2. Enhancing Education: Preparing New Nurses for New Challenges

2.1. RN Education Now

Quality education is central to quality patient care; effective instruction prepares individuals to be more capable in the care they provide (Bednash, 2005).  There are three different entry-levels for RN education: associate degree programs, diploma programs, and baccalaureate degree programs.  It takes approximately two years to complete an associate degree program, three years for a diploma program, and four years for a baccalaureate program or nursing doctorate.  RN program settings include community colleges for educating associate degree nurses (ADN); hospitals for diploma programs; and colleges or universities for baccalaureate nurses (BSN).  Before a student who has completed RN education can work as a nurse, he or she must complete the National Council Licensure Examination (NCLEX) of the National Council of State Boards of Nursing (NCSBN) exam.  Every RN, regardless of his or her education pathway, has the authority to perform all of the duties and responsibilities within the scope of the RN license in the state where the nurse is licensed. 

In 2004 there were 1,581 pre-licensure RN programs in the United States (National Council of State Boards of Licensing, 2004).  RNs with diplomas or associate degrees can continue their education to obtain baccalaureate or higher nursing degrees and enhance their skills in the areas of problem solving, critical thinking, and care of aggregates and families in a variety of settings. 

RN-to-BSN Programs

Opportunities for RNs to continue their education include RN-to-BSN programs which are for diploma or associate-degree prepared registered nurses interested in earning a baccalaureate degree.  It takes one to two years to complete the RN-to-BSN program, depending on the student’s past academic achievement, type of program, and the school’s requirements.  Many of these programs are offered online.  In 2005, there were 628 RN-to-BSN programs across the United States (American Association of Colleges of Nursing, 2005a).  RN-to-BSN programs offer more advanced education to help impart critical thinking, clinical reasoning, and analytical skills.  As such, they facilitate understanding of complex issues affecting patients and health care delivery and prepare nurses for a broader scope of practice.

Accelerated-BSN Programs

There has been a dramatic increase in the number of accelerated-BSN programs.  In these programs, entering students have already earned a bachelor’s degree in another discipline and have completed or are completing prerequisite science courses.  These intense programs can be completed in 11 to 18 months and are the quickest route to RN licensure for those with a prior degree.  Many of these programs enable students to complete a master’s degree in nursing within a total of three years. 

Second degree students are often older, highly motivated, and have higher academic expectations than traditional entry-level students.  Accelerated programs involve high admission standards, continuous study with no session breaks, and have the same number of clinical hours as traditional programs (American Association of Colleges of Nursing, 2005a). 

Advanced Practice

RNs with baccalaureate degrees may continue their education in master’s programs to prepare them for advanced practice roles as a nurse practitioner (NP), clinical nurse specialist (CNS), certified nurse midwife (CNM), certified registered nurse anesthetist (CRNA), or educator or manager/administrator.  RNs who received their initial education in diploma and ADN programs can obtain a master’s degree in RN-to-MSN programs, which bypass the need to obtain a baccalaureate degree to complete the master’s degree.  According to the AACN (2005a), there were 137 U.S. programs that can transition RNs with diplomas and associate degrees to a master’s degree level (Master of Science in Nursing degree) in 2005.  RN-to-MSN programs typically can be completed in approximately three years.  Most of these programs are offered in a classroom setting, although some are offered online or in a blended online and classroom format.  Specific requirements vary depending on previous coursework and the institution. 

2.1.1. Trends in Nursing Education

Over the past three decades, there have been wide fluctuations in nursing program enrollment which complicates projections of future nurse supply as well as determination of educational and faculty capacity requirements (Yordy, 2006).  More recently, there has been an upward trend in nursing education enrollment.  Nursing school enrollments have risen for the fifth consecutive year (American Association of Colleges of Nursing, 2005c).  Total enrollment in all nursing programs leading to the baccalaureate degree rose from 126,954 in 2003 to 147,170 in 2004.  For example, there was an increase in enrollment in RN-to-baccalaureate-level education programs of 6.2 percent (or 1,826 students) between 2003 and 2004.  In 2005 there were 151 accelerated BSN programs, up from 105 in 2002, with 6,090 enrollees in 2004. 

