty Loan Program, which saw increases in funding between 2008 and 2010. The Nurse Corps programs received an additional investment of $27 million from the American Recovery and Reinvestment Act (ARRA) in 2009, and since then has been funded at a higher level than before that increase occurred. Similarly, base appropriations for the Nurse Faculty Loan Program increased between 2008 and 2009 from $7,860,000 to $11,500,000, but in 2009, this program also received a further investment of $12,000,000 from the ARRA, and it has been funded at that higher level since then (HRSA, 2009, 2011, 2013, 2015) (see Figure 3-5).

FIGURE 3-5

Health Resources and Services Administration (HRSA) Title VIII funding, fiscal years 2005-2016. SOURCES: HRSA, 2009, 201120132015.

Comprehensive information on sources of and recent trends in other funding for nursing education programs, including that provided by states and private sources, is lacking. AACN does provide a list of state loan forgiveness programs on its state policy resources page⁷; some of the listed programs are for practicing nurses, and many are for nurse educators and faculty.

Employment

Employer preference for BSN AACN data indicate an increasing preference for hiring baccalaureate-educated nurses. However, a majority of employers do not require nurses to have a baccalaureate (see Table 3-1).

TABLE 3-1

Percentage of Employers Indicating a Requirement or Preference for Baccalaureate-Prepared Nurses, 2011-2014.

Other data likewise show that market forces tend to be favoring the baccalaureate over the associate's degree. At the committee's July workshop, the Accreditation Commission for Education in Nursing (ACEN) presented data showing that the mean job placement rate has decreased for nurses with associate's degrees and diplomas while remaining relatively steady for those with baccalaureate and master's degrees (Stoll, 2015) (see Figure 3-6).

FIGURE 3-6

Mean job placement rate by degree type. * Data for 2013-2014 are preliminary. SOURCE: Stoll, 2015.

An annual survey of California hospitals showed that in 2014, 9.8 percent of responding hospitals required nurses to have a baccalaureate as a condition for employment, an increase from 8.2 percent in 2013, 7.3 percent in 2012, and 4.6 percent in 2011 (Bates et al., 2015). The percentage of responding hospitals preferring a baccalaureate degree also increased from 52.3 percent in 2011 to 60.5 percent in 2014. In 2014, 11.8 percent of hospitals said they required new hires to complete a baccalaureate within a certain amount of time, typically 2-3 years. While other studies have found that salary differentials between nurses with associate's and baccalaureate degrees are due to factors beyond just educational attainment (Duffy et al., 2014; Spetz, 2002), 69 hospitals in the California survey (32.9 percent of respondents) indicated that they do base salary on the type of degree held, and nearly half use advanced certification as a basis for salary differentials. Likewise, Auerbach and colleagues (2015) found that there has been a consistent $10,000 wage gap between nurses with an associate's degree in nursing (ADN) and those with a bachelor's degree in nursing (BSN) over the past decade, but this gap has not widened as might be expected with an increasing preference for BSN preparation.

In addition to the employment trends described above, as of 2013, ANCC Magnet^® recognition required that organizations have a plan for how they will achieve an 80 percent baccalaureate-educated nursing workforce by 2020 (Lewis, 2015). However, ANCC is not prescriptive about how organizations should achieve this goal or what milestones should be reached in the interim. Currently, Magnet hospitals are more likely than other hospitals to employ baccalaureate-prepared nurses. According to ANCC, 55.6 percent of nurses working in Magnet hospitals have a BSN or higher degree (ANCC, 2014). As of January 1, 2013, Magnet recognition also required that nurse leaders have a minimum of a baccalaureate in nursing and that chief nursing officers (CNOs) have a master's or higher degree (ANCC, 2015).

