Barbara Zittel, PhD, RN
Edtrina Moss, MSN, RN-BC, NE-BC
Ann O’Sullivan, MSN, RN, NE-BC, CNE, ANEF
Terry Siek, MSN, RN, NEA-BC
This article explores the theme that, as professionals, all registered nurses (RNs) are accountable for their own educational development and execution of their individual professional role. To assure that RNs perform to the full scope of their practice and impact the highest possible patient outcomes, a standardized educational preparation of RNs at the BSN level is essential, either through initial education or educational progression. The authors support the need for BSN preparation with a brief review of research to identify seminal works that demonstrate the added value, both economically and in terms of patient outcomes, that results when higher percentages of BSN-prepared RNs provide care. They also discuss RN accountability for educational progression and barriers to earning the BSN. The article summary offers recommendations and action steps to support BSN education and promote RN full scope of practice.
Citation: Zittel, B., Moss, E., O’Sullivan, A., Siek, T., (September 30, 2016) "Registered Nurses as Professionals: Accountability for Education and Practice" OJIN: The Online Journal of Issues in Nursing Vol. 21, No. 3, Manuscript 1.
Key Words: barriers to RN scope of practice, Institute of Medicine report, BSN in 10, RN educational progression, model of professional nursing practice, nursing education.
The American Nurses Association 2015 Professional Issues Panel (Panel), Barriers to RN Scope of Practice, was established to identify and clarify barriers that inhibit registered nurses (RNs) from practicing to the full extent of their education, experience, and scope of practice (as determined by relevant state nurse practice acts). The Panel Steering Committee worked to identify barriers that prevent RNs from working to the full extent of their education and training, explore the basis for these barriers, and develop recommendations to address them.
Panel findings were organized around four key RN roles in the healthcare delivery system: RN as professional, RN as advocate, RN as innovator, and RN as collaborative leader.
Each of these four roles will be the basis of separate, detailed articles in this OJIN topic. This article considers the perspective that, as professionals, all RNs are accountable for their own educational development and execution of their own profession. To support the ability of RNs to perform at the fullest scope of their practice, we consider a standardized educational preparation for RNs at the baccalaureate of science in nursing (BSN) level. We will explore the need for BSN preparation with a brief review of seminal research, discuss RN accountability for educational progression, and describe barriers to earning the BSN degree.
Standardized Educational Preparation of RNs at the BSN Level
...participants identified that the major barrier to RN practice at the highest level of the legal scope of practice is non-standardized educational preparation of RNs at the BSN level... At the onset of the discussions, Panel members queried Steering and Advisory Committee members via a poll regarding their perceptions of barriers to RNs performing to the full scope of their practice. From a long list of barriers, poll participants identified that the major barrier to RN practice at the highest level of the legal scope of practice is non-standardized educational preparation of RNs at the BSN level, either through initial education or educational progression post diploma or associate degree. A subcommittee, consisting of three members of the Steering Committee and 21 members of the Advisory Committee, was then formed to consider this information. The work of the subcommittee was guided by one overarching theme: Nurses pursuing a baccalaureate degree in nursing, either directly or through educational progression, to practice clinical nursing. The subcommittee was charged to identify evidence to support the need for a BSN to practice clinical nursing; to identify barriers; and to offer guiding recommendations to provide guidance to advance the BSN as the essential educational component of RN practice.
Supporting the Need for RNs to Pursue a BSN
...there is a strong and positive relationship between RN level of education and patient outcomes. The seminal work of Aiken, Clarke, Cheung, Sloane, and Silber (2003) documented that each 10% increase in the proportion of BSN-prepared RNs decreases the risk of patient death and failure to rescue by 5%. These findings resulted in significant forces that quickly thrust the nursing profession into a new era of change. Initially, some in the profession refuted the research methodology, challenged the assumptions, and discredited the conclusions. However, additional evidence by multiple researchers, both national and international, has been gathered to validate the initial findings—that there is a strong and positive relationship between RN level of education and patient outcomes (Aiken, Clarke, Sloane, Lake, & Cheney, 2008; Aiken et al., 2014; Estabrooks, Midodzi, Cummings, Ricker, & Giovanetti, 2005; Friese, Lake, Aiken, Silber, & Sochalski, 2008; Kane, Shamliyan, Mueller, Duval, & Wilt, 2007; Tourangeau et al., 2007). Subsequent research by Blegen, Goode, Park, Vaughn, and Spetz (2013) demonstrated the positive impact of higher levels of BSN-prepared staff members for patients in acute care facilities with specific diseases, such as congestive heart failure, decubitus ulcers, postoperative deep vein thrombosis, and pulmonary emboli.
