Health care in the United States is experiencing a paradigm shift toward population-focused community-based care that requires nurses who possess an enhanced level of critical thinking, clinical judgment, and complex decision making (Fraher, Spetz, & Naylor, 2015; Health Resources & Services Administration, 2016; Salmond & Echevarria, 2017). As a result, baccalaureate preparation has been deemed paramount to advancing the profession of nursing toward fulfillment of these expanded professional expectations (American Association of Colleges of Nursing [AACN], 2019a; Institute of Medicine [IOM], 2011). With approximately half of all new graduate RNs entering the profession with associate degree preparation (National Council of School Boards of Nursing [NCSBN], 2019b), greater collaboration among stakeholders in nursing education is integral toward developing seamless transition to baccalaureate and advanced preparation in nursing (AACN, 2019b).
This article describes the implementation of an innovative and highly accessible model for developing academic and clinical practice partnerships designed to ease the barriers to baccalaureate preparation, foster mutual respect among leaders in nursing education, enhance collaborative efforts in research and evidence-based practice, and improve patient outcomes. Ultimately, implementation of the Academic and Clinical Practice Model is designed to provide seamless entry to baccalaureate preparation for RNs.
Primarily in reaction to a series of nursing shortages worldwide that peaked following World War II, three distinct levels of educational preparation served as entry to practice into the nursing profession in the United States (Buerhaus, Skinner, Auerbach, & Staiger, 2017). These three levels of educational preparation include the baccalaureate nursing degree (BSN), the associate degree in nursing (ADN), and the hospital diploma. At completion, graduates from any of these three modes of educational preparation are entitled to take the same board examination, and on successful completion, to receive the same RN credential (AACN, 2019c; NCSBN, 2019a).
The BSN typically is completed in 4 years and prepares graduates for a broader scope of practice and enhanced professional identity through coursework in nursing research and evidenced-based practice, population health, leadership, and management, as well as enhanced course offerings in science and humanities (AACN, 2019c). The BSN also provides preparation for graduate study, which is necessary for advanced nursing roles such as nurse educator, nurse practitioner, or nurse anesthetist (AACN, 2019c).
Community colleges serve an important role in the education of RNs in the United States. With approximately half of all RNs attaining their prelicensure education through associate degree preparation (Buerhaus, Auerbach, & Staiger, 2016), a variety of factors make community college ADN programs attractive to students. These factors include favorable admission policies, lower tuition costs, program reputation, proximity to home, and shorter program duration, usually 3 years (Buerhaus et al., 2016). Community colleges typically serve a diverse student population including adult students, minority students, first-generation college students, and students from low-income groups (Ma & Baum, 2015). Hospital diploma programs have declined significantly, with 3% of new graduate RNs attaining their RN credential through hospital diploma preparation (Auerbach, Buerhaus, & Staiger, 2015).
BSN programs have experienced significant growth, with approximately 993 programs in the United States. The growth in baccalaureate programs can be attributed to a number of factors. First, the American Nurses Credentialing Center (ANCC), through the Magnet Recognition Program®, began recognizing health care organizations based on attaining specific nursing quality standards, including expansion of baccalaureate-prepared nursing at the bedside and in administrative roles (ANCC, 2019). Furthermore, beginning with the seminal work of Aiken, Clarke, Cheung, Sloane, and Silber (2003) and Aiken et al. (2011), a series of studies outlined improved outcomes achieved in hospitals using a greater percentage of nurses with baccalaureate preparation (Blegen, Good, Park, Vaughn, & Spetz, 2013; Chang & Mark, 2009). Finally, the IOM (2011) and the Robert Woods Johnson Foundation (RWJF) (2013) has recommended that by 2020, 80% of RNs hold a baccalaureate degree; however, progress toward these goals has been slow, and meeting the goal is highly unlikely (Ma, Garrard, & He, 2018).