Auerbach and colleagues (2015) report that the unemployment rate for nurses with a baccalaureate degree is lower than that for nurses with an associate's degree, and this gap has widened in recent years; a similar gap in hospital employment also appears to be growing. According to the authors, “the timing of the divergence in unemployment rates between ADN and BSN-prepared RNs, and to some extent, the increase in employment of BSNs in hospitals found in this analysis, appears to have occurred several years before the 2010 Institute of Medicine (IOM) report The Future of Nursing: Leading Change, Advancing Health was released. . . . The IOM emphasized the need for a more highly educated nursing workforce, and its wide dissemination more than likely provided ‘tipping point' information that influenced employers' decisions to prefer the more highly educated BSN” (Auerbach et al., 2015, pp. 11-12). These authors also identify shifts in locations of practice for baccalaureate- and associate's-prepared nurses between 2003 and 2013. The percentage of nurses with baccalaureate degrees in office-based and ambulatory care settings fell from 9.1 percent in 2003 to 7.7 percent in 2013, while the percentage of nurses with associate's degrees in long-term care increased from 13.0 percent to 18.0 percent. Roughly 10 percent of nurses with associate's degrees “shifted from hospitals to long-term care settings over the period” (Auerbach et al., 2015, p. 10). Nurses with baccalaureate degrees bring skills and competencies, leadership capacity, and organizational skills that are needed in all practice settings, including, and perhaps increasingly, those outside of the hospital setting.

Discussion

The recommendation of The Future of Nursing calling for 80 percent of nurses to hold a baccalaureate degree by 2020 has been described as “aspirational” (McMenamin, 2015). With approximately half of the nation's 3 million nurses currently holding an associate's degree, it will be extraordinarily difficult to achieve this goal by 2020. The effort to build a baccalaureate-prepared nursing workforce is not new, but has been boosted by this recommendation of The Future of Nursing, as well as the efforts of the Campaign and other organizations. As far back as 1965, recognizing the increasing complexity of knowledge needed by nurses, ANA published a position paper recommending that “minimum preparation for beginning professional nursing practice . . . should be baccalaureate degree education in nursing” (ANA, 1965). This position paper was reaffirmed by an ANA House of Delegates resolution in 1978, calling for the baccalaureate degree to be the entry degree for nursing by 1985 (ANA, 1995).

The Future of Nursing cites evidence to support the association between higher proportions of nurses with a baccalaureate degree and better patient outcomes, but it characterizes this evidence as inconclusive. Since the report's publication, however, the body of evidence on this association has strengthened (Aiken et al., 2011, 2014; Blegen et al., 2013; Cho et al., 2015; Kutney-Lee et al., 2013; Naylor et al., 2015; Yakusheva et al., 2014a,b; You et al., 2013). Studies show that hospitals with a higher percentage of nurses with baccalaureate degrees have better patient outcomes, and many of the outcomes associated with having a higher proportion of BSN-prepared nurses are associated with cost savings (Yakusheva et al., 2014a,b). With quality of care becoming increasingly important as a determinant of payment for health care services, this evidence suggests that providers may have a financial incentive to have a more highly educated nursing workforce.

Findings and Conclusions

Activity

Residencies at various levels and in different settings have been developed or expanded in the years since the publication of The Future of Nursing. In general, these programs have been established and funded by the institutions that hire nurses, with the aim of enhancing on-the-job training and retention of new hires.

The University HealthSystem Consortium (UHC) and AACN have developed a program for postbaccalaureate residencies (McElroy, 2015; UHC/AACN, 2007). A UHC study conducted in 2000 showed that while many UHC hospitals had a program to prepare new graduates to become competent practitioners, there was little uniformity in the length, curriculum, or content of these programs. The UHC/AACN residency program, which started in 2002, is a year-long program built on an evidence-based curriculum, and it is designed for nurses providing direct care in a hospital acute care setting (Goode et al., 2013; McElroy, 2015; UHC/AACN, 2007). Evaluation of the program has shown that it improves retention; increases nurses' “confidence, competence, ability to organize and prioritize, communication, leadership”; and reduces stress levels (Goode et al., 2013; UHC/AACN, 2007, p. 1). More than 130 hospitals and health systems across the country are currently participating in the UHC/AACN program, and annual participation increased from 362 nurses in 2002 to 3,579 in 2010 to more than 9,000 in 2014 (McElroy, 2015). Overall, approximately 45,000 nurses have completed the program.

