The BSN: Imperative for Professional Practice

National Healthcare CNO SummitApril 27, 2012April 27, 2012

Susan Bowar-Ferres, PhD, RN, NEA-BCNYU College of NursingNYU College of Nursing

Former SVP/CNO NYU Medical Center

BSN: The Imperativep

Objectives:j1. To describe the historical context

(Good, bad, and ugly)( , , g y)2. To discuss the Evidence

a. Business Case3. To describe BSN momentum

a. IOM Recommendation #4b. BSN in Ten Legislative Initiatives c. Market-Driven Initiatives

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Rationale for BSNRationale for BSN

Patient focusIncreasing complexity of careNeed EBP, collaboration, technology, critical

i treasoning, care managementPatient outcomes

Professional focusProfessional focusKnowledge workersEquity among professionsNursing faculty and APN shortagesRetention of professional nurses

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BSN PreparationBSN Preparation

• Scholarship for evidence‐based practiceScholarship for evidence based practice

• Information management

l h li d fi• Health care policy and finance

• Inter‐professional communication and collaboration

• Organizational & systems leadership, vital to g y p,patient safety

• Disease prevention and population healthDisease prevention and population health

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BSN ImperativeBSN Imperative

• Educational Drivers – Competencies E i l f B l Ed i (2008)Essentials of Baccalaureate Education (2008)Essentials of Associate Degree Education

• Practice DriversDifferentiated PracticeDifferentiated Practice Hiring / Staffing Some Hospitals settings but not long term care, home

carecare New models of care

• Legislative / Codification Drivers• Justice Drivers

Difference in settingsDifference in colorDifference in career advancement

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ANA Chronology of BSN C o o ogy o S1960 Promote baccalaureate programs as the basic education for

professional nursing1965 Published Educational Preparation for Nurse Practitioners and

Assistants to Nurses All nursing education in an institution of higher learning: BS Entry into practice, AD Nurse the technical nurse.

1978 Three resolutions: By 1980 Ensure 2 categories of nursing practice By 1985 Preparation for entry into professional nursing would be the

baccalaureate in nursing. By 1988 Establish a mechanism for a comprehensive statement for y p

two categories of nursing, actively support career mobility. 1983 Establish the BS degree as the educational requirement for

professional nursing p g1985 Resolution: Registered Professional Nurse & Assoc/Technical Nurse

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Other Positions / RecommendationsOt e os t o s / eco e dat o s

1983 Magnet Hospitals 2001 National Council Advisory Council on Education & Practice

(Report to HHS) 2002 Magnet Hospitals Revisited (2002)g p ( )2005 AONE2008 Magnet Nursing Recognition Program (2005, 2008)2010 Carnegie Report (Benner)2010 Carnegie Report (Benner) 2010 National Council of State Boards of Nursing (September)

2010 Institute of Medicine Report (October)p ( )2010 Tri-Council Endorsement (October)

(ANA, AONE, AACN, NLN)2011 Regional Action Coalitions (Implementation of IOM)2011 Regional Action Coalitions (Implementation of IOM)

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RecommendationsRecommendations

National Advisory Council on Nurse Education and Practice (2001)(2001)

urged that two-thirds of the basic nurse workforce hold a baccalaureate or higher degree in nursing by 2010.

AONE 2005 Guiding Principles for Future Care Delivery

The educational preparation of the nurse of the future should be at theThe educational preparation of the nurse of the future should be at the baccalaureate level:  Prepares the nurse to function as an equal partner, collaborator and manager of the complex patient care journey envisioned by AONE

ANDGiven that the role in the future will be different, it is assumed that BSN curriculum will be re‐framed

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RecommendationsRecommendations

ANA Resolution (2008)ANA Resolution (2008)Support initiatives to require registered nurses (RNs) to obtain a baccalaureate degree in ( ) gnursing within ten years after initial licensure, exempting (grand-parenting) those individuals who are licensed or are enrolled as a student in a nursing program at the time legislation is enactedenacted

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RecommendationsRecommendations

National Council of State Boards of Nursing (2010)NCSBN endorses continued learning at all levels of nursing and supports the May 2010T i C il li t t t thTri‐Council consensus policy statement on the Advancement of Nursing Education.

