The Institute of Medicine’s (IOM) landmark report, The Future of Nursing: Leading Change, Advancing Health, was released in October 2010 and provides a blueprint for action, with recommendations, to meet nursing workforce needs in the future. Supported by the Robert Wood Johnson Foundation (RWJF), the Future of Nursing report outlined the following recommendation, highlighting the need for a transformed nursing education system:
Recommendation 4: Increase the proportion of nurses with a baccalaureate degree to 80 percent by 2020. Academic nurse leaders across all schools of nursing should work together to increase the proportion of nurses with a baccalaureate degree from 50 to 80 percent by 2020. These leaders should partner with education accrediting bodies, private and public funders, and employers to ensure funding, monitor progress, and increase the diversity of students to create a workforce prepared to meet the demands of diverse populations across the lifespan. (Chapter 7, p. 11)
The Future of Nursing: Campaign for Action
The Center to Champion Nursing in America (CCNA) is a national initiative of the RWJF, AARP, and the AARP Foundation. Improving education opportunities for nurses has been one of the CCNA’s top priorities since it launched in 2007, with an initial focus on increasing education capacity and addressing the nursing faculty shortage (Reinhard, 2008; Reinhard & Hassmiller, 2009). These efforts transitioned into a new phase with the publication of the IOM report (2010). The CCNA provides the technical assistance framework for the Future of Nursing: Campaign for Action. The Campaign builds on the major recommendations of the IOM report (2010) and the ongoing efforts of nursing leaders and health care–related organizations to drive action at the national, state, and local levels. Currently, state-based organizations, called Action Coalitions, in 50 states and the District of Columbia provide a foundation for implementation of the IOM recommendations, including ambitious education recommendations.
The Nursing Education Learning Collaborative
In 2011, the CCNA held a series of five webinars, titled “Equip and Empower for Educational Transformation: Getting to 80% Baccalaureate by 2020” (Reinhard, Hassmiller, & Sroczynski, 2011). Attended by more than 450 nurse educators and other key stakeholders, these webinars and the subsequent dialogue with nursing education and practice leaders across the United States resulted in the formation of a collaborative learning community. The Learning Collaborative on Advancing Education Transformation formalized a network of state and national nurse leaders and stakeholders to facilitate the sharing of resources and the dissemination of information. Although regional education strategies varied, they shared underlying components that are key to advancing transformation. The striking similarities of common practices to meet academic progression goals across the country were immediately apparent. However, sharing successful strategies was difficult due to the regional variations in terminology. Out of these rich discussions and the consensus-building process, the CCNA identified four models encompassing common practices and strategies as showing the greatest promise for education transformation. The four models are:
- Shared curriculum.
- Competency or outcomes-based curriculum.
- RN-to-Bachelor of Science in Nursing (BSN) degree conferred by community colleges.
- Accelerated options, such as RN-to-Master of Science in Nursing (MSN) programs.
The learning community informing these models started as a conversation with nurse leaders involved in the implementation of the educational recommendations of the IOM report (2010). Many of these nurse leaders had been involved in this work prior to 2010 but found the IOM report to be a powerful accelerant to achieving education transformation.
Regional Education Meetings
Acknowledging the evolving nursing education environment, the CCNA subsequently hosted a series of face-to-face, regional educational meetings to gather nurse educators, regional experts, and other stakeholders to broaden the understanding of the models identified and how they might best be developed to advance the IOM recommendations (CCNA, 2012). At each meeting, the CCNA staff solicited input about any innovative models that were not previously defined. Representatives from 47 states participated in the series of meetings, with each meeting being attended by 24 to 36 invited nurse leaders representing the states in their region and stakeholders engaged in nursing education transformation. The meetings met the following key objectives to: (a) contribute to the national understanding of the four models identified as showing the greatest promise for education transformation, with the goal of seamless academic progression; (b) examine which models and strategies were most appropriate in specific settings; (c) identify essential partners needed to advance action in each region; and (d) begin to develop an action plan to move forward with the most promising practices in individual states and regions.