Transition-to-practice residency programs for nurse practitioners (NPs) operate in various health care settings, including retail clinics, federally qualified health centers (FQHCs), U.S. Department of Veterans Affairs (VA) primary care centers, and hospitals. CVS MinuteClinic has a 6-month program intended to better prepare new NP graduates for delivering care in the unique nontraditional context of a retail clinic (Gagliano, 2015). The program links new-graduate employees with preceptors who are available to support them and review their charts.

Community Health Center, Inc., an FQHC in Connecticut serving primarily low-income and uninsured populations, operates the nation's first NP transition-to-practice residency program, launched in 2007 (Flinter, 2015). At that time, the goals of the program included attracting and retaining NPs as primary care providers in the safety net setting, as well as preventing attrition by helping NPs attain the skills necessary to practice. The program has shown success in improving competence and clinical performance appraisals. The main challenge to maintaining the program is a lack of funding. Flinter (2011, 2015) notes that while the Patient Protection and Affordable Care Act (ACA) authorized funding for family NP residency programs⁸ in FQHCs, that funding has never been appropriated. Some organizations have chosen to invest in these programs because of the potential return on investment, but many organizations have the will, need, and capability but not the funding to do so.

In addition to offering residencies for postbaccalaureate and mental health nurses, the Veterans Health Administration has 12-month residencies for NPs that are operated out of its VA Centers of Excellence in Primary Care Education (Gilman, 2015). This program, launched in 2011-2012 in part in response to recommendations of The Future of Nursing (see Box 3-4), involves formal instruction, clinical supervision and interprofessional precepting, and clinical electives. The objectives are to “advance clinical competency in team-based, patient-centered primary care,” and to “advance [the] ability to work in, lead, and improve clinical teams” (Gilman, 2015). In its first 4 years, 42 residents completed the program.

Currently, 21 nurse residency programs are accredited by either the American Nurses Credentialing Center (ANCC) (accredits RN residencies, RN fellowships, and APRN fellowships) or the Commission on Collegiate Nursing Education (CCNE) (accredits postbaccalaureate nurse residencies).⁹ An additional 11 programs have requested applicant status from CCNE, the first step in the accreditation review process.¹⁰ CCNE's accreditation program grew out of recognition that the programs being implemented varied greatly, and it also was encouraged by the work of UHC and AACN to develop a curriculum that would create some commonality in year-long residency programs in acute care settings (although CCNE accreditation is not limited to programs subscribing to the UHC/AACN curriculum) (Butlin, 2015). Standards and procedures for nurse residencies are based largely on concepts of interprofessional education and collaboration. CCNE requires that residencies be built on an academic–practice partnership to bridge the transition between learning and entry into practice, and that programs be 1 year in length. Standards address faculty, institutional commitment and resources, curriculum, and program effectiveness (CCNE, 2008). To date, accreditation has been limited to acute care settings, but CCNE has heard from its communities of interest of the need to extend accreditation to all practice settings, including ambulatory care and home health (Murray, 2015).

The National Council of State Boards of Nursing (NCSBN) began work on transition-to-practice programs in 2007 (NCSBN, 2011, 2015b). In 2011, NCBSN began to study transition-to-practice models for new nurse graduates in hospitals (Phase I) and long-term care, home health, and other settings (Phase II) (NCSBN, 2015c). NCSBN's research shows that residencies in hospitals have better outcomes (in terms of competence, errors, work stress, job satisfaction, and retention) when they

• are formalized and integrated into the institution;
• last at least 6 months;
• include content on patient safety, clinical reasoning, communication and teamwork, patient-centered care, evidence-based practice, quality improvement, and informatics;
• are customized to specialty areas; and
• include time for graduates to apply the content and receive feedback (Spector et al., 2015a).