Tri‐Council for Nursing (2010)Tri Council for Nursing  (2010)Strong endorsement of the new Institute of Medicine (IOM) report on The Future of Nursing and calls for collaboration among stakeholders to advance the report’s recommendations

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RecommendationsRecommendations

Institute of Medicine Recommendation # 4(October 2010)

Increase the proportion of nurses with a baccalaureate p pdegree to 80 percent by 2020.

These leaders should partner with education accreditingThese leaders should partner with education accrediting bodies, private and public funders, and employers to ensure funding, monitor progress, and increase the di it f t d t t t kf d t tdiversity of students to create a workforce prepared to meet the demands of diverse populations across the lifespan.

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EvidenceEvidence

Aiken et al (2003)Aiken et al (2003) • Cross-sectional analyses of outcomes data • 232,342 general, orthopedic, and vascular , g , p ,

surgery patients discharged from 168 Pennsylvania hospitals during 18 monthsOdd f 30 d t lit d f il t• Odds of 30 day mortality and failure to rescue were reduced 5% with every 10% increase of BSN by 10% decrease in both likelihood ofBSN by 10% decrease in both likelihood of mortality within 30 days and the odds of failure to rescue were reduced 5% in surgical pts

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EvidenceEvidence

Estabrooks et al (2005)Estabrooks et al (2005)• Cross-sectional analyses of outcome data• 18 000 patients in 49 Canadian hospitals18,000 patients in 49 Canadian hospitals • Those with a higher proportion of BSN-prepared

nurses were associated withnurses were associated with Lower rates of 30-day patient mortality in medical patients (AMI, Stroke, CHF, OPD, ed ca pat e ts ( , St o e, C , O ,Pneumonia)

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EvidenceEvidence

Tourangeau et al (2006)Tourangeau et al (2006) • 46,993 medical patients (MI, stroke, pneumonia,

septicemia) in Canadian hospitalsp ) p• Those hospitals with a higher percentage of

BSN prepared nurses were associated with p pLower mortality within 30 daysLower failure to rescue rates

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EvidenceEvidence

Goode & Blegen (2009)Goode & ege ( 009)• Longitudinal study of 21 US hospitals over 84 quartersq

• Those hospitals with a higher proportion of BSN educated nurses found to have 

Lower rates of CHF mortalityHospital‐acquired pressure ulcers (HAPUs), Failure to rescueLength of inpatient stay.

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EvidenceEvidence

McGinnis (2008)( )• 5000 New York RNs survey• BSN prepared nurses compared to AD nurses

Scored higher in job satisfaction related to job autonomy and growth,

J b t d d dJob stress and demandsMore likely to have been in their jobs 

more than 10 yearsmore than 10 years

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EvidenceEvidenceKendall‐Gallagher, Aiken, Sloan & Cimiotti (2011)• A 10% increase in hospital proportion of baccalaureate and certified baccalaureate staff decreased the odds of adjusted inpatient 30‐day mortality by 6% and 2%adjusted inpatient 30 day mortality by 6% and 2%

• Nurse specialty certification is associated with better patient outcomes; effect on mortality and failure to rescue in general surgery patients is contingent uponrescue in general surgery patients is contingent upon baccalaureate education.

• Specialty certification of nurses was also associatedwith lower mortality and failure to rescue, butonly among nurses with BSN or higher education

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Evidence & CostEvidence & Cost

Analysis for New York when 60% RNs are BSN a ys s o e o e 60% s a e Sprepared:• 6000 fewer surgical deaths annuallyg y• 10% reduction in 200,000 HAPUs annually (additional 3.98 days LOS, $17.5M savings)( y , $ g )

• Reduction in LOS by 0.2 days = 400,000 additional patient days

• Every 1% reduction in nurse turnover = $12.9M annually

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Fueling the Workforce: Creatingth Pi li f F lt !the Pipeline for Faculty!