most... hospital-acquired conditions are directly influenced by nursing care and impacted by a staffing model comprising of a higher percentage of BSN-prepared RNs. Concomitant with these findings was change in the acute care facility reimbursement model utilized by the Centers for Medicare & Medicaid Services (CMS, 2013). Instead of reimbursing acute care facilities for the volume and diagnoses of patients, the new scheme would reimburse by value-based purchasing (i.e., the quality of care received as evaluated by patient outcomes and patient perceptions of care). In this new Inpatient Prospective Payment System, participating acute care facilities would be penalized for the development of hospital-acquired conditions. Research has demonstrated that most of these hospital-acquired conditions are directly influenced by nursing care and impacted by a staffing model comprising of a higher percentage of BSN-prepared RNs. These conditions include such complications as decubitus ulcers, postoperative deep vein thrombosis, pneumonia, urinary tract infections, and ventilator-associated pneumonia.
In 2010, the Institute of Medicine (IOM, 2011) released its report, The Future of Nursing: Leading Change, Advancing Health. The result of a 2-year partnership among the Robert Wood Johnson Foundation, the American Association of Retired Persons (AARP), and IOM, the report recommended an action-oriented blueprint for the future of nursing, including changes in public and institutional policies at the national, state, and local levels. One of the eight major recommendations in the IOM report was the need to increase the proportion of nurses with a BSN to 80% by 2020. The recommendation has been termed the “80-20 proposal.”
Chapter 4 of the IOM report provides compelling evidence to support a greater number of nurses either entering the workforce with a BSN or progressing to achieve this degree earlier in their career. While the report acknowledged that a BSN education will not solve all challenges brought about by future changes in healthcare delivery, it contended that such education does provide nurses with a greater range of competencies in such areas as research, leadership, systems reasoning, quality improvement, community care, health policy, and health policy financing. These are skills essential for all nurses to meet increasingly complex healthcare needs of the world’s diverse population.
Accountability for Educational Progression
...Panel subcommittee members felt that RN education is fragmented, not standardized, and confusing to the public. Standard 12 (Education) of the Scope and Standards of Practice (ANA, 2015) emphasizes the RN’s responsibility to seek knowledge and competence, including ongoing educational activities and lifelong learning. In considering the standard on education and the issue of educational progression, Panel subcommittee members felt that RN education is fragmented, not standardized, and confusing to the public. For example, when one of the authors informed a group of state legislators that persons graduating with a diploma, associate, baccalaureate, or entry-level master's degree all completed the same examination for licensure, they responded with disbelief and puzzlement (personal communication, B. Zittel, March 2015). In comparison, all other major healthcare professions require one entry point, at the baccalaureate level or above. In the last several years, the professions of physical therapy and pharmacy have moved to doctoral education as the entry level requirement.
Despite strong evidence to support the need for RNs to pursue a BSN degree, despite all of the recommendations and reports, despite the many discussions, progress has been slow. A culture change is needed in which persons interested in pursuing RN practice will commit to lifelong learning, with the BSN degree as the minimal educational attainment. One subcommittee member shared the following comment in this regard:
Nursing has been talking about the BSN as entry level since 1965 and has made little progress. Leadership in other disciplines focused on what was best for patients. Nursing needs to do the same. It is time that we as a profession look at the evidence—and make the important choice to be advocates for our patients and in a timely manner develop a system that best prepares nurses to meet the needs of the patients we care for. (personal communication, C. Lee, February 2016).
Unfortunately, culture change is typically a slowly evolving process with many barriers to change.
Barriers to Earning a BSN
RNs have documented for many years that time and cost are the two major barriers to continuing their education to the BSN level. RNs have documented for many years that time and cost are the two major barriers to continuing their education to the BSN level (Altmann, 2011; Bahn, 2007; Delaney & Piscopo, 2004). Barriers related to time are inflexible schedules and the demands of family. Cost barriers, in addition to tuition, include loss of or a decrease in salary and loss of healthcare benefits during the time the nurse is in school. Additionally, there is the low- or no-pay differential between diploma or associate degree-prepared RNs and BSN-prepared RNs.