There has also been an increase in enrollments in nursing programs leading to master’s degrees.  For example, the number of RN-to-MSN programs has almost doubled over the past 10 years, from 70 to 137, and about 26 new RN-to-MSN programs are being planned as of 2005.  In addition, enrollments and graduations rose in both master’s and doctoral degree nursing programs, with a very slight increase in the number of graduates from master’s degree and doctoral programs in 2004 (American Association of Colleges of Nursing, 2005a; American Association of Colleges of Nursing, 2005c).

These trends underline the importance of increasing the capacity of nursing education programs and faculty staff levels to accommodate growing numbers of students enrolling in nurse education programs and pursuing nursing careers.  Effective approaches and strategies for achieving expanded capacity should be assessed and implemented.  However, policies should consider fluctuations in enrollment and changing patterns as nursing students seek to enter or advance in their field.

While the increases in enrollments are a positive indicator, the representation of men in nursing education programs remains low.  Men accounted for 8.8 percent of all baccalaureate graduates, 10.6 percent of master’s, and 4.0 percent of doctoral program graduates in the fall of 2004.  Racial and ethnic minorities accounted for 23.8 percent of undergraduate enrollees and 21.5 percent of graduate-level enrollees (Berlin, Wilsey, & Bednash, 2005).  The National Advisory Council on Nurse Education and Practice recommends prioritizing funding for schools of nursing that identify and implement plans for recruiting and retaining more diverse faculty and students.  The National Advisory Council on Nurse Education and Practice also supports evaluating and disseminating best-practice models that increase nursing school graduation rates for those groups with lower completion rates.

2.1.2. Education Level of New Entrants

According to findings from the 2004 NSSRN, the most common initial preparation for nursing in 2004 was an associate degree.  Over the past two decades there has been a downward trend in the number of nurses whose initial education was a diploma.  The number of RNs completing associate degrees has, since 1996, exceeded the number of RNs graduating from diploma programs.  Out of all graduates, the percentage of RNs who initially completed a baccalaureate program increased from 17.3 percent in 1980 to an estimated 30.5 percent in 2004. 

A small proportion (0.5 percent) of RNs is estimated to have received their initial nursing preparation through a master’s degree or doctoral program in 2004 (Health Resources and Services Administration, 2004).  However, from 2000 to 2004, there was a 37 percent increase in the number of RNs receiving their master’s or doctorate degrees (Health Resources and Services Administration, 2004).

In their analysis of recent trends in the nurse workforce, Buerhaus, Staiger, and Auerbach (2004) reported that younger RNs have tended to enter those nursing programs requiring the least amount of time to complete: 71 percent of RNs ages 21–34 graduated from two-year associate degree programs, with the greatest numbers of graduates falling in the group aged 30–34.  Berlin et al. (2005) cite NSSRN data showing that less than one-fifth (17.4 percent) of nurses educated in associate degree programs go on to complete a four-year nursing degree program. 

2.1.3. Overcoming Barriers to Enrollment

A 2004 survey by the AACN found that 32,797 qualified applicants were not accepted into schools of nursing in 2004, largely due to faculty shortages and resource constraints (American Association of Colleges of Nursing, 2005b).  The most common reasons for not accepting qualified applicants into entry-level programs, as cited by nursing schools responding to the survey, included insufficient faculty (76.1 percent), admissions seats filled (75 percent), and insufficient clinical teaching space (54.5 percent). 

In view of the current nursing shortage and with the prospect of the shortage worsening, the capacity of nursing education programs must be expanded.  Approaches include addressing the faculty shortage, collaborative linkages and partnerships, and greater deployment of funding.  One major source of Federal funding for nursing is the Nursing Workforce Development programs under Title VIII of the Public Health Service Act.  Funding from Title VIII increased 129 percent between 2000 and 2005 (Health Resources and Services Administration, 2004).  Other Federal funding for nursing is available through the Department of Labor’s Workforce Investment Act (WIA) in which nursing has been identified as a high demand profession.  As a result of the WIA, significant resources have been directed into nursing education and capacity-building (Skillman, Sadow-Hasenberg, Hart, & Henderson, 2004).