Overview of the Four Promising Models of Academic Progression
The four promising models initially identified for education transformation continue to provide a framework for progress. Currently, 44 Action Coalitions are actively engaged in academic progression projects and are refining one or more of the four models. The four promising models are discussed in this article. Additional information is available at http://www.campaignforaction.org.
This model is centered on collaboration among academic institutions to share or coordinate curricula, thus reducing duplication and promoting seamless student progression. Commonality may apply to the entire curriculum or to components within it (such as uniform prerequisites or a common curriculum across programs). Success occurs where there is coordination of prerequisites, corequisites, and graduation requirements, as well as nursing core curriculum. Teaching methods are not dictated, and outcomes may or may not be directly addressed; however, a single guiding set of standards across institutions is desirable. A gap-analysis process is applicable to both the competency and shared curriculum models to systematically identify and coordinate curriculum and degree requirements.
Curricular components may be shared across a segment of education (such as the associate degree in nursing [ADN] curriculum or nursing prerequisites) or may encompass the entire ADN-to-BSN degree program with common course content and numbering. The shared curriculum model is often complementary to the competency-based model, as it may include defined sets of the knowledge, skills, and attitudes required. This model enhances seamless progression in nursing education and reduces duplication by fostering, coordinating, and documenting degree articulation. A shared curriculum model provides an efficient use of resources, benefitting both the institutions involved and the students. Models that promote a shared curriculum include regional approaches in Texas and California and statewide initiatives in Oregon, New Mexico, and Wyoming.
Characteristics and Potential Areas for Implementation. Successful models are student centered and facilitate seamless progression. When fully implemented, the share curriculum model greatly simplifies student advising and promotes transparency for students. Reducing duplication and redundancy conserves resources and supports a more seamless academic progression experience for students. Schools may share faculty and simulation facilities, as well as organizational structure, such as admission requirements and enrollment procedures. Learning collaborative participants identified the shared curriculum model as a comprehensive, albeit time-consuming, option, requiring alignment of many divergent groups. Particular attention to nursing prerequisites and all graduation requirements are needed for success and may be challenging. A regional collaborative model— called the collaborative nursing education continuum model (CNECM)—at Sonoma State University in California, was an early adaptation of the shared curriculum model and illustrates many of the components.
Competency or Outcomes-Based Curriculum
This model supports the use of different educational approaches toward a commonly defined goal or outcome. The scope of the curriculum reaches beyond skill-based competencies and includes knowledge, attitudes, and skills. The curriculum and teaching methods are not standardized but students must meet defined, uniform outcome criteria. This model has overlap with shared curriculum models, but either can be initiated independently. The competency model is not an end in itself for seamless progression, but it can serve as an entry point for the development of a shared curriculum.
Competency-based curricula define the level of competence that students are expected to achieve regarding clinical and professional outcomes. The goal is to prepare students to meet a predetermined set of performance standards, which helps to identify appropriate course content and reduce redundancy. This student-centered model focuses on understanding and performance and integrates competency evaluation throughout the curriculum. These programs require consensus on the competencies that nurses need to more fully address the needs of consumers and health care institutions. Massachusetts has been a forerunner in the development of competency-based education through the development of a set of core nursing competencies (Sroczynski, Gravlin, Route, Hoffart, & Creelman, 2011).
Characteristics and Potential Areas for Implementation. Consensus across nursing education programs for a unified set of competencies offers significant benefits for students, employers, and educators. This model is inclusive of existing institutions and is potentially scalable for substantial numbers. It requires extensive collaboration and alignment across institutions, practice settings, and, ideally, across geographic lines.