In recent years, two additional major barriers have been identified: a) absence of mentoring and guidance, and b) lack of exposure to evidence supporting the importance of a BSN or higher degree, specifically how patients benefit. Some within the profession have argued that the only way to assure that all RNs earn a BSN is to mandate it. In most states/jurisdictions, that can only be accomplished through a bill passed by the state legislature. In a few states, that can occur by regulatory action of the State Board of Nursing. While Ohio, Rhode Island, Illinois, Vermont, and New Mexico have or have had coalitions to consider such a mandate, only New York and New Jersey currently have bills in the legislature that require future RNs to obtain a BSN within 10 years of graduation from a diploma or associate degree nursing program. It should be noted that in New York, letters of support for the legislation have been received from over 120 organizations including the medical society, the healthcare association representing acute and long term care facilities, and from the councils for both the associate degree and baccalaureate degree and higher programs (personal communication, B. Zittel, January 2016).
Faculty and deans from associate degree programs have been some of the strongest supporters of the legislation. Opposition has come from unions who believe that a baccalaureate of science (BS) in Nursing is not essential; that is, the BS could be obtained in any major. Such unions also wish that the legislation include a provision for funds to reimburse costs to RNs who continue their education to earn the BS. (personal communications, B. Zittel).
Despite these barriers, many changes are occurring. Some examples of recent changes include:
- As of 2013, the American Nurses Credentialing Center requires all nurse managers and nurse leaders to hold a BSN or higher degree in order to obtain Magnet® status. Further, hospitals applying for Magnet designation must have specific plans to achieve the IOM 80-20 recommendation (ANCC, 2013).
- Chief Nursing Officers (CNOs) in acute care facilities are providing a strong business case for BSN education, including evidence of economic benefits (Yakusheva, Lindrooth, & Weiss, 2014). These benefits include improved patient outcomes that reduce healthcare costs and avoid payment reductions per new CMS guidelines, and offer an argument to increase the number of BSN-prepared RNs in their organizations. Based on a recent New York state survey (Zittel, 2016), 77% of the acute care facilities sampled preferentially hire BSN-prepared RNs.
- Funding to pursue the BSN degree available for RNs in acute care facilities continues to increase. The New York state survey (Zittel, 2016) found that 97% of facilities provide funding for RNs to continue their education to the BSN level (93% in 2013) while 94% provide funding for RNs to pursue graduate education (88% in 2013).
- Zittel (2016) also found that select New York state acute care facilities demonstrated an increase from 27% in 2013 to 71% in 2015 in facilities requiring diploma- or associate-prepared new hires to complete the BSN within a prescribed number of years as a condition of continued employment.
- An unexpected finding of the New York state survey (Zittel, 2016) was that almost 70% of acute care facility respondents indicated that higher pay is provided to staff RNs with BSNs. That figure in 2013 was 54%. While the amount of that differential was not determined, the increase in the number of facilities providing this benefit is significant.
- The Tri-Council for Nursing (2010), including the American Association of Colleges of Nursing, ANA, the American Organization of Nurse Executives, and the National League for Nursing (NLN), published a consensus statement calling for all registered nurses to advance their education in the interest of enhancing quality and safety across healthcare settings. The statement encouraged all nurses, regardless of the initial education that resulted in licensure, to advance their education to the baccalaureate, master’s, and doctoral degree levels. The statement asserts that, “A more highly educated nursing profession is no longer a preferred future; it is a necessary future in order to meet the nursing needs of the nation and to deliver effective and safe care” (p. 1).
- In 2010, the Organization for Associate Degree Nursing (OADN) and the ANA committed to partnering with nursing and healthcare leaders, state legislatures and regulatory agencies, universities, colleges, and other stakeholders to support and adopt innovative and emerging strategies to assure that all nurses have access to seamless academic progression programs.
- In 2012, the Joint Statement on Academic Progression for Nursing Students and Graduates was issued by the American Association of Community Colleges, the Association of Community Colleges Trustees, the American Association of Colleges of Nursing, the NLN, and the Organization for Associate Degree Nursing (OADN). This collaborative statement indicates understanding that the partnering of these organizations can foster and inspire academic progression for nursing students and RNs to meet the common goal of “…a well educated, diverse, nursing workforce to advance the nations’ health” (American Association of Colleges of Nursing, 2012, para. 2).
- In 2015, ANA and OADN issued a joint position statement, Academic Progression to Meet the Needs of the Registered Nurse, the Health Care Consumer, and the U.S. Health Care System (ANA & OADN, 2015). The joint statement is a commitment to partner among themselves and with other stakeholders to support seamless academic progress with an emphasis on reaching IOM’s 80-20 recommendation.
