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Entry Level into Nursing Practice by Tina Bombe Ferris State University
Entry Level
into
Nursing
Practice
by
Tina Bombe
Ferris State University
INTRODUCTION
For many years there has been great debate regarding the educational requirement
into entry level nursing practice. This topic has been scrutinized since 1965 when the
American Nurses Association (ANA) “released their first position statement advocating
for the bachelor of science in nursing (BSN) as an entry level requirement” (Starr and
Edwards, 2010, p.10) Currently, the associates degree in nursing (ADN) level of
education has been sufficient, but there are many who argue the baccalaureate degree
level of education is more appropriate.
OBJECTIVES
After review of this presentation, the learner will
identify:
Theorists/theory on nursing education and framework
Historical Trends in Nursing Education
Assessment of Health Care Environment
Inference, Implications, Consequence
Recommendations for Quality and Safety (QSEN)
ANA standards
Future of Entry Level Into Nursing Practice
INTRODUCTION
Identify Problem or Issue of Topic:
Should the entry level into
nursing practice
be the
Bachelor of Science in Nursing degree?
Nursing Theorists on Education
in Nursing Practice
Florence Nightingale (1820-1910)
Known as the founder of modern nursing
First advocate for nursing and established it as a profession
Created the first nursing training school known at Nightingale
School of Nursing at St. Thomas’ Hospital in London which
opened in 1860
Remains an prominent influence to all nurses today
Mary Adelaide Nutting (1858-1948)
World’s first professor of nursing (Welch, 2006)
Pioneer in nursing education and reform
Member of first class of nurses to graduate at Johns Hopkins
School of Nursing in 1891
Helped launch the American Nurses Association (Welch, 2006)
Nursing Theorists on Education
in Nursing Practice
Mildred Montag (1908-2004)
Pivotal in the structure of nursing education
Based on her dissertation, helped create the two year ADN
nursing program
Patricia Benner (1955-present)
Present day theorist
Co-Writer on Educating Nurses: A Call for Radical Transformation
Recommended preparing all entry-level registered nurses at
the baccalaureate level
Recommended requiring all RNs to earn a master’s degree
within 10 years of initial licensure
Found that many of today’s new nurses are “undereducated”
to meet practice demands across settings.
Historical Evolution in Nursing
Educational Programs
Before we look at the future, we have to look at the past…
Scheckel, M. (2009). Nursing education: Past, present, future. In G. Roux & J. Halstead (Eds.), Issues and trends in nursing
(pp. 27-55). Retrieved from http://www.jblearning.com/samples/0763752258/52258_CH02_Roux.pdf
Current Framework on
Nursing Education
ADN Education
National League for Nursing
Accrediting Commission (NLNAC) is
the authority that oversees and governs
the educational criteria for the ADN
program
State Board of Nursing has the
authority to suspend, revoke, penalize
and give licensure
We pay the State of Michigan for
license renewal and NCLEX exam fees
Technical/conceptual framework
BSN and Higher Education
American Association of Colleges
of Nursing (AACN) is the is the accrediting body for baccalaureate and higher educational programs such as MSN and DNP
Baccalaureate prepared nurses provide an element of critical thinking, leadership skills, and professionalism are essential to patient satisfaction and overall outcomes
The ADN program is held by a different educational standard than the BSN program.
Theory
Nursing theories provide students with a
basis for their curriculum and education.
There are two theories on education we will focus on:
Kolb’s Experiential Learning Theory (non-nursing based)
Boyer’s Model of Scholarship (BSN and higher nursing based
theory)
Kolb’s Experiential Learning Theory
A four-stage cyclical theory of
learning
Kolb’s experiential learning theory is a
holistic perspective that combines:
1. Concrete Experience
2. Reflective Observation
3. Abstract Conceptualization
4. Active Experimentation
“Learning is the process whereby knowledge is created through the
transformation of experience” (Kolb, 1984).