Enrollment in nursing education programs has historically grown through Federal programs that implement capitation grants which are formula grants to schools based on the number of students enrolled.  Capitation grant funding helps schools of nursing to improve their ability to educate students, pay higher teacher salaries, and improve faculty recruitment.  The Nurse Training Act of 1971 (P.L. 92-158) and the Nurse Training Act of 1975 (P.L. 94-63) facilitated increased enrollments in schools of nursing and mitigated nursing workforce shortages.  From 1971 to 1978, Congress provided capitation grants to schools of nursing in support of nursing education.  During the last two years of the program, Congress provided collegiate schools of nursing with $400 for each full time baccalaureate student enrolled in the last two years of a nursing program.  Associate degree schools of nursing were granted approximately $275 for each student enrolled.  Diploma schools of nursing received $275 for each student enrolled.  For FY 1977 and FY 1978, $55 million was appropriated.  To qualify, schools of nursing had to demonstrate increased enrollments over the previous year.  These grants were not prescriptive in their conditions, but allowed schools of nursing the flexibility to direct dollars to areas of greatest need.  Schools used the funds to hire new faculty, equip learning/audiovisual laboratories, enhance clinical laboratories, and recruit students (American Association of Colleges of Nursing, 2006a).

Carpenter’s 2005 testimony to the United States House Subcommittee on Select Education summarized more recent legislative initiatives:

Congressional legislation also has been introduced in both the House and the Senate to increase the capacities of schools of nursing via capitation grants, conceptually rooted in the Nurse Training Act (P.L. 94-63)…. The Nurse Education, Expansion, and Development (NEED) Act of 2005 (H.R. 3569) would provide capitation grants to schools of nursing to hire new and retain current faculty, purchase educational equipment, enhance audiovisual and clinical laboratories, expand infrastructure, or recruit students. In the Senate, Senators Jeff Bingaman (D-NM) and John Cornyn (R-TX) introduced the Nurse Faculty Education Act of 2005 (S. 1575). The grant funding provided by the bill may be used by schools to hire new or retain existing faculty, purchase educational resources, and support transition into the faculty role with the ultimate goal of increasing the number of doctorally-prepared nurse faculty. Priority would be given to those institutions from states experiencing the greatest nursing shortages. However, given the federal budget environment, these programs continue to receive inadequate funding to meet the demonstrated needs.

Full funding of these programs could have a dramatic impact on the capacity of nursing schools to educate new students, thus widening the pipeline and increasing the supply of nurses.

2.1.4. Nursing Faculty Shortage

One of the major impediments to expanded enrollment in nursing education programs is the shortage of nursing faculty.  As a result of this faculty shortage, nursing schools have insufficient capacity and are turning away qualified applicants (The Maryland Statewide Commission on the Crisis in Nursing, 2005, Buerhaus et al., 2004). 

In 2006, the National League for Nursing (NLN) estimated the number of budgeted, unfilled, full-time positions nationwide was 1,390, when considering all nursing education programs in the United States and its territories.  This represents a 7.9 percent vacancy rate in baccalaureate and higher degree programs, an increase of 32 percent since 2002; and a 5.6 percent vacancy rate in associate degree programs, an increase of 10 percent in the same period (National League for Nursing, 2006).  According to a survey conducted by AACN, the shortage of faculty is a result of budget constraints; the aging of the faculty and a wave of retirements; and job competition from clinical sites and private sector arenas that provide higher compensation (American Association of Colleges of Nursing, 2006b).  Areas of related concern include the increasing percentage of part-time faculty and the large number of nurse faculty who are not prepared at the doctoral level.

The estimated number of part-time baccalaureate faculty has grown 72.5 percent since 2002. The majority of baccalaureate and higher degree programs and almost half of associate degree programs reported hiring part-time faculty members as their primary strategy to compensate for unfilled, budgeted, full-time positions (National League for Nursing, 2006).  While this approach allows for greater flexibility, often part-time faculty are not an integral part of the design, implementation, and evaluation of the overall program.

Data show that nurse faculty were less well-credentialed in 2006 than they were four years earlier.  More than 56 percent of full-time baccalaureate and higher degree program faculty do not hold earned doctorates; fewer than 10 percent of full-time faculty in associate degree and diploma programs hold any credential higher than the master's degree (National League for Nursing, 2006).  Only 350 to 400 nursing students receive doctoral degrees each year and the pool of doctorally-prepared candidates for full-time nursing professorships is very limited (National League for Nursing, 2005).  Educators without doctoral degrees may lack credibility within a university setting and have limited opportunities to advance into leadership positions.  Institutions with low numbers of doctorally prepared educators may be less likely to be awarded funds to support research or educational innovations.