Summary and Recommendations
As professionals, all RNs are accountable for their own educational development and execution of their own professional role. We offer some concluding recommendations toward that goal, based on the work of the Panel, as follows:
Recommendation 1: Commitment to Lifelong Learning
Prospective/potential applicants to the profession must commit to a goal of lifelong learning with the attainment of a BSN as a minimal degree.
Rationale: RNs must accept accountability for their own educational progression.
- Counsel prospective applicants to the profession regarding the need to continue their education to achieve the BSN degree as quickly as possible in their careers.
- Provide information about benefits both to their patients and themselves in attaining the BSN degree.
Recommendation 2: Stakeholder Unity
Individuals, organizations, state boards for nurses, and educators must make policy decisions to develop a standardized educational preparation that permits new RNs to be licensed with a diploma or associate degree but requires progression to a BSN within a certain amount of time after licensure.
While the BSN degree continues to be viewed as the educational foundation for professional nursing practice, because of inability to establish this standard as the entry requirement, continued action is needed. Rationale: In soliciting additional recommendations from Advisory Committee members to address barriers preventing RNs from pursuing the BSN degree, the subcommittee co-chairs reviewing this issue quickly realized that an impasse had been reached. The members were evenly split regarding the best course of action going forward. Several Advisory Committee members argued that it was again time to recommend the BSN as the entry to practice requirement and to no longer permit licensure of RNs unless such applicants held a BSN. Other members responded with a “been there, done that” perspective. They argued instead for adoption of a new model in which future RNs prepared at the diploma and associate degree levels would continue to be licensed, but to continue to practice, they would need to complete a BSN degree within a certain number of years after initial licensure. It was noted that the acute care industry appears to be adopting this model to ensure that newly hired RNs without a BSN are strongly encouraged to obtain the degree. While the BSN degree continues to be viewed as the educational foundation for professional nursing practice, because of inability to establish this standard as the entry requirement, continued action is needed. Actualization of this recommendation will result in the assurance that all future licensed RNs will hold a BSN and the IOM 80-20 recommendation will not only be reached, but surpassed.
- Work collaboratively to both require and support standardized educational preparation for nurses at the BSN level.
- Consider creative new methods to ensure that all future licensed RNs will earn this degree.
Recommendation 3: BSN and Specialty Certification
Pursue specialty certifications once the BSN degree is achieved.
Certification is most valuable when it is accompanied by a BSN. Rationale: Certification is most valuable when it is accompanied by a BSN. Evidence has demonstrated that although specialty certification is associated with better patient outcomes, such outcomes occurred only when care was provided by nurses with a BSN level nursing education (Kendall-Gallagher, Aiken, Sloane, & Cimiotti, 2011). With limited monies for continuing education and tuition reimbursement, a better return on investment may be achieved by allocating funds for RNs to continue to the BSN level instead of certification.
- Prioritize allocation of funds to support BSN completion education.
- Encourage specialty certification for BSN prepared nurses.
Recommendation 4: Mentoring
Mentoring/guidance in both academic and practice venues must be provided to assist RNs to continue their education.
Rationale: Several long-established organizational methods (e.g., tuition reimbursement, career ladder advancement policies, salary differentiation, flexible scheduling) to increase the number of RNs pursuing a BSN degree are commonly in place. However, additional measures that include the availability of mentors in the academic and clinical settings to provide guidance can provide additional support for nurses as they pursue BSN or higher level education.
- Implement a formal support system that includes easier access for RNs to information/resources about returning to school and includes information about partnerships with universities/colleges.
- Consider employment of a nurse champion at the organizational level (perhaps in staff development) who specializes in advancing RN education to assist individuals and the entire organization to meet educational goals.
Recommendation 5: Seamless and Unified Progression Models
Seamless academic progression models must be implemented to support RN educational advancement to the BSN level or higher.
Rationale: All organizations involved in nursing education, including accrediting organizations; nursing faculty and administrators; diploma, associate, BSN, and higher councils; and regulatory bodies, must actively collaborate to implement and evaluate new models to support the educational advancement of RNs. Support by key stakeholders to develop expectations and seamless models available to and encouraged for nurses in every state would likely go far to increase the number of BSN-prepared nurses.
- Develop seamless articulation models to simultaneously enroll students in diploma/associate degree and BSN programs.
- Establish the expectation across the United States that immediately upon meeting the diploma/associate degree curricular requirements, education will continue to the BSN level.