Higher Education Based on
Boyer’s Model of Scholarship
The American Association of Colleges of Nursing (AACN)
developed higher education curriculum criteria based on Boyer’s
Model of Scholarship.
In the AACN section of Defining Scholarship for the Discipline of Nursing (2012) states “Boyer
challenged all disciplines to embrace the full scope of academic work, moving beyond an exclusive
focus on traditional and narrowly defined research as the only legitimate avenue to further the
knowledge of the discipline, and to obtain rewards for professional performance. He proposed that
scholarship involves four areas that are critical to academic work” (para. 3). These are the scholarship of
Discovery
Teaching
Application
Integration
“These four aspects of scholarship are salient to academic nursing, where each specified area supports
the values of a profession committed to both social relevance and scientific advancement” (AACN,
2012, para.5).
Higher Education Based on
Boyer’s Model of Scholarship
Baccalaureate Essentials
Essentials I through IX delineate
the outcomes expected of
graduates of Baccalaureate
nursing programs.
The nine Essentials are:
1. Liberal Education for Baccalaureate Generalist Nursing Practice
2. Basic Organizational and Systems Leadership for Quality Care and Patient Safety
3. Scholarship for Evidence Based Practice
4. Information Management and Application of Patient Care Technology
5. Healthcare Policy, Finance, and Regulatory Environments
6. Interprofessional Communication and Collaboration for Improving Patient Health Outcomes
7. Clinical Prevention and Population Health
8. Professionalism and Professional Values
9. Baccalaureate Generalist Nursing Practice
American Association of Colleges of Nursing. (2009). The essentials of baccalaureate education for professional nursing practice. Retrieved from
http://www.aacn.nche.edu/education-resources/BacEssToolkit.pdf
Multi-Systems Approach on Nursing Education
the assumption is baccalaureate
prepared nurses produce better patient
outcomes, provide higher quality care
and reduce mortality among patients.
What organizations are saying this?
Assessment of the Health
Care Environment
In October 2010, the Institute of Medicine released its landmark report on The Future of Nursing, initiated by the Robert Wood Johnson Foundation
Called for increasing the number of baccalaureate-prepared nurses in the workforce to 80% by 2020
The expert committee stated “to the demands of an evolving health care system and meet the changing needs of patients, nurses must achieve higher levels of education.”
Institute of Medicine. (2010). The Future of Nursing: Leading Change, Advancing Health.
Washington, DC: National Academies Press.
Assessment of the Health
Care Environment – Systems Approach
Assessment of the Environment –
Systems Approach
Who is the AACN. How are they affiliated with higher education. What are their goals.
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In May 2010, the Tri-Council for Nursing (AACN, ANA, AONE, and NLN) issued a consensus statement calling for all RNs to advance their education in the interest of enhancing quality and safety across healthcare settings.
In the statement titled Education Advancement of Registered Nurses, the Tri-Council organizations present a united view that a more highly educated nursing workforce is critical to meeting the nation’s nursing needs and delivering safe, effective patient care.
In the policy statement, the Tri-Council finds that “without a more educated nursing workforce, the nation's health will be further at risk.”
Assessment of the Health
Care Environment – Systems Approach
Quality and Safety Issues
Tri-Council for Nursing. (2010). Educational advancement of registered nurses: A consensus position.
Retrieved from http://www.aacn.nche.edu/education-resources/TricouncilEdStatement.pdf.
In December 2009, Dr. Patricia Benner and her team at the
Carnegie Foundation for the Advancement of Teaching
released a new study titled Educating Nurses: A Call for Radical
Transformation
Recommended preparing all entry-level registered nurses at
the baccalaureate level
And requiring all RNs to earn a master’s degree within 10
years of initial licensure
Found that many of today’s new nurses are “undereducated”
to meet practice demands across settings.
Assessment of the Health
Care Environment – Systems Approach
Benner, P., Sutphen, M., Leonard, V. & Day, L. (2009). Educating Nurses: A Call for Radical Transformation.
Carnegie Foundation for the Advancement of Teach. San Francisco: Jossey-Bass.