In 2012-2013, NCSBN studied the implementation of its transition-to-practice program in nonhospital settings, including nursing homes and public health and home health settings (Alexander, 2015; Spector et al., 2015b). NCSBN had difficulty finding health care delivery organizations to participate in the program (Alexander, 2015); 34 sites volunteered, but only 23 moved forward with the study and hired nurses during the study period (Spector et al., 2015b). Once settings had been separated into experimental (NCSBN transition-to-practice program) and control (existing transition-to-practice or similar programs), there was not enough statistical power to conduct quantitative analysis. The study did find, however, that NCSBN transition-to-practice sites had higher retention than the control programs, although retention was considerably lower than that seen in hospital settings (55 percent versus 83 percent) (Spector et al., 2015a,b). Qualitative analysis showed that site coordinators, preceptors, and participants held many positive views about the NCSBN program. New nurses indicated that their overall confidence and competence had improved. They did note that the curriculum of the program was too hospital-focused and should be tailored to include topics more related to long-term care and other nonhospital settings. Both participants and preceptors mentioned feeling overwhelmed at times by the added work. Some preceptors also felt that administrative support for the program was inadequate, and site coordinators noted a lack of resources as a barrier to the program's implementation.

Many of the Campaign's state Action Coalitions are working on transition-to-practice nurse residency programs. Nearly three-quarters of states responding to a 2013 survey indicated that they were working toward implementing this recommendation of The Future of Nursing, and 31 percent said it was a main area of focus.¹¹ The Campaign does not have a dashboard indicator for this recommendation, but “percent of hospitals that have new RN graduate residencies” is a supplemental indicator for the recommendation promoting baccalaureate-educated nurses (discussed in the previous section). This indicator uses data from surveys of hospitals conducted in 2011 (N = 214) and 2013 (N = 195) by Pittman and colleagues, which found an increase in the proportion of surveyed hospitals with RN graduate residency programs from 36.9 percent in 2011 to 45 percent in 2013 (CCNA, 2015b; Pittman et al., 2013b).

Several of the State Implementation Program (SIP) grants have residency programs as a primary focus (CCNA, 2013b). Examples include the following:

• Idaho has evaluated transition-to-practice nurse residency programs throughout the state to identify those that work best and are most appropriate for small, rural hospitals and critical access hospitals (CCNA, 2015c).
• The Nurse Residency Task Force in the Iowa Action Coalition has developed a competency-based curriculum for a nurse residency program that can be completed using online tools and learning modules (CCNA, 2014a; RWJF, 2014b).
• The New Jersey Action Coalition received $1.6 million from the Centers for Medicare & Medicaid Services (CMS) to develop an RN transition-to-practice program for long-term care (CCNA, 2013c). The first 1-year program started in spring 2014 and was recently completed (CCNA, 2014b), and a second iteration is currently under way (Boyd, 2015). The New Jersey Action Coalition also has created a curriculum outline for a 6-month APRN residency program in FQHCs (CCNA, 2014b).

In addition to activity at the state level, the Campaign has been working at the federal level to garner continued support for the Medicare Graduate Nursing Education (GNE) demonstration program (CCNA, 2015a). While not defined as a transition-to-practice nurse residency program, the GNE demonstration, which began in 2012, provides funds to hospitals to offset the cost of clinical training for APRNs (CMS, 2012). RWJF, AARP, and the Alliance for Health Reform hosted a briefing on Capitol Hill in 2015 to inform policy makers about the importance of graduate nursing education and training (Alliance for Health Reform, 2015).

Progress

Progress on recommendation 3 from The Future of Nursing is difficult to track for several reasons: the word “residency” is used for a variety of different programs, from simple workplace orientations to year-long intensive training and education programs; there are residency programs offered to nurses at all levels of education (associate's, baccalaureate, and advanced practice); and residencies take place in all practice settings, from hospitals to home health care. The length of nurse residency programs varies greatly, ranging from 6 weeks to 1 year. Because of this variation and because comprehensive data on residencies are sparse, it is difficult to gauge growth in programs overall, within particular settings, and for nurses of different educational levels since The Future of Nursing was released in 2010. Pittman and colleagues (2013c) report that among the organizations they sampled, more were offering RN residencies in 2013 (41.6 percent) than in 2011 (31.7 percent). More than half of these residency programs were created between 2010 and 2013, suggesting that The Future of Nursing may have played a role in the increase. Among these residencies, 67 percent were required for new RN hires, up from 7.7 percent in 2011.