More recently, recognizing that neither BSN nor ADN programs possess the capacity to prepare all applicants for nursing practice, leaders from both ADN-granting and BSN-granting institutions have begun to work together to create seamless academic progression through clinical partnerships and dual-enrollment agreements (Brady, 2015). Such collaborative efforts have been endorsed by the AACN, the Organization for Associate Degree Nursing, the American Association of Community Colleges Trustees, and the National League for Nursing through recommitment to the removal of educational barriers to baccalaureate preparation and to the advancement of professional development for all nurses (AACN, 2019b). The AACN (2019a) also has specifically called for increased collaboration between nursing education institutions and clinical practice through the development of formal academic-practice partnerships.
Academic and Clinical Practice Partnerships
A number of organizations have advocated for the expansion of partnerships between colleges and universities and both ADN-granting institutions and clinical health delivery systems. In a joint collaboration document, the AACN and the American Organization of Nurse Executives (2012) outlined guiding principles regarding academic and clinical practice partnerships. These guiding principles included creating collaborative relationships between academia and clinical practice that foster mutual respect, knowledge sharing, evidence-based practice, recognition of academic achievement (including seamless academic progression), development of collaborative models for improved patient outcomes, and joint collection and analysis of data related to the RN workforce.
Such partnerships are intended to benefit all engaged institutions by providing voice to leaders in nursing toward creation and implementation of health care policy, seamless academic progression, and innovative curricular delivery models. Furthermore, the AACN (2019b) advocates for enhanced academic and clinical practice partnerships to ensure that curriculum and delivery are more closely aligned with not only clinical practice, but also with the mission of the schools of nursing in the United States. Finally, the AACN (2019b) envisioned academic and clinical practice partnership models among multiple schools of nursing and multiple clinical health delivery systems within a specific geographic region.
Participatory action research (PAR) has been chosen as the theoretical framework for implementation of the model. PAR, a subgroup of action research, has been defined as:
A participatory process concerned with developing practical knowledge in pursuit of worthwhile human purposes. It seeks to combine action and reflection, theory and practice in participation with others, in the pursuit of practical solutions to issues of pressing concern to people, and more generally the flourishing of individuals and their communities.
Developed from critical theory and constructivism, PAR provides for the systematic collection and analysis of data through engagement with communities and stakeholders of interest for the purpose of taking action and bringing about change. PAR arises from the work of Kurt Lewin (1946), who is considered the founder of action research. Lewin, a psychologist and Jewish refugee from Nazi Germany, believed that people would be more motivated in the workplace if they were involved in decision making. The origins of PAR also can be attributed to the work of critical theorist Paulo Freire (1970), an author of critical pedagogy and adult educator who challenged the social relationships and power balance within traditional education. Freire believed that individuals must become cognizant regarding social, economic, and social circumstances in order to take action to liberate the oppressed. Finally, PAR is considered constructivist as knowledge is socially constructed through the research process (Baldwin, 2012).
Ultimately, the purpose of PAR is to create empowerment, social justice, accessibility, and participation (Bradbury, 2015). PAR differs from other types of research in that participants are active contributors, not merely subjects of the research (Bradbury, 2015). PAR provides an opportunity for collaboration among individuals with diverse knowledge and expertise in a particular issue to make meaningful change for the benefit of the community.
PAR can be used to inform qualitative action research methodology by providing a framework for systematic inquiry that encourages collaboration between researchers and stakeholders for the purpose of enacting social change (Young, 2013). Three types of qualitative data collection and analysis were used in the model: stakeholder interviews, focus group data collection, and questionnaires and surveys. Consistent with PAR, the Academic and Clinical Practice Partnership Model allows for a number of data collection points to ensure that partnership agreements reflect the needs of all stakeholders in the process. Using the three aforementioned methods of data collection, triangulation was achieved to enhance relationship building and problem solving among all stakeholders.
The research site was the school of nursing within a large public midwestern university. The school of nursing offers nursing education programs in BSN prelicensure, BSN completion, master of science in nursing (MSN), and doctor of nursing practice (DNP). In response to demand in the nursing education market, the school of nursing at the research site recently had unveiled a new dual-enrollment BSN program. Dual-enrollment programs allow students to enroll concurrently in the ADN program at the community college and the BSN completion program at the college or university. Dual-enrollment programs are specifically designed to meet the needs of ADN nursing students while providing a seamless path to baccalaureate preparation. Students enrolled in a dual-enrollment program take the NCLEX-RN® at the completion of the ADN program and continue in the BSN program.