New graduates (New York)New graduates (New York)60% AD, 36% BSN, 3% Diploma

Of 60% ADOf 60% AD, Less than 20% get BSN, only 12% get MS

Of 36% BSN 40% get MSOf 36% BSN, 40% get MSNew nursing education models needed

AD to MSAD to MSOregon AD programs offering BSN

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Oregon Model & ReplicationsOregon Model & Replications

Oregon Health & Science UniversityOregon Health & Science University5 main campuses, 8 community collegesShare competency-based curriculumShare competency-based curriculumSeamless transition AD in 3, + 1 BSN

ReplicationsReplicationsHawaii, New York, North CarolinaNew Mexico – uniform curricula shared faculty poolNew Mexico uniform curricula, shared faculty pool

California

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Regional Action Coalitions Appointed by RWJF/AAPR Campaign for Action 2011Campaign for Action - 2011

MapMap

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Regional Action CoalitionsRegional Action Coalitions

• Grown to 48 as of March 2012  • Pending…OR, AL, DC

Ch i N i C litiChampion Nursing Coalitions• 43 Member organizations

Champion Nursing Councils• 23 National Organizations to implement

strategies• AACN‐AONE Academic‐Practice Partnership 

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Graduates from basic nurse baccalaureate programs are over 3 times more likely to obtain graduate degreesy g g

I iti l BSN G d t I iti l ADN G d tInitial BSN Graduates Initial ADN Graduates

Adapted from: Aiken, Cheung, Olds. 2009. Health Affairs 28(4)

BSN in Ten ModelsBSN in Ten Models

• New YorkBills A1977, S1223 reintroduced by their sponsorsin April 2011; gathering momentum

• New JerseySimilar Bills introduced; waiting for budget

• Rhode IslandBill introduced in assembly in 2011;

withdrawn for more workwithdrawn for more work• Oklahoma

2008 Action Plan; apparently deferred2008 Action Plan; apparently deferred

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BSN in Ten ModelBSN in Ten Model

New York BillsNew York Bills• Would require registered nurses to attain a

bachelor’s degree in nursing within ten yearsbachelor s degree in nursing within ten years of their initial licensure as a requirement for re-registration to practice in NY.re registration to practice in NY.

• Grandparents in all existing RNs, students enrolled in programs at the time of theenrolled in programs at the time of the legislation, or accepted into such programs.

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NY BSN in Ten Transition IssuesNY BSN in Ten Transition Issues

• Applies to future educated grads of AD and diploma programs• Applies to future educated grads of AD and diploma programs• Preserves all levels of education• Grandparenting will not intensify any potential shortage.• Future AD and diploma graduates would have 10 years from

initial licensure to complete BSN degree • No licenses would be removed. New RNs not meeting the

requirement would have “hold” placed on their license with provision for extenuating circumstances

• If passed in 2012 and signed by the Governor earliest that a• If passed in 2012 and signed by the Governor, earliest that a licensee would be placed on any “hold” would be in 2024.

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Organizational DriversOrganizational Drivers

NYU Langone Medical Center (2005) Required BSN for hire (CNO approval for exceptions)

North Shore LIJ Health System (2010)North Shore LIJ Health System (2010)Requires BSN or if hired with AD, must enrollwithin 24 months, and earn BSN within 5

f hiyears of hireHudson Valley, Cortland, NYVirginia Magnet Hospitals (5) require BSN within 5Virginia Magnet Hospitals (5) require BSN within 5Military and VA require BSN for practiceMagnet Structural Outcomes – Initial & Redesignation

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Magnet© Recognition ProgramMagnet© Recognition Program

BSN Requirements:q• Effective 1/1/2013 (at time of application)  100% Nurse Managers and Nurse Leaders

• Since 2008, applicants must set targets for staff nurse BSN completions, and graph trends over 2 years and demonstrate meeting or exceeding targetsdemonstrate meeting or exceeding targets

• Effective 6/1/2013, applicants must provide an action plan and set a target, which demonstrates evidence of progress toward having 80% of direct care nurses obtain a baccalaureate degree in nursing or higher by 2020.2020.

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Magnet© Recognition ProgramMagnet© Recognition Program

BSN Requirements:S equ e e ts:Effective 2008 For direct care nurses:• A stated goal or goals (a number or percentage)A stated goal or goals (a number or percentage) for improvement of BSN for any group of nurses in the organization 

• Goal can be for the entire 2‐year period prior to submission  or for each year 

• Each goal that is stated must be met or exceeded• Each goal must show 2 years of graphed data

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Nurses Move Mountains!Nurses Move Mountains!