Discussion

While the educational programs available for nurses provide a solid foundation for the delivery of safe and effective care, rapid changes in the health care environment call for additional training to build on the fundamentals of nursing. Novice nurses need opportunities not only to practice their skills but also to learn how to apply those skills in the real world. Nurses today increasingly must care for multiple patients with complex needs, navigate new forms of technology, and manage the needs of the chronically ill in resource-constrained settings. Transition-to-practice residencies provide an opportunity for novice nurses to understand these complexities and learn how to use their nursing skills for optimal patient care.

While evidence regarding the impact of residency programs on patient outcomes is limited, the available evidence suggests that transition-to-practice residencies for nurses appear to have positive outcomes, including improving nurses' abilities to organize, manage, and communicate, as well as higher retention levels. For example, nurses who completed the UHC/AACN residency were more likely to be retained by their employers and reported improved abilities to organize, prioritize, communicate, and provider leadership (Goode et al., 2013; McElroy, 2015). Likewise, evaluations of APRN residency programs have found that graduates reported improved confidence and competence and strengthened role identity (Flinter, 2011, 2015).

Despite these benefits, information is lacking about whether these outcomes translate into better patient care. Moreover, barriers remain to implementing residencies for every nurse, including cost and a lack of data on the value of these programs. The Future of Nursing offers subrecommendations for addressing these barriers; however, few of these measures have been implemented.

Findings and Conclusions

Activity

Several major initiatives, as well as a number of smaller funding programs, have been undertaken to support students in seeking doctoral degrees in nursing. Three private philanthropic organizations—the Jonas Center for Nursing and Veterans Healthcare, the Rita & Alex Hillman Foundation, and RWJF—have contributed significant funds to the effort to increase doctorally prepared nurses. These organizations' programs encourage nurses to pursue a doctorate earlier in their career and place emphasis, wholly or in part, on increasing the number of nurses with research-focused PhDs in nursing.

The Jonas Center has committed $25 million to doubling the number of nurses with doctorates, and the number of scholars it has funded increased from 6 in 2009 to 600 (400 PhD and 200 DNP) in 2015 (Curley, 2015). As the latter figures suggest, the Jonas Center supports PhD and DNP nurses in a 2:1 ratio. Scholars receive a $10,000 scholarship from the Jonas Center and $12,500 in matching funds from their school of nursing. The program focuses on diversity, with 38 percent of scholars coming from underrepresented groups, and on leadership, requiring scholars to complete a 40-hour leadership project.

The Rita & Alex Hillman Foundation's Hillman Scholars Program in Nursing Innovation was launched in 2011 to support PhD nursing students (Hillman Foundation, 2015). The program is now offered at the University of Michigan, University of North Carolina at Chapel Hill, and University of Pennsylvania, and it incorporates interdisciplinary coursework, clinical practice, research, and mentorship to advance innovation through nursing research and leadership. As with the RWJF and Jonas Center programs, the goal of the program is for nurses to achieve their doctorate early in their career so as to maximize opportunities and contribute to the improvement of health and health care.

RWJF has invested $20 million in the Future of Nursing Scholars program, whose mission is to create “a diverse cadre of PhD prepared nurses” (RWJF, 2013, 2015c). The program awards $75,000 to each scholar over the course of 3 years, and the scholar's school is required to provide $50,000 in support (RWJF, 2015d). Awards were provided to 14 schools to support 17 nurses in 2014, the program's inaugural cohort, and to 25 schools to support 48 nurses in 2015 (RWJF, 2014a, 2015a).

The American Cancer Society also supports nurses seeking graduate study in cancer nursing practice and research through two programs. The Graduate Scholarships in Cancer Nursing Practice program provides a stipend of $10,000 per year for graduate students pursuing a master's degree in cancer nursing or a DNP (American Cancer Society, 2015b). The Doctoral Degree Scholarships in Cancer Nursing program provides a stipend of $15,000 per year for 2 years for students pursuing a doctorate in nursing or a related area to prepare the graduate for a career as a cancer nurse scientist (American Cancer Society, 2015a).