The average age of doctorally prepared nursing faculty in baccalaureate and graduate nursing programs holding the rank of professor is 57.3.  Among associate professors, the average age is 55; among assistant professors, the average age is 51.  The average age at which nursing faculty members retire is 62.5 (American Association of University Professors, 2006).

The shortage of nurse educators, especially among doctorally prepared nursing faculty, will likely become a more pressing problem with the retirement of existing nursing faculty (Hinshaw, 2001).  Education programs in NLN’s 2006 survey indicated that almost two-thirds of all full-time nurse faculty members were 45 to 60 years old and likely to retire in the next five to 15 years.  A mean of 1.4 full-time faculty members left their positions in 2006; nearly one quarter of these were due to retirement (National League for Nursing, 2006).  Approximately 1,800 full-time faculty members leave their positions each year.  By 2019, 75 percent of the current faculty population is expected to retire (National League for Nursing, 2005).

A number of factors may contribute to the nursing faculty shortage.  For example, although student enrollments have once again increased in recent years, Yordy (2006) suggests that such fluctuations and the resulting uncertainty may deter nurses from pursuing a nurse faculty career since the need for faculty decreases when enrollment of nursing students declines.  As noted in section 1.4, academic salaries that are not competitive with salaries for nurses in practice are another factor contributing to the shortage.  In addition, there are increased opportunities within the nursing profession in alternative areas such as research and administration (Bednash, 2000; Hinshaw, 2001), further drawing qualified prospective teachers away from education.  Another challenge is that Federal appropriations to universities are declining (Aiken, 2005).  For example, support for Medicare GME funds declined by 34 percent between 1991 and 2001 (Aiken, 2005). 

Gerland, 2006).  This approach may be worth replicating.  Also, because the overwhelming majority of nurses with master's and doctoral degrees began their education in baccalaureate programs (Berlin et al., 2005), it has been suggested that efforts to overcome the faculty shortage should focus on boosting enrollment four-year nursing programs. 

The National Advisory Council on Nurse Education and Practice recommends and supports providing incentives to encourage practicing nurses to become clinical faculty.  Hinshaw (2001) suggests implementing initiatives that support nurses who enter doctoral studies early in their careers.  The AACN recommends establishing online resources for nurses considering teaching careers and creating partnerships to build student capacity and fill vacant faculty slots (American Association of Colleges of Nursing, 2006b).  To complement such programs, policymakers should support nursing education models that increase faculty productivity (Yordy, 2006).

2.2. Future Challenges in RN Curriculum Development

Critical thinking skills are considered an essential component of the nursing profession in today’s increasingly complex health care environment.  Ineffective critical thinking based on insufficient knowledge or expertise can lead to inappropriate responses, resulting in poor clinical nursing judgment (Ritter, 1998).  In a review of 18 studies conducted between 1992 and 2003, Brunt (2005) described this skill set as “the process of purposeful thinking and reflective reasoning where practitioners examine ideas, assumptions, principles, conclusions, beliefs, and actions in the context of nursing practice.”  In a recent review of almost 200 studies on clinical judgment in nursing, Tanner (2006) concluded that clinical reasoning arises from an engaged, concerned position related to a particular patient and situation, and is informed by knowledge and rationale processes.  Critical thinking skills influence what nurses notice and how they interpret findings, respond, and reflect on their responses. 

Analytical thinking includes the ability to scrutinize facts in a detail-oriented fashion.  An analytical thinker must be able to look beyond surface statements and identify hidden agendas.  This involves gaining critical insights about personal biases.  Curricular enhancements to support analytical thinking could incorporate analysis of text, reports, and policy documents to identify the central arguments of the text.  Curricular enhancements can also include exercises to identify and comment on logical consistency of arguments and the way arguments are presented.