In a study released in the May 2008 issue of the
Journal of Nursing Administration, Dr. Linda Aiken
and her colleagues confirmed the findings on:
Link between RN education level and patient
outcomes
Leading nurse researchers found that every 10%
increase in the proportion of BSN nurses on the
hospital staff was associated with a 4% decrease in
the risk of death.
Assessment of the Health
Care Environment – Systems Approach
Quality and Safety Issues
Aiken, L.H., Clarke, S.P., Sloane, D.M., Lake, E.T. & Cheney, T. (2008). Effects of hospital care
environment on patient mortality and nurse outcomes. Journal of Nursing Administration, 38(5), 223-229
Linda H Aiken, PhD, FAAN, FRCN, RN
Claire M. Fagin Leadership Professor in Nursing, Professor of Sociology, and
Director of the Center for Health Outcomes and Policy Research
Excerpt from the National Summit on
Health Care Quality and Value October 2010
Statistical Information:
-80,000 new ADN nurses
graduate every year
-Only 5,000 of the 80,000
will ever get a Master’s
degree, NP, or faculty
member
Assessment of the Health
Care Environment – Systems Approach
What resources do we have available to initiate a bachelors degree into practice?
Institution of mobility programs (Nursing programs that facilitate the seamless articulation or transition from one degree in nursing to another.)
-LPN to RN, RN to BSN, RN to MSN, and
BSN to PhD Institution of online programs in nursing
Assessment of the Health
Care Environment - Resources
What resources could be made available to help institute a bachelors degree into practice?
Allowing nurses to take continuing
educational courses toward their BSN degree
Grandfathering in a BSN into practice for
nurses whom have had their degree for a set amount of time
Allowing a BSN in 10 degree
Assessment of the Health
Care Environment - Resources
PROBLEM:
Mandating a
BSN as entry level
into nursing
practice
Root Cause Analysis
Cause: Education & Curriculum
Educational Structure
-Discrimination against ADN
programs
-Who will redesign the structure
-Multi-level entry into nursing
Practice verses linear
Cause: Nursing Profession
-nursing shortage
-turn away potential nurses from the
profession
-not have funding to continue college
-too close to retirement
Cause: Organizations
-ANA suggesting BSN into
practice
-AACN suggesting BSN
into practice – suggest
better patient outcomes
Cause: Government
-set policy to mandate BSN
into entry level
-government controlled
verses state controlled
According to the data just presented… What will happen if we continue the way we are?
(or if it is not broke….don’t fix it?) It is presumed nursing will not be taken seriously as a
profession “Nursing as a profession has suffered due to the multifarious levels of entry into practice and the lack of differentiations among educational degrees of nurses. By implementing a baccalaureate degree proposal, nursing can rebuild its image of professionalism by meeting the characteristics that professions embody” (Lane and Kohlenberg, 2010, p.221).
Patient outcomes will continue to decline Mortality rates will continue to increase
Inference
Research states that BSN prepared nurses provide higher quality
of care and have decreased patient occurrences, decreased
mortality rates, improved patient satisfaction, and longer nurse
retention (Lane & Kohlenberg, 2010).
Baccalaureate prepared nurses provide an element of critical
thinking, leadership skills, and professionalism are essential to
patient satisfaction and overall outcomes (Hansten & Washburn,
1998; Massachusetts Association of College of Nursing, 2005).
Implications
According to the data just presented… What will happen if we make some changes?
Create nursing shortage
Mandating a BSN as entry level will detour potential nurses
into the profession
ADN nurses might not have the resources (time or money) to
pursue a BSN degree
Structurally change the whole curriculum of nursing
Discredit the ADN nursing programs
Many experienced ADN will be considered ‘lower in stature’
based on education verses experience
Consequences
According to the data just presented… What consequences may we incur if we
mandate a BSN as entry level?