CareFirst BlueCross BlueShield's (CareFirst) Project RN provides stipends to nursing students specifically pursuing advanced degrees to become nurse educators through the company's nurse education partnership program. Project RN was launched in 2007. Between 2007 and 2012, CareFirst invested more than $2 million in the program; it invested another $1 million in 2013 and $960,000 in 2014 (CareFirst BlueCross BlueShield, 2013, 2014, n.d.).

One Campaign state Action Coalition, Georgia, considered the doubling of doctorally prepared nurses to be its top priority (TCC Group, 2013; see Chapter 1, Figure 1-3). Of the states responding to a 2013 survey, 78 percent indicated that they were working toward implementing this recommendation, but only 25 percent said it was a main focus for them (see Chapter 1, Figure 1-2).¹⁴

The Campaign tracks progress on this recommendation by using data on the number of students enrolled in doctoral programs (CCNA, 2015b). The recommendation focuses on the number of nurses with doctorates in the workforce; however, progress in the workforce will take considerable time to become discernible because doctoral degrees typically take years to complete. The Campaign also has identified supplemental indicators with which to track progress on this recommendation, including the number of employed nurses with a doctoral degree, the number of doctoral program nurse graduates each year, and the diversity of nurse doctoral graduates.

Progress

Since The Future of Nursing was released, enrollment in doctoral programs has risen. Enrollment in DNP programs has grown rapidly over the past 5 years, while enrollment in PhD programs has grown at a slower rate. Since fall 2010, enrollment in DNP programs has more than doubled, from 7,034 to 18,352 students (a 161 percent increase).¹⁵ Meanwhile, enrollment in PhD programs has increased by 15 percent over the past 5 years, with 5,290 students now pursuing the research-focused doctorate.

Doctoral programs that confer the DNP degree have grown rapidly over the past 10 years. In 2006, 20 such programs existed; by 2014, this number had grown more than 10-fold, to 262 programs.¹⁶ PhD programs also have grown, from 103 programs in 2006 to 133 programs in 2014 (see Figure 3-7). DNP and PhD enrollments and graduations also have grown. Enrollments in and graduations from PhD programs have increased modestly over the past 15 years, while enrollments in and graduations from DNP programs have increased exponentially (see Figures 3-8 and 3-9, respectively). Growth also appears to be occurring among baccalaureate-to-DNP and master's-to-DNP programs (Auerbach et al., 2014). Of 400 schools surveyed by AACN in 2013 that had APRN education programs, 25 percent had baccalaureate-to-DNP programs, and 57 percent had master's-to-DNP programs. A survey conducted in 2013 found that 11 to 14 percent of schools were providing baccalaureate-to-DNP programs without offering a terminal master's program, but more were planning to do so in the future. In 2010, by comparison, this was the case for only one school (Auerbach et al., 2014).

FIGURE 3-7

Numbers of nursing PhD and DNP programs, 2000-2014. SOURCE: Data received from AACN, August 28, 2015.

FIGURE 3-8

Enrollments in nursing PhD and DNP programs, 2000-2014. SOURCE: Data received from AACN, August 28, 2015.

FIGURE 3-9

Numbers of nursing PhD and DNP graduates, 2000-2014. SOURCE: Data received from AACN, August 28, 2015.

Discussion

As noted, both DNP and PhD nurses are critical to fill the need for faculty positions and for leadership roles in academics, health care delivery, health care planning and policy, and other arenas. In addition, nurses with doctoral degrees in fields outside of nursing, including public policy, business, health administration, public health, and other fields, will be especially well prepared for important leadership and educational roles in an evolving health care environment.