Ultimately, the dual-enrollment program provides ADN students with a “head start” in baccalaureate preparation. Such programs avoid long academic breaks, ultimately decreasing the time to baccalaureate preparation. Dual-enrollment programs have been shown to increase the number of BSN-prepared nurses while strengthening relationships and partnerships between baccalaureate and associate degree programs (Bopp & Einhellig, 2017). The AACN (2019b) and the IOM (2016) support expansion of academic agreements, specifically, dual-enrollment agreements, as an evidence-based solution toward increased baccalaureate preparation for RNs.
At the same time, the research site was seeking to increase academic and clinical practice partnerships. Such partnerships are intended to strengthen the relationships between the college or university and clinical practice to ensure optimal transition to practice for new graduate nurses, joint participation in research endeavors, and preparation of preceptors and mentors for students at all levels (BSN, MSN, and DNP).
The following research questions guided the model development and implementation:
- What are the needs of leadership within ADN programs in developing academic partnerships for the purpose of increasing baccalaureate preparation in the profession?
- What barriers do leaders within ADN programs foresee for development of academic partnerships?
- What barriers do leaders in potential clinical partnership organizations foresee for development of a partnership agreement?
- What barriers do leaders in potential clinical partnership organizations foresee to baccalaureate completion for the practicing nurse?
- How can leaders within ADN programs, potential clinical partnership organizations, and 4-year colleges and universities work together to break down the barriers to baccalaureate preparation in nursing?
Academic and Clinical Partnership Model
The purpose of the Academic and Clinical Practice Partnership Model is twofold. First, the model delineates the process of building partnerships between a 4-year midwestern university and ADN-granting academic institutions for the purpose of academic progression to the baccalaureate level. Second, the model illustrates the process of building academic and clinical practice partnerships for the purpose of enhancing academic progression of practicing nurses, improving transition to practice for new graduate nurses, increasing joint research endeavors, and providing preceptors and mentors for students at all levels.
The model was developed and implemented at the research site during the 2018–2019 academic term. Figure 1 shows the overall process delineated by the model. The overall process included eight aspects:
Research institution team.
Stakeholder roundtable event—focus group.
Identification of barriers to enrollment.
Interventions to reduce barriers to enrollment.
Academic and clinical practice partnership agreements.
Evaluation of outcomes.
Academic and Clinical Practice Partnership Model.
Research Institution Team
From the school of nursing, the administrative members of the research team included the interim chairperson, the director of undergraduate studies, the RN completion coordinator, and the undergraduate curriculum committee chairperson. As experts in administrative process and curriculum construction, their voices were integral in developing academic agreements that were not only feasible but also consistent with institutional curriculum requirements. The vice provost/director of community college partnerships served as the primary negotiator and navigator of the agreement through the university system as required for approval. Of the three faculty members included on the team, one was a faculty-lead in the RN completion program and the other two faculty members provided additional perspective and research interest in the barriers to baccalaureate preparation in nursing. Students were the subject of a companion study conducted concurrently regarding the barriers to baccalaureate preparation. For that reason, student perceptions were not included in the model.
The research institution team identified seven primarily rural ADN programs for potential academic partnerships. The identified ADN programs were located within a 60-mile radius of the research site. Rural ADN programs were chosen as the short-age of nurses prepared at the baccalaureate level is particularly acute in rural areas in the United States (National Rural Health Association, 2012).
After obtaining Institutional Review Board approval from the research institution, nursing education leadership from the seven identified ADN programs were contacted via e-mail to participate in the potential partnership activities. Six of the seven leaders from the identified ADN programs agreed to participate. Of the six programs participating in the academic partnership-building activities, two ADN programs self-identified as semi-urban or suburban, and four programs self-identified as rural programs. The ADN programs ranged in size from approximately 60 students to 250 students.
Given the short time line for the grant implementation (6 months) and the challenging midwestern winter weather, the team opted to implement an innovative plan to engage the ADN programs identified for the academic partnership-building project. Rather than engage in the extensive travel necessary to meet with each program face-to-face, the team opted to engage in a series of discovery conversations. The discovery conversations were a series of virtual conversations using common meeting technology that virtually put all of the participants in the same room, thus eliminating the cost and time associated with travel.