RN-to-BSN Degree Conferred by Community Colleges
This model allows community colleges to develop ADN-to-BSN programs and award a postlicensure BSN. It is not a traditional prelicensure 4-year BSN program housed at the community college. In response to a growing demand for more highly educated nurses, several community colleges have successfully begun such programs. The American Association of Colleges of Nursing position paper (2005) supports the ADN-to-BSN offered at community colleges, with the proviso that such programs are to be nationally accredited. There may be an initial partnership with a 4-year institution; however, the degree is awarded by the community college. Legislative support is often required at the state level for community colleges to begin offering these programs. At the forefront of those implementing this model were St. Petersburg College in St. Petersburg, Florida, and Olympic College in Bremerton, Washington.
Characteristics and Potential Areas for Implementation. This may be a practical and essential model for rural states and regions with fewer 4-year schools and in areas with place-bound students. This model has a potential to substantially increase the number of BSN graduates, but implementation can require significant start-up time and financial support. This may limit the ability to rapidly produce BSN graduates to meet the 80% BSN workforce target by 2020. Recruiting and retaining faculty who are qualified to teach upper-division coursework may add to the challenge already present due to the nursing faculty shortage. This model offers flexibility for working students, particularly with the inclusion of online courses. This model is commonly more affordable for students, although the institution or state may incur increased implementation costs, which could potentially be passed on to the student.
Accelerated Options, Such as RN-to-MSN Programs
This model supports students completing advanced degrees in a more efficient manner than can be provided by traditional educational pathways. Several opportunities exist to expedite the transition of nurses directly to an advanced degree. ADN-to-MSN programs have been the exemplar of the accelerated options meeting the needs of the ADN nurse returning to school for advanced degrees. These ADN-to-MSN programs are specifically designed for RNs who have not already completed a BSN. This model streamlines the educational process by avoiding redundant coursework and facilitates career transition into advanced practice and specialty roles. All programs must include the BSN essentials as defined by the American Association of Colleges of Nursing (2008). This model generally provides ADN nurses with a BSN, as well as an MSN; however, some programs do not include this option. Universities in many states and online programs offer variations of this model.
Characteristics and Potential Areas for Implementation. The RN-to-MSN exemplar of this model is a university-based program providing an option for a broad range of students with varying levels of preparation at entry. It may be ideal for circumstances in which employers support advanced education for their nurses via on-site classes or career ladders. The model offers improved efficiency for students and values the practice experience of ADN-educated nurses. This model facilitates entry into leadership roles, as well as teaching and advanced practice roles.
Common Strategies for Success
Several themes emerged from the meetings as being critical to the success of any model for academic progression. Learning collaborative participants were unanimous in recognizing the need for inclusive partnerships from the onset of the planning process, and there was an appreciation that the work is resource intensive and requires funding support. All new programs must maintain a high level of quality, with recommendations that minimum standards include national nursing accreditation and analysis and response to outcome data. Support from experts with experience in developing and implementing the models was seen as a key strategy to assist in widespread dissemination. The CCNA responded to this suggestion by creating and deploying a team of nurse consultants to assist states in moving forward with developing their state or local models for academic progression.
An element universally present in successful programs was the strong emphasis on early and inclusive partnerships. Although specifics varied by model, the participants agreed that transformative change may encounter resistance and requires support from a broad constituency. Prior to the development of a focused action plan, the leadership team should cast a wide net for potential stakeholders and participants. In the initial approach to key individuals, it is essential to leverage existing relationships and develop talking points for outreach. A joint needs assessment may be useful to clarify the shared goal of improved health within the community and to establish a clear link with improved nursing education systems. It is important to build collaboration through the development of explicit mutual expectations. Participants should devise a strategic plan with specific action steps, benchmarks, and time lines through a consensus-based process. Early meetings may benefit from the services of a professional facilitator—a role that has been supported by the CCNA team of nurse experts. As the process advances, more formal structures may be needed, including a memorandum of understanding or letter of commitment from some participants. Key action steps for successful partnerships are outlined in Table 1.