Better patient outcomes
More well-rounded nurse
Deeper thought process and reflection
Nurse would not only have technical knowledge (ADN), but
have depth of knowledge in critically thinking, evidence based
and leadership
Patient’s Point of View
Who would be responsible for the curriculum for a BSN only entry level
What would happen to all of the community colleges who offered a 2 year nursing degree
Who would come up with a new framework for BSN entry
How do we begin to incorporate something that has not been able to be accomplished for over 47 years?
Educational Point of View
I looked at all of the discussion from this week and
acquired the nursing point of view.
The majority thought:
The majority did not agree with mandating the BSN as entry level
This would create a nursing shortage
From the nursing shortage, this would cause a higher nurse to patient
ratio
Nurses may not have the time or money to go back to school
Life long learning should be incorporated into receiving a BSN degree
Many agreed with multi-level entry into nursing
Many agreed with the BSN in 10
Nursing Point of View
Recommendations for Quality and Safety
Robert Wood Johnson Foundation (RWJF) funded 3 phases of the Quality
and Safety Education for Nurses (QSEN) project.
Goal: “address the challenge of preparing future nurses with the knowledge,
skills and attitudes (KSA) necessary to continuously improve the quality and
safety of the healthcare systems in which they work” (Quality and Safety
Education for Nurses [QSEN], 2010, para. 1).
Phase I (2005)
Defined 6 competencies for nursing education
Phase II (2006)
Developed curriculum based on IOM reports/ QSEN competencies
Phase III (2008)
Incorporated 6 competencies into nursing education programs
During Phase III, (RWJF) and (IOM) launched a two-year initiative to respond to the need to assess and transform the
nursing profession. As part of its report, The Future of Nursing: Leading Change, Advancing Health, the committee considered
many challenges that face the nursing education system and some of the solutions that will be required to advance the
system. It determined:
Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression.
Committee recommends that the proportion of nurses with baccalaureate degrees be increased to 80 percent by 2020.
QSEN Phase III
Popovich, M. Improving patient outcomes through advanced nursing education [PowerPoint slides] . Retrieved from
http://www.google.com/url?sa=t&rct=j&q=improving%20patient%20outcomes%20through%20advanced%20nursing%20education.%20dr.%20
melissa%20popovich.%20director%20of&source=web&cd=1&cad=rja&ved=0CCIQFjAA&url=http%3A%2F%2Fdocuments.clubexpress.com%2
Fdocuments.ashx%3Fkey%3DvJGad0kKIcLA%252F%252FYM9anK6vd7hsliysON1c3EE9MKeWrTNwtakaPSMA%253D%253D&ei=S5RoUO
HpLujb0QGJ3YHoDw&usg=AFQjCNFQrx-nkXR7ZHbh5ZBtlqbZek2RhQ
American Nurses Association (ANA)
Standards on Education
“ANA’s long-held position is that the baccalaureate degree is
the entry degree into nursing” (ANA, 2010, p.20).
Lane and Kohlenberg (2010) state: “The 2008 ANA resolution on
education advancement for nurses lists three implementation
strategies:
(a) support for legislative proposals mandating attainment of the
baccalaureate degree within 10 years of licensure as an RN;
(b) encouragement for collaboration between schools of
nursing; and
(c) advocacy at the legislative level for
financial support for educational advancement” (p.224).
American Nurses Association (ANA)
Standards on Education
Standard 8. Education
“The registered nurse attains knowledge and
competence that reflects current nursing
practice” (ANA, 2010, p.49).
Practices in ongoing educational activities
Demonstrates a commitment to lifelong learning
Seeks formal and independent learning experiences to develop
and maintain clinical and professional skills and knowledge.
American Nurses Association (ANA)
Standards on Education
Standard 12. Leadership
“The registered nurse demonstrates leadership
in the professional practice setting and the
profession” (ANA, 2010, p.55).
Demonstrates a commitment to continuous, lifelong learning
and education for self and others.
American Nurses Association (ANA)
Standards on Education
Standard 13. Collaboration
“The registered nurse collaborates with the
healthcare consumer, family and others in the
conduct of nursing practice” (ANA, 2010, p.58).