A semistructured interview guide was used to elicit stake-holder responses regarding interest in an academic partnership agreement toward dual-enrollment/baccalaureate completion for students presently enrolled in the ADN program. The discovery conversations provided an opportunity for stakeholders to describe their needs regarding baccalaureate preparation, the needs and aspirations of students currently enrolled in the ADN program regarding dual-enrollment, and any barriers to creating an academic partnership agreement, as well as developing a meeting of the minds regarding the process toward an academic partnership agreement.
A total of six discovery conversations were held during February 2019. All members of the research institution team attended all of the discovery conversations. Notes were taken at each meeting, and the research institution team met immediately after each discovery conversation to discuss the session and develop items for inclusion in potential academic partnership agreements.
Roundtable Discussion: Focus Group
The purpose of the roundtable discussion was to engage with stakeholders, primarily within rural communities, toward the development of academic and clinical practice partnerships. Leaders from four of the six participating ADN programs in the discovery conversations attended the roundtable discussion held in March 2019. In addition to the four ADN programs, nine clinical delivery systems, within geographical proximity to the ADN program attendees, were identified for engagement in the roundtable discussion. As stakeholders in baccalaureate preparation of RNs, clinical delivery systems not only employ graduates from ADN programs, but also often provide support for practicing RNs to complete baccalaureate preparation. Clinical delivery systems provide opportunities for college and university programs through clinical placements, preceptorships, and mentorships for BSN, MSN, and DNP programs. Of the nine clinical delivery systems identified for participation, six organizations accepted the invitation to participate in the roundtable discussion.
For the roundtable discussion, the room was organized with a series of tables. Each roundtable included one to two representatives from an ADN program, one to two representatives from each geographically positioned clinical delivery system organization, a facilitator from the research institution, and a scribe or note taker. Seating representatives from ADN programs together with geographically positioned health care delivery system organizations allowed stakeholders to discuss geographically relevant topics and barriers at the roundtable. A semistructured interview guide was provided to the facilitator, and responses were recorded on paper by the scribe.
Informed consent was obtained from all of the participants involved in the roundtable discussion. Each roundtable group had an opportunity to share their responses and perceptions with the larger group. In the final session, the roundtable participants worked together to develop themes and to brainstorm solutions to the barriers of baccalaureate preparation.
Roundtable Results: Identifying Barriers to Enrollment
The roundtable attendees discussed a number of issues regarding baccalaureate preparation of RNs including: the perceived benefits of baccalaureate preparation; the knowledge, skills, and attitudes expected of the baccalaureate-prepared nurse; identifying the barriers to baccalaureate preparation; and addressing the identified barriers. Perceptions obtained from the roundtable conversation were used to inform continuous quality improvement at the research institution, as well as in the development of academic and clinical practice partnerships.
Perceived Benefits of Baccalaureate Preparation. The stake-holders and attendees identified four primary benefits: enhanced critical thinking and moving beyond the tasks, acquisition of a solid base in evidence-based practice, preparation for nursing leadership, and improved career trajectory. Roundtable participants discussed the importance of enhanced critical thinking as a result of baccalaureate preparation. The group agreed that enhanced critical thinking prepares graduates toward “big picture” thinking and provides graduates with an orientation to quality improvement and patient safety. Baccalaureate preparation was perceived by the group to provide a solid base in evidence-based practice, a skill-set optimal to modern nursing practice. Finally, stakeholders agreed that career trajectory is enhanced through preparation for nursing leadership, increased confidence, and an orientation toward professional development and nursing certification.
Knowledge, Skills, and Attitudes. A set of knowledge, skills, and attitudes were identified by stakeholders and attendees as essential for the baccalaureate-prepared nurse. In regard to knowledge, it is expected that the baccalaureate-prepared nurse possesses an understanding of the art as well as the science of nursing. Participants discussed the importance of practicing nursing from a theory base as essential to the modern practice of nursing. A solid base in evidence-based practice and nursing research was identified as essential, leading to a nursing workforce engaged in safety and quality improvement in health care.