Although, as discussed above, there has been significant growth in enrollment in DNP programs in recent years, the relatively small increase in enrollment in PhD programs for nurses is concerning. According to testimony at the committee's July 2015 workshop from Darlene Curley, executive director, Jonas Center for Nursing and Veterans Healthcare, “PhD numbers are growing too slowly to fill the vacant faculty positions and impending baby boomer retirements.” More emphasis is needed on increasing the number of PhD nurses through expansion of programs, incentives for nurses to return to school, and more scholarships for baccalaureate-to-PhD programs. Students also need to be encouraged to pursue a PhD early in their career so they can practice for a longer period of time in the research, faculty, and leadership roles that a doctorate enables.

Studies and stakeholders have noted that the progress seen in enrollments in and graduations from doctoral programs, primarily DNP programs, puts the field on track to achieve the goal in The Future of Nursing of doubling the number of nurses with doctorates by 2020 (Curley, 2015), despite some identified barriers. However, simply doubling the number of nurses with doctorates is not sufficient. An assessment of the mix of doctorally prepared nurses is needed. It should be noted that a DNP typically takes less time to complete than a PhD. A DNP usually takes 3-4 years to complete, while a PhD usually takes 4-6 years, including years spent on academic work and years spent conducting research and producing a dissertation (AACN, 2006; Ellenbecker, 2010; Johnson, 2014).

Findings and Conclusions

Activity

The Campaign has not focused a significant amount of activity on this recommendation. There is no Campaign dashboard indicator in this area, and the Campaign noted that it has worked on this broad recommendation but has not worked toward the second or third subrecommendation.¹⁸ A 2013 survey of state Action Coalitions conducted by the Campaign's external evaluators asked Action Coalitions to identify the level of focus and effort in 15 major topic areas relating to the recommendations of The Future of Nursing and Campaign goals, none of which concerned lifelong learning (TCC Group, 2013).

Beyond the Campaign, the Joint Accreditation for Interprofessional Continuing Education, established in 2009 as a collaboration among the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and ANCC, provides a streamlined accreditation process and standards for interprofessional continuing education for these fields (Joint Accreditation for Interprofessional Continuing Education, 2013). Joint accreditation allows organizations to develop innovative programs to further build the competency of clinicians working in health care teams. “To be eligible for Joint Accreditation, an organization needs to demonstrate that for the previous 18 months its structure and processes to plan and present education by and for the healthcare team have been fully functional; and that at least 25% of its educational activities have been designed by and for healthcare teams” (Joint Accreditation for Interprofessional Continuing Education, 2013).

Progress

In the most recent NCSBN member board profile report, produced in 2014, 11 of the 49 responding jurisdictions (Colorado, Connecticut, Guam, Hawaii, Iowa, Maine, Maryland, Mississippi, Missouri, Oregon, Wisconsin) reported having no continuing competency requirements for licensure maintenance; 36 jurisdictions have such requirements (NCSBN, 2014).¹⁹ Various methods can be used to meet these continuing competency requirements, including competency examinations or assessments, minimum practice hours, and continuing education. The content and quantity of continuing education requirements for RN licensure and NP credentialing also vary significantly across the United States (AACN and AAMC, 2010; NCSBN, 2014).

A few states have instituted continuing competency requirements for nurses since 2010:

• In Washington, continuing competency requirements were instituted for RNs and licensed practical nurses (LPNs) in 2011 (Washington State Department of Health, n.d.).
• In Georgia, Governor Nathan Deal signed a continuing competency bill into law on May 6, 2013, requiring that all RNs and LPNs meet continuing education competency requirements by January 1, 2016, and March 31, 2017, respectively (Georgia General Assembly, 2013).
• In Oklahoma, continuing competency requirements for RNs and LPNs were instituted effective January 1, 2014 (Oklahoma Board of Nursing, 2014).

Discussion

The Future of Nursing cites several contemporaneous reports covering continuing education (IOM, 2011). A 2010 IOM report, Redesigning Continuing Education in the Health Professions, states that there are “major flaws” in the way continuing education is “conducted, financed, regulated, and evaluated”; that the science behind continuing education is “fragmented and underdeveloped”; and that continuing education should bring health professionals together for interprofessional learning “with a common goal of improving patient outcomes” (IOM, 2010, pp. 2-3). The report notes that although some states have long required nurses to complete continuing education programs, these programs do not always increase competence. A 2010 report from the Association of American Medical Colleges (AAMC), AACN, and the Josiah Macy Jr. Foundation recommends that continuing education evolve away from classroom learning and toward action-oriented, site-of-care training; that education be focused on the development of key competencies rather than mere knowledge acquisition; and that health professionals be educated together in an interprofessional setting (AACN and AAMC, 2010).