Partners with other disciplines to enhance healthcare consumer
outcomes through interprofessional activities, such as
education, consultation, management, technological
development, or research opportunities.
Is Magnet Status
in our Future of Nursing?
© 2012 by Health Forum LLC, an affiliate of the American Hospital Association
© 2012 American Nurses Credentialing Center
A subsidiary of the American Nurses Association. All Rights Reserved
Why was the Magnet Program created?
The ANCC created the Magnet Program in 1994 to
acknowledge healthcare organizations that provide the very
best in nursing care. The Magnet Program aims to raise
awareness of the importance of the nursing profession. It
provides nurses with up-to-date information on best practices
in nursing. And it promotes workplace standards and
behaviors that help nurses do their very best.
© 2011 Departments of Nursing | NYU Langone Medical Center
The reason for this presentation was to explore the idea of
mandating the BSN as entry into nursing practice. I wanted to
provide a look at the past, present and future of nursing. There
are many hurtles that need to be overcome before I believe this
transition will take place, but before the end of my life, I think I
will see it come to pass. Based on everything I know and
researched, I am happy to be taking the steps needed to complete
my BSN on my own terms before the day comes when I am
forced to. Before it gets to that point, we as nurses have a duty to
unite and express our opinion on what would be the best
transition available for us as a whole.
Summary
1. How do you marry the two educational frameworks into
perfect harmony if in the event the ADN where eventually
eliminated?
2. What organizational body is better prepared to do such a huge
undertaking to merge both educational programs?
3. Based on the information discussed in this presentation, how
many years do you foresee the entry level into nursing practice
being changed?
Discussion Question
REFERENCES
Aiken, L.H., Clarke, S.P., Sloane, D.M., Lake, E.T. & Cheney, T. (2008). Effects of hospital care environment on patient mortality and
nurse outcomes. Journal of Nursing Administration, 38(5), 223-229
American Association of Colleges of Nursing. (2012). Defining scholarship for the discipline of nursing. Retrieved from
http://www.aacn.nche.edu/publications/position/defining-scholarship
American Association of Colleges of Nursing. (2009). The essentials of baccalaureate education for professional nursing practice.
Retrieved from http://www.aacn.nche.edu/education-resources/BacEssToolkit.pdf
American Nurses Association. (2010). Nursing: Scope and standards of practice (2nd ed.). Silver Spring, MD: Author.
Benner, P., Sutphen, M., Leonard, V., & Day, L. (2009). Educating nurses: A call for radical transformation. San Francisco: Jossey-
Bass.
Hansten, R., & Washburn, M. J. (1998). Professional practice: Facts & impact. American Journal of Nursing, 98(3), 42–45.
Klainberg, M.K. and Dirschel, K.M. (2010). Today's nursing leader managing, succeeding, excelling. Sudbury, MA: Jones and
Bartlett Publishers.
REFERENCES
Lane, S. H., & Kohlenberg, E. (2010). The future of baccalaureate degrees for nurses. Nursing Forum, 45(4), 218-227. doi:
10.1111/j.1744-6198.2010.00194.x.
Quality and Safety Education for Nurses. 2010. Project overview. Retrieved from http://www.qsen.org/overview.php
Scheckel, M. (2009). Nursing education: Past, present, future. In G. Roux & J. Halstead (Eds.), Issues and trends in nursing (pp. 27-
55). Sudbury, Massachusetts: Jones and Bartlett.
Starr, S., & Edwards, L. (2010). Why should I get a BSN? Tar Heel Nurse, 72(3), 10-12.
Tri-Council for Nursing. (2010). Educational advancement of registered nurses: A consensus position. Retrieved from
http://www.aacn.nche.edu/education-resources/TricouncilEdStatement.pdf
Welch, Cathryne. (2006). Living up to every possibility: M. adelaide nutting, 1858-1948. NEAA
Courier, 9, 4-5. Retrieved from http://www.foundationnysnurses.org/media/courier/Winter2007-MAN-PartII.pdf