Regarding the skills expected of the baccalaureate-prepared nurse, stakeholders/attendees expect nurses to possess skills in critical thinking, communication, interdisciplinary collaboration, and advocacy for both patients and the profession of nursing. Regarding the attitudes expected of the baccalaureate nurse, a leadership orientation was deemed crucial. Attendees noted that nurses with a leadership orientation possess emotional intelligence, seek to make meaningful contributions to the organization, demonstrate a commitment to continuous quality improvement, and take pride in the profession of nursing.
Barriers to Baccalaureate Preparation. As reflected in the Academic and Clinical Partnership Model, the results from the roundtable discussion were used to identify barriers to baccalaureate preparation. These barriers included: a competition mentality between providers of nursing education; one size does not fit all students—multiple paths to baccalaureate preparation are needed; lack of mentorship programs for practicing nurses seeking baccalaureate preparation; and reduced access to baccalaureate preparation due to financial hardship.
In the present environment of shortages of nursing faculty and clinical placements, participants expressed a need to end the competition mentality between associate degree and baccalaureate nursing programs. Multiple paths to nursing with seamless transition to baccalaureate preparation is critical to advance academic progression. Considering the significant barriers common to ADN-prepared nurses, who are often older with numerous competing priorities, one size does not fit all. Given that neither ADN nor BSN programs have the capacity to provide prelicensure preparation for all nurses, stakeholders must work together to meet the common goal of promoting the value of academic progression for all nurses. Attendees of the roundtable discussion stressed the importance of developing mentorship programs and mentoring relationships, specifically designed for practicing nurses seeking academic progression. Finally, stakeholders indicated a need for financial incentives for RNs seeking baccalaureate preparation, including career ladder incentives, private scholarships, and government financial aid programs.
Consistent with PAR, a follow-up survey was sent to stake-holders and roundtable participants via e-mail immediately following the roundtable discussion. The survey elicited responses regarding general satisfaction with the roundtable discussion and served as a member check for the themes that emerged from the discussion. The survey results indicated that stakeholders and roundtable participants were satisfied with the roundtable event. In addition, the stakeholders and roundtable participants confirmed that the themes identified were accurate, complete, and reflected the perceptions of the stakeholders in attendance.
Interventions—Breaking Down the Barriers
The stakeholders and attendees agreed that the roundtable discussion itself represented a significant first step in reducing the competition mentality among nursing education programs. It was agreed by all of the roundtable stakeholders and participants that collaborative efforts were key to increasing the number of baccalaureate-prepared RNs in the state. As a result of the roundtable discussion, the research institution developed the following interventions to address the barriers to academic progression for RNs. To address flexibility in RN completion programs, several potential portals of entry to baccalaureate completion were created at the research institution. The portals of entry were designed to meet the differing learning and engagement readiness of various students and included a choice of dual-enrollment/traditional RN completion, as well as differing entry points, including a summers-only option. In addition, course offerings for RN completion were converted from a semester model to an 8-week course model. Eight-week course offerings more closely aligned with ADN partners and allowed for increased flexibility for RN completion students.
Stakeholders indicated an interest in developing preceptor and mentorship programs specifically designed for the practicing nurse returning to school. This feedback was used to inform partnership agreements toward the creation of such programs between the college or university and the clinical practice partner. Finally, as a result of the roundtable discussion, the research institution is working closely with academic and clinical practice partners to create financial incentives designed to increase access to baccalaureate preparation.
Evaluation of Outcomes
The following outcomes were identified by the research team as measures for successful implementation of the Academic and Clinical Practice Partnership Model:
- Completion of academic partnership agreements with three ADN-granting institutions.
- Completion of one clinical practice partnership agreement.
- Increased student enrollments and retention within the baccalaureate completion program at the research institution as a result of implementation of new academic and clinical practice partnership agreements.
- Ongoing satisfaction among the academic and clinical practice partnership stakeholders.
Integral to the model implementation is periodic evaluation of outcomes. Continuing communication through additional surveys and roundtable discussions is paramount to creating seamless entry to baccalaureate preparation for both ADN nursing students and practicing nurses within the state. Evaluation of outcomes may lead to the discovery of previously unknown barriers to baccalaureate preparation, requiring a new set of interventions and new or revised academic and clinical practice partnership agreements. As more is learned about the barriers that exist in baccalaureate preparation and completion, systematic efforts will address these barriers progressively to promote student success.