Unfortunately, little progress has been made over the past 5 years on either the recommendation of The Future of Nursing or the findings of these other reports. While there have been some efforts toward interprofessional learning, such as the Joint Accreditation for Interprofessional Continuing Education, continuing education has not kept pace with the needs of the increasingly complex, team-based health care system.

One obstacle that stands in the way of achieving progress on the recommendation of The Future of Nursing related to lifelong learning is a lack of data on lifelong learning and continuing education for nurses. Information about requirements for licensure or accreditation is collected by individual organizations through member surveys, and thus there is no single, comprehensive source of such data. In addition, evidence is lacking with regard to whether nurse certification and credentialing lead to better patient outcomes (Hickey et al., 2014; IOM, 2015; Johantgen, 2013; Newhouse, 2014).

Recognizing this gap in knowledge, the IOM convened the Standing Committee on Credentialing Research in Nursing and held a public workshop in September 2014 to discuss priorities for research and knowledge in this area (IOM, 2015). Workshop speakers highlighted various barriers to understanding the impact of nurse credentialing, including the lack of common terms and data points, and limited and inconsistent data collection by multiple credentialing and certification organizations and through national datasets. Further, speakers noted the importance of connecting more comprehensive credentialing data with metrics on performance and outcomes. They also identified the need to align research in nurse credentialing with changes in health policy and health care systems, including greater emphasis on integrated and coordinated care, team-based care, and value-based payment. Specifically, participants noted that the shift toward global and quality-based payment schemes may make it more likely that organizations and nurses will obtain credentials, but only if strong evidence can show that credentials improve skills and outcomes. In talking about the maintenance of credentials, “[Jody] Frost [from the American Physical Therapy Association] added that ongoing assessment strategies have to consider that professions are changing, and individuals need to be measured against competencies relevant today, not when they graduated from their educational institution” (IOM, 2015, p. 62). Presenters Susan Hassmiller from RWJF and Robin Newhouse from the University of Maryland School of Nursing both noted that advances in nurse credentialing research could have implications not just for The Future of Nursing recommendation related to lifelong learning and continuing competencies but also for nurses being able to practice to the full extent of their education and training and nurses partnering with other health care professionals in the improvement and redesign of the health care system. Yet despite the potential for nurse credentialing to improve knowledge and practice competencies as suggested by the workshop participants, barriers exist for individuals and organizations, including the cost of initial and sustained certification and a lack of support for or perceived value of certification (Haskins et al., 2011; Perlstein et al., 2014).

AACN has said that it “would like to see more data collected about the full spectrum of educational experiences completed by RNs” and that it is “ready to work with the Health Resources and Services Administration, National Council of State Boards of Nursing, and other stakeholders to develop a plan to collect this data.”²⁰

A bullet under The Future of Nursing recommendation on lifelong learning calls for updating curricula to “ensure that graduates at all levels are prepared to meet the current and future health needs of the population” (see Box 3-6). In a changing health care environment, nurses and other providers will increasingly require skills necessary to be comfortable in providing care in both hospital and community-based settings. As Tanner (2010, p. 347) puts it, “As care continues to shift from hospitals to community-based settings, as the population ages and care management in the community becomes more complex, and as new health care needs emerge, a new kind of nurse will be needed. Educational programs must be redesigned to better prepare this nurse.” Yet health professions education is still highly oriented toward acute care, despite some efforts to change this paradigm (Paterson et al., 2015; Spector, 2012; Thibault, 2013). Thibault (2013) acknowledges the important roles of competency-based educational models, technology, clinical education, and interprofessional education (see Chapter 5) and notes that “future needs will require more clinical experiences that are longitudinal, integrated, immersive, and community based” (p. 1930).

Findings and Conclusion