Traditional teaching strategies must be adjusted to facilitate the implementation of critical thinking and analytical skills in clinical practice.  A more traditional approach to teaching involves pedagogical discourse that encourages a dependency on the expertise of the educator (Myrick & Yonge, 2004); however, the Committee on Quality of Health Care in America Institute of Medicine report (2001) emphasized the need to implement strategies beyond the traditional focus on fact memorization to attain a core of knowledge about basic mechanisms of disease that better prepare students for practice.  Examples include: teaching evidence-based practice; teaching application of critical appraisal skills in patient settings including those in which the patients’ cultures may differ from their own; conducting literature searches; evaluating and understanding evidence; and training in multidisciplinary, multicultural teams to provide an appropriate mix of services.

Fesler-Birch (2005) emphasized the need for a learning environment that fosters autonomy, scholarship, and collaboration.  The author cited barriers such as traditional education methods and nursing curricula, faculty expectations, limited resources, and competitive nursing markets.  Components of skills instruction needed to impart critical thinking skills include concept analysis, problem-based learning, the Socratic method of teaching, contextually specific metacognition, and thinking instruction.  Fesler-Birch (2005) stressed the need for more empirical data to scientifically explore the possible link between critical thinking skills and patient outcomes. 

In 2000, the National League for Nursing created a standardized RN critical thinking test and developed questions that require a sound understanding of theory basic to the practice of nursing in clinical settings.  These questions relate to the health of adults and children, women's health, and mental health.  The test serves to evaluate the student's knowledge in nine content areas: research, legal/ethical understanding, therapeutic communication skills, health care systems, cultural and spiritual considerations, leadership and management, quality improvement, health promotion and illness management, and client education and empowerment (National League for Nursing, 2001).

The educational curriculum of baccalaureate nursing programs includes extra time and focus on developing a broad range of skills, including critical thinking and analytical skills, needed to address the emerging challenges in nursing.  The American Organization of Nurse Executives (AONE), in collaboration with state and regional AONE chapter leaders, concluded that a BSN degree in nursing is the educational level that best prepares nurses to function as part of the complex patient care environment of the future. 

2.2.2. Connecting Associate and Baccalaureate Degree RN Programs

Nationwide, there are significant numbers of articulation agreements between ADN and diploma programs and four-year institutions that help students seeking a baccalaureate-level education, allowing some of their course work to be transferable.  The National Advisory Council on Nurse Education and Practice recommends giving funding preference to pre-baccalaureate (associate degree/diploma) education programs that demonstrate a plan to encourage baccalaureate preparation with partnerships between baccalaureate and pre-baccalaureate programs.  Accelerated baccalaureate and master’s degrees in nursing programs for non-nursing graduates provide a way for individuals with undergraduate degrees in other disciplines to build on prior learning experiences and to transition into the field of nursing. 

There are various exemplar articulation programs that transition ADN nurses into BSN programs.  For example, to simplify the nursing enrollment process, the Oregon Education Consortium (consisting of eight community colleges and four Oregon Health Sciences University (OHSU) nursing schools) is working towards standardizing nursing schools’ admission requirements and curricula (Robert Wood Johnson Foundation, 2006b).  Under this new system, students would take the same prerequisite courses to apply to all state nursing schools, and new admission standards would grant community college students in two-year nursing programs automatic admission into the bachelor’s degree programs at OHSU’s four nursing schools.  Education officials also are working to update and standardize nursing curricula to better prepare RNs to meet health care needs and use emerging medical technologies (Robert Wood Johnson Foundation, 2006b).    

2.2.3. Technology Options for Enhancing the Effectiveness of Nursing Education in the Future

Technology offers important options for enhancing the effectiveness of nursing education.  For example, technologies such as simulation technology and interactive and Internet-based instruction improve both quality of education and access for students.

Simulation Technology

Undergraduate nursing programs are increasingly using simulation technology, involving interactive computerized models to simulate realistic practice settings and situations and help nursing students develop and apply critical thinking skills (Medley & Horne, 2005).  Simulation laboratories are being used in some hospitals to provide nursing orientation, conduct competency checks, and enhance risk management training.  Models used in this training modality range from equipment that teaches a single skill to very advanced equipment that presents clinical scenarios.  Processes for instruction described by Medley and Horne (2005) include determining the content best taught through simulation, establishing learning objectives, replicating reality through the environment