Academic and Clinical Practice Partnership Agreements. The initial goal was to enter into academic partnership agreements with a minimum of three ADN programs. At the conclusion of the model implementation, the research institution was in the process of completing six new academic partnership agreements with identified ADN programs and two new academic and clinical practice partnership agreements. The academic partnership agreements provided the basis for articulation from the ADN program to the BSN program, paving the way to dual-enrollment for ADN students.
As a result of the feedback obtained from the discovery conversations and roundtable discussion, various points of entry were developed based on student readiness for baccalaureate coursework, including a summers-only option, a moderately paced option, and an accelerated option. Based on the option chosen, ADN graduates could complete the BSN within 3 to 12 months after completing their ADN. Based on feedback from the model implementation, the academic and clinical practice partnership agreements contained the following elements: potential for increased numbers of clinical placements for under-graduate prelicensure students, additional preceptor opportunities for both undergraduate and graduate students, enhanced collaborative research opportunities between the institutions, and enhanced recruitment and retention of practicing nurses into baccalaureate degree completion from the clinical institution. Ultimately, the academic and clinical practice partnership agreements provide a pathway to a common goal—an increase in baccalaureate preparation for RNs.
This article describes the implementation of an innovative and highly accessible model for developing academic and clinical partnerships. Implementation of the model served as a launch pad for inclusion of rural ADN programs and health care delivery systems in the academic progression discussion. Through academic and clinical partnership agreements, a common understanding between the research institution and stake-holders was forged regarding academic progression, optimal transition to practice, joint research endeavors, and preceptors and mentors for students at all levels. Leaders in nursing education and clinical practice must continue to work together to create partnerships toward seamless pathways to baccalaureate preparation for all students and practicing nurses.
- Aiken, L.H., Cimiotti, J.P., Sloane, D.M., Smith, H.L., Flynn, L. & Neff, D.F. (2011). Effects of nurse staffing and nurse education on patient deaths in hospitals with different nurse work environments. Medical Care, 49(12), 1047–1053 doi:10.1097/MLR.0b013e3182330b6e [CrossRef]
- 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), 1617–1623 doi:10.1001/jama.290.12.1617 [CrossRef]
- American Association of Colleges of Nursing. (2019a). AACN's vision for academic nursing white paper. Retrieved from https://www.aacnnursing.org/Portals/42/News/White-Papers/Vision-Academic-Nursing.pdf
- American Association of Colleges of Nursing. (2019b). Academic progression in nursing: Moving together toward a highly educated nursing workforce. Retrieved from https://www.aacnnursing.org/Portals/42/News/Position-Statements/Academic-Progression.pdf
- American Association of Colleges of Nursing. (2019c). Fact sheet: The impact of education on nursing practice. Retrieved from https://www.aacnnursing.org/Portals/42/News/Factsheets/Education-Impact-Fact-Sheet.pdf
- American Association of Colleges of Nursing and American Organization of Nurse Executives Task Force on Academic-Practice Partnerships. (2012). Guiding principles to academic-practice partnerships. Retrieved from http://www.aacnnursing.org/Academic-PracticePartnerships/The-Guiding-Principles
- American Nurses Credentialing Center. (2019). American Nurses Credentialing Center. Magnet recognition program model. Retrieved from http://www.nursecredentialing.org/Magnet/ProgramOverview/New-Magnet-Model
- Auerbach, D.I., Buerhaus, P. & Staiger, D.O. (2015). Do associate degree registered nurses fare differently in the nurse labor market compared to baccalaureate-prepared RNs?Nursing Economic$, 33(1), 8–13.
- Baldwin, M. (2012). Participatory action research. In Gray, M., Midgley, J. & Webb, S.A. (Eds.), The Sage handbook of social work (pp. 467–482). Thousand Oaks, CA: Sage.