In conclusion, the nursing profession cannot pause for another fifty years to implement these recommendations. It is time to realize our full potential as nurses! We owe it to our profession, we owe it to ourselves, and most especially, we owe it to our patients.
Portions of the research for this article were performed by an American Nurses Association (ANA) Professional Issues Panel entitled “Barriers to RN Scope of Practice.” The panel was composed of volunteers from a variety of nursing backgrounds who contributed through participation on the Panel’s Steering Committee and Advisory Committee. While the articles were generated by authors participating in a Professional Issues Panel convened by ANA, the conclusions and recommendations articulated by any author do not necessarily reflect those of the Association.
Barbara Zittel, PhD, RN
Barbara Zittel is the immediate past Executive Secretary to the New York State Board for Nursing where she was responsible for the scope of practice determination, discipline, and licensure of 320,000 licensed practical nurses, registered nurses, and nurse practitioners. Currently, she serves as Co-Director of the Robert Wood Johnson Foundation/AARP Academic Progression in Nursing grant in New York and has just completed a three-year term as a Trustee to Ellis Medicine, a 438-bed community and teaching healthcare system serving New York’s Capital Region. She is an active member of the Medical Reserve Corp assisting in disaster nursing. Barbara is a recipient of numerous awards including: the 2015 New York University, College of Nursing, Legislative Award; the 2015 Foundation of New York State Nurses, Driscoll Award; and the 2014 American Nurses Association Barbara Thoman Curtis National Honorary Award.
Edtrina Moss, MSN, RN-BC, NE-BC
Edtrina Moss has more than 18 years of nursing experience and expertise in dialysis, transplant, critical care, ambulatory care, nursing education, care coordination, utilization management, and leadership. She has served in the roles of nurse educator, transplant coordinator, nurse manager and program director. She is a member of the Texas Nurses’ Association Policy Council and serves as content expert reviewer for the American Academy of Ambulatory Care Nursing’s Care Coordination & Transition Management curriculum and certification. She is also a student at Texas Woman’s University – Houston Campus, where she has completed all course work for a PhD in Nursing. Her research focus is exploring differences of self-reported competence of certified and non-certified registered nurses. She is board certified in ambulatory care and a board certified nurse executive. Edtrina is employed with the Veterans Health Administration in Houston, Texas.
Ann O’Sullivan, MSN, RN, NE-BC, CNE, ANEF
Ann O’Sullivan has 45 years of experience in nursing, including critical care, Clinical Nurse Specialist, Director of Nursing, and associate professor, and currently serves as Assistant Dean for Support Services at Blessing-Rieman College of Nursing and Health Sciences. Ann has served in many roles in the American Nurses Association, including state Board of Directors and President, chair of Health Policy, chair of Assembly Nursing Practice, and many others. She is currently Vice-President of ANA-Illinois and chairs the Illinois Expert Panel of Scope of Practice. At the national level, Ann served as chair of the Reference Committee, member and vice-chair of the Congress of Nursing Practice and Economics. Ann chaired the workgroup that revised the 2010 ANA Scope and Standards of Practice and was co-editor of Essential Guide to Nursing Practice (2012). Ann has also served in leadership roles in Sigma Theta Tau, Pi chapter, Illinois Organization of Nurse Leaders and the steering committee for the revision of the Illinois Nurse Practice Act. She is a Certified Nurse Educator and Certified Nurse Executive. Ann was inducted as a Fellow in the Academy of Nurse Educators. She has been awarded the Nurse Educator Award and Anne Zimmerman Honorary Member Award by the Illinois Nurses Association.
Terry Siek, MSN, RN, NEA-BC
Terry Siek, Vice President of Patient Care and Chief Nursing Officer at Hays Medical Center, graduated from Fort Hays State University in 1991 with a BSN and in 2002 with an MSN. Mr. Siek is responsible for the practice of all nursing staff at the 200-bed tertiary care center in rural Kansas. He has also served as the State President of the Kansas Organization of Nurse Leaders and is currently Secretary for the Kansas State Nurses Association. He is also active in Sigma Theta Tau in various roles, most recently being named to the Board of Directors of Nursing Knowledge International. His board memberships also include United Way of Ellis County, Kansas Nursing Foundation, St. Rose Health Center and the Kansas Heart and Stroke Collaborative, a $12.5 million Centers for Medicare & Medicaid Services innovation grant. He is very passionate about his profession and advocates for nursing locally, regionally, statewide and nationally.
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© 2016 OJIN: The Online Journal of Issues in Nursing
Article published September 30, 2016
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