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ReferencesReferences

Aiken, L. H. (2010). Nurses for the future. New England Journal of Medicine,December 15, 2010 (10.1056-11639)

Aiken, L. H., Clarke, S. P., Cheung, R. B., Sloane, D. M., & Silber, J. H. (2003). Educational levels of hospital nurses and surgical patient mortality. JAMA 290(12) 1617 1623JAMA, 290(12), 1617-1623.

Aiken, L. H., Clarke, S. P., Sloane, D. M., Lake, E. T., & Cheney, T. (2008). Effects of hospital care environments on patient mor-tality and nurse outcomes JONA 38(5) 223-229outcomes. JONA, 38(5), 223 229.

American Nurses Association. (2008). Compendium of ANA Education Positions, Position Statements, and Documents

American Nurses Credentialing Center (2008). Application Manual: Magnet© g ( ) pp grecognition program, ANCC, Silver Spring, MD

AONE.(2005). Education and Practice Partnership for the Future. Resolution of the voting body at 2005 Annual Meeting.

Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Educating nurses: A call for radical transformation. San Francisco, CA: Jossey-Bass.

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ReferencesReferencesBoyd, T. (2010). It’s academic: studies spur push to BSN-in-10, Nursing

Spectrum pBoyd, T. (2010). Hospitals begin to require BSN, Not Waiting for BSN in 10

Legislation. Nursing Spectrum.Budden, J. (2011). A survey of nurse employers on professional and practice

issues affecting nursing, Journal of Nursing Regulation, 1(4), 17-25.Estabrooks, C. A., Midodzi, W. K., Cummings, G. G., Ricker, K. L., &

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ReferencesReferencesKendall-Gallagher, D., Aiken, L., Sloane, D., & Cimiotti, J.  (2011). Nurse specialty 

certification, inpatient mortality,  and failure to rescue, Journal for Nursing Scholarship, 43(2), 188‐194.

Larson, J. Major changes proposed in nursing education. Nursing News,(January 7, 2011).

National Council of State Boards of Nursing (NCSBN®) Policy Position Statement (2010).

National Advisory Council on Nurse Education and Practice. (2001). Nursing: A t t i t f th h lth f th ti Fi t t t th tstrategic asset for the health of the nation. First report to the secretary

of Health and Human Services and the Congress. Bethesda, MD: Health Resources Services Administration Education.

Tanner C The Oregon Model cited in the IOM ReportTanner, C. The Oregon Model, cited in the IOM Report.Tri-Council for Nursing. (2010). Educational advancement of registered nurses:

A consensus position, Nurse Leader, 8(5),19-22.

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References

Tourangeau, A. E., Doran, D. M., McGillis Hall, L., O’Brien Pallas, L., Pringle, D Tu J V & Cranley L A (2006) Impact of hos pital nursing careD., Tu, J. V., & Cranley, L. A. (2006). Impact of hos-pital nursing care on 30-day mortality for acute medical patients. Journal of Advanced Nursing, 57(1), 32-44.

Van Den Heede, K., Lasaffre, L., Diya, L., Vleugels, A., Clarke,, , , , y , , g , , ,S. P., Aiken, L. H., & Sermeus, W. (2009). The relationship betweeninpatient cardiac surgery mortality and nurse numbers and educational level: Analysis of administrative data. International Journal

f N i St di 46(6) 796 803of Nursing Studies, 46(6), 796–803.Zimmerman, D., Cooney-Miner, D., Zittel, B. (2010). Advancing

the Education of nurses, JONA, 40 (12), 529-533.Zimmerman, D. & Cain, J. (2012). Changing winds: Forecasting and

moving your organization to an 80% BSN-prepared workforce, AONE Annual Meeting, Boston, MA.

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ReferencesReferences

Zittel, B. (2012). Advancing the education of registered nurses: The New York initiative, Journal of Nursing Regulation, 2(4), 10-15.

Zittel, B. (2011). Statutory & regulatory mandates for change, Stewart Conference, New York, NY.

Personal communications with Nurse Leaders of Regional Action Coalitions

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