- Blegen, M., Good, C., Park, S., Vaughn, T. & Spetz, J. (2013). Baccalaureate education in nursing and patient outcomes. Journal of Nursing Administration, 43(2), 89–94 doi:10.1097/NNA.0b013e31827f2028 [CrossRef]
- Bopp, A.J. & Einhellig, K. (2017). Dual enrollment nursing partnerships. Nursing Education Perspectives, 38(2), 106–107 doi:10.1097/01.NEP.0000000000000119 [CrossRef]
- Bradbury, H. (2015). The Sage handbook of action research (3rd ed.). Thousand Oaks, CA: Sage.
- Brady, M. (2015). Academic progression for associate degree nursing students: Evolution, not revolution. Journal of Nursing Education, 54(7), 359–360 doi:10.3928/01484834-20150617-10 [CrossRef]
- Buerhaus, P., Auerbach, D. & Staiger, D. (2016). Recent changes in the number of nurses graduating from undergraduate and graduate programs. Nursing Economic$, 34(1), 46–48.
- Buerhaus, P., Skinner, L., Auerbach, D. & Staiger, D., (2017). State of the registered nurse workforce as a new era of health reform emerges. Nursing Economic$, 35(5), 229–237.
- Chang, Y.-K. & Mark, B.A. (2009). Antecedents of severe and nonsevere medication errors. Journal of Nursing Scholarship, 41(1), 70–78 doi:10.1111/j.1547-5069.2009.01253.x [CrossRef]
- Fraher, E., Spetz, J. & Naylor, M.D. (2015). Nursing in a transformed health care system: New roles, new rules. Retrieved from https://pdfs.semanticscholar.org/e065/a43c70564c54a568c61ad2ba11c2bf697e13.pdf
- Freire, P. (1970). Pedagogy of the oppressed. New York, NY: Seabury Press.
- Health Resources and Services Administration. (2016). Preparing nurses for new roles in population health management. Retrieved from https://www.hrsa.gov/sites/default/files/hrsa/advisory-committees/nursing/reports/2016-fourteenthreport.pdf
- Institute of Medicine. (2011). The future of nursing: Leading change, advancing health. Washington, DC: National Academies Press.
- Institute of Medicine. (2016). Assessing progress on the Institute of Medicine report: The future of nursing. Washington, DC: National Academies Press.
- Lewin, K. (1946). Action research and minority problem. In: Lewin, G.W. (Ed.), Resolving social conflicts (pp. 143–152). New York, NY: Harper & Row.
- Ma, C., Garrard, L. & He, J. (2018). Recent trends in baccalaureate-prepared registered nurses in U.S. acute care hospital units, 2004–2013: A longitudinal study. Journal of Nursing Scholarship, 50(1), 83–91 doi:10.1111/jnu.12347 [CrossRef]
- Ma, J. & Baum, S. (2015). Trends in community colleges: Enrollment, prices, student debt, and completion. New York, NY: College Board.
- National Council of State Boards of Nursing. (2019a). NCLEX examination. Retrieved from https://www.ncsbn.org/nclex.htm
- National Council of State Boards of Nursing. (2019b). Number of candidates taking NCLEX examination and percent passing, by type of candidate. Retrieved from https://www.ncsbn.org/Table_of_Pass_Rates_2018.pdf
- National Rural Health Association. (2012). Health care workforce distribution and shortage issues in rural America. Retrieved from https://www.ruralhealthweb.org/getattachment/Advocate/Policy-Documents/HealthCareWorkforceDistributionandShortageJanuary2012.pdf.aspx?lang=en-US
- Reason, P. & Bradbury, H. (2008). The SAGE handbook of action research: Participative inquiry and practice (2nd ed.). Thousand Oaks, CA: Sage.
- Robert Woods Johnson Foundation. (2013). Campaign for action: Dashboard indicators. Retrieved from https://campaignforaction.org/resources/#p=1
- Salmond, S. & Echevarria, M. (2017). Healthcare transformation and changing roles for nursing. Orthopaedic Nursing, 36(1), 12–25 doi:10.1097/NOR.0000000000000308 [CrossRef]
- Young, L. (2013). Participatory action research. A new science for nursing? In Beck, C.T. (Ed.), Routledge international handbook of qualitative nursing research (pp. 319–330). London: Routledge.