Action Steps of Successful Initiatives: Partnerships
Certain stakeholder groups have a unique focus and contribution. Nursing faculty from both universities and community colleges are critical to the success of any model and must be intimately involved in the planning and development of the change process. Other representatives of the academic institution who should participate include relevant leaders (e.g., presidents, deans, directors) and students from various program levels. Virtually all models discussed in this article require input from the admissions office, the registrar, and the financial aid office. The models have the potential to affect faculty from other departments and their participation should be solicited early in the process. In institutions with significant union presence, labor representatives should be included. Participants from information technology may also be critical to help facilitate the anticipated changes and to develop the infrastructure necessary for tracking data.
Practice partners and nursing employers have an obvious stake in the outcome of nursing education change. It is important to include representatives from outpatient settings, long-term care, and public health, as well as acute care facilities. They provide critical input about the evolving needs in the workplace. This partnership creates an opportunity for shared learning, as practice partners deepen their understanding about the benefits of a more highly educated workforce and share innovative clinical learning opportunities. Employer incentives for academic progression within the existing workforce are critical to success and may include preferential hiring, tuition reimbursement, scheduling support, career ladders, and pay differential.
Inclusion of legislative and regulatory partners will vary based on the model selected and the unique structure within each state. In all cases, the state Board of Nursing should be solicited for input. State workforce centers and representatives from the Department of Labor should also be considered.
Physicians and other health professionals have a valuable contribution in informing interprofessional collaboration standards. Opportunities for interdisciplinary education should be considered with any substantial change to existing curriculum frameworks. Organizations such as state hospital associations and business associations should also be considered as partners where appropriate.
Health care consumers must also be included in the stakeholder group. Individuals and consumer organizations can represent patients and their families and offer a powerful voice in any consideration of new nursing education structures. Major insurers and members of state exchange boards (where relevant) form a specialized subset of consumer groups and provide a unique perspective. Key stakeholder groups are outlined in Table 2.
Stakeholder Groups: Partnerships
Regardless of the team’s composition, the leaders must foster a spirit of excellence, collaboration, and accountability. The group should be encouraged to share concerns and challenges openly to create the best opportunity for successful and lasting change.
All participants in the learning collaborative identified a need for adequate financial support to initiate and sustain the change process. Advancing educational transformation through any model requires time and expertise. Historical reliance on an all-volunteer workforce has significantly limited progress. Each institution, region, and state will need to assess potential options for funding assistance. Regional meetings included breakout sessions to strategize for this important barrier to progress.
Those who had been successful in securing financial support emphasized the importance of focusing on the goals of the funder. Talking points should include improvements to the health of the community, and appeals for funding assistance should be linked to the unique mission of the individual funder, not to the advancement of the nursing profession. Additional strategies include the development of a short, clear plan with a specific time line and funds in place for sustainability. Projects requiring matching funds may stimulate new sources of funding and can help demonstrate the commitment of the participants. In all cases, clear expectations are needed and, in some instances, may need to be formalized through a memorandum of understanding or similar document.
The learning collaborative group recommended that the topic of funding be further evaluated by the CCNA for additional focus. Subsequent communications with the Action Coalitions reinforced funding as being a significant barrier, and the CCNA developed and shared funding resources through the Campaign for Action’s Web site ( http://www.campaignforaction.org/resource/fundraising-toolkit-materials). In addition, as a direct response to these concerns, two additional RWJF-funded programs were launched. The Academic Progression in Nursing program provides $300,000 over 2 years for academic progression projects in nine selected states. The focus of the Academic Progression in Nursing grants, now in its third year, is to measure successful implementation of one of the promising education models in supporting seamless academic progression for nursing students in each of the nine states. The second RWJF program—the State Implementation Program (SIP)—provides state Action Coalitions with up to $150,000 in matching funds over 2 years for selected projects. Twenty of the 31 awarded SIP grants have chosen to focus on education initiatives. SIP grants require matching funds from stakeholders within the individual states, thus enhancing partnerships and strengthening commitment (RWJF, 2012).
From the earliest convening of the learning collaborative and throughout the regional meetings, participants emphasized that new mechanisms for academic progression must ensure high-quality nursing education. As a consistent measure of quality, all programs should seek and maintain national professional nursing accreditation, as well as institutional accreditation. Many models of improved academic progression represent a substantial departure from traditional structures. As new programs are developed, leaders should track student outcome measures required by their chosen national accreditation body. The goal of seamlessness (ease of) student movement from one degree to the next should also be measured. In addition, it is important to collect sufficient data to ensure that processes include a diverse student group to foster a workforce more closely representing the general population.
All stakeholders need to continue to refine and standardize terminology to enhance information sharing and communication. The learning collaborative participants provided suggestions to improve dissemination of accurate information, reduce duplication of efforts, and enhance acceptance of the models. Those suggestions included providing clear links to accurate descriptions, examples, and toolkits for each model on the Campaign for Action’s Web site ( http://www.campaignforaction.org). The group emphasized the value of having resources available to those investigating the models, including access to individuals who have experience with design and implementation.
The learning collaborative group also recommended more guidance regarding approaches to legislative barriers. A national legislative analysis, with the goal of a unified approach, may be most beneficial for some issues. Standardization of terms and data collection methodologies were also viewed as being highly important. Data collection should be standardized across public, private, and proprietary settings to allow comparative evaluation of outcomes.
Some common themes identified across all models, such as consistency in accreditation and regulatory standards across multiple agencies, would significantly expedite the implementation time line. In addition, coordination of prerequisites, corequisites, and core nursing curriculum across programs is needed. Finally, there is a need to clarify the “80 by 20” message (IOM, 2010) to existing diploma- and associate degree–educated nurses to encourage their participation in educational advancement through seamless academic progression.
One area identified for future focus was the need for better links among public, private, and proprietary schools, including national online programs. Strengthening partnerships and improving communication among academic and practice partners is also necessary to address the issue of clinical placements and academic progression of the existing nursing workforce. Some participants expressed the challenge of securing administrative support for this work in their academic institutions. Both university and community college participants expressed the need for stronger support from their administrations, but this challenge seemed more prevalent among community colleges.
Participants from states with large geographic areas designated as rural, remote, or frontier indicated widespread implementation of any education transformation model for academic progression to address the unique needs of these areas, such as travel distances, transportation, and online access.
A final, consistent recommendation was the need for continued development and support of a formal mechanism for state and national meetings of nurse educators and other interested stakeholders. Consensus existed among participants that continued communication among stakeholders would allow for more rapid and cost-effective sharing of models and recommendations for seamless academic progression.
Conclusions and Next Steps
Learning collaborative activities continue to focus on the issues and recommendations outlined in this article, with additional opportunities for consultation and sharing. Targeted activities to develop solutions and open-source sharing of successes across stakeholder groups has proven successful in facilitating progress. For example, the challenge of securing administrative support for the current work, particularly in the community colleges, was addressed by a specific project, whereby a group of community college presidents was convened in 2013 to discuss mutual goals and challenges. A white paper (RWJF, 2014) to share the discussion, developed primarily by Fairman and Meyer, provided the following statement in their summary:
All participants at the meeting said it is imperative that community colleges, universities, and their clinical partners take a unified approach to ensuring that the country has the well-prepared, highly educated nursing workforce it needs. They expressed interest in continuing the conversation and addressing additional unresolved issues. (p. 10)
The white paper indicated common goals and provided a platform for future discussions.
Another example of a solution developed to address an identified challenge was the need to coordinate prerequisites and corequisites. A group of experts representing ADN and BSN programs, practice, and Campaign for Action staff were convened in July 2014 to propose an ideal set of prerequisite and general education courses as national standards. An outcome of this work was a document outlining proposed BSN foundational courses,” which was widely disseminated and provided an essential tool supporting collaborative curriculum design (Polansky, Meyer, & Giddens, 2014). In a framework of open source (Chesbrough, 2006) innovations, states and institutions are building on the most promising practices in a spirit of mutual collaboration and commitment to advancing academic progression models across the country. Grantee’s progress in the Academic Progression in Nursing and SIP programs is shared across the network using virtual discussions, and face-to-face meetings. All of the materials and webinars are archived on the Campaign for Action’s Web site ( http://www.campaignforaction.org/).
As a direct result of this collaborative, open-source sharing, solution-targeted activities, and unprecedented network of support, partnerships between community colleges and universities supporting streamlined academic progression have been strengthened throughout the United States. Despite these successes, progress is slow, with 49% of BSN-prepared nurses in 2009 and increasing to 51% in 2013 (Campaign for Action, 2015), so additional strategies to accelerate progress are being explored and shared. One such strategy generated interest in the learning collaborative; therefore, a think tank was convened in January 2015 to further explore its potential. This strategy provides an option for graduates to enter the workforce with an RN and a BSN. It builds on successful academic progression models and increases BSN capacity, while taking advantage of the programs, faculty, and infrastructure already in place at the community colleges. The program is created by a community college and a university in partnership, and students take the NCLEX® after completing their BSN degree. New Mexico has adopted this strategy in their statewide model, Kansas uses this strategy in a selected project, and several other states are exploring the implementation of this strategy. Overwhelming support has been noted for this emerging strategy as an important option to build on current successes and accelerate progress toward obtaining the IOM’s goal.
The response to the grassroots consensus process was overwhelmingly positive. The participants deeply engaged in the work of identifying education transformation models in their states and regions. Although their states and regions had significant variation, many commonalities were identified. This resulted in learning from colleagues engaged in similar work across the United States. Grouping the types of approaches into four models provided a common framework with better standardization of terminology. This common language for academic progression facilitates sharing and accelerates nursing education transformation. All university, community college, and practice–learning collaborative participants identified the urgent need for a more highly educated nursing workforce to meet the health care needs of Americans. By continuing to share the challenges and successes, advancing education models that support seamless academic progression, and using a common language and framework, professional education goals for the future can be met.
The time is now to seize the moment for real and sustainable change in nursing education to provide higher educated nurses to serve the increasingly complex health needs of individuals, families, and communities. Is there any reason to believe that the proportion of nurses with bachelor’s degrees is associated with better outcomes? In an interview, acclaimed nursing researcher, Linda Aiken, says, “Yes,” and stated, “Our research shows hospitals that employ greater numbers of nurses with a BSN have lower mortality rates and better outcomes” (Kerfoot & Douglas, 2013. p. 276). The growing evidence, based on more than a decade of research by Aiken (2011) and others provides even more urgency to this work (Aiken, Clarke, Cheung, Sloane, & Silver, 2003; Bobay, Yakusheva, & Weiss, 2011; Pittman, Kurzman, & Johnson, 2014; Yakusheva, Lindrooth, & Weiss, 2014). The integrated national network. built through grassroots consensus sharing of promising practices, can serve as an accelerant to this essential education transformation.
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Action Steps of Successful Initiatives: Partnerships
|Build on existing relationships
|Create talking points for various audiences
|Complete a dual needs assessment with partners
|Focus goals on patient, community, and family
|Develop a strategic plan, with action steps and measurable outcomes
|Consider using a facilitator for early meetings
|Develop a formal memorandum of understanding
Stakeholder Groups: Partnerships
|University and community college
||Nursing, biology, humanities
||Dean, president, provost
||Admissions, registrar, financial aid, information technology
||Across levels of programs
||Representation from acute care, home health, community health, and long-term care
| Health professionals
||Physicians, pharmacists, physical therapists
| Consumer groups
||AARP state offices, other consumer groups, insurers
||Labor representatives when a significant presence exists in the practice or academic setting
||If needed, particularly when pursuing a community college baccalaureate model
||Board or Commission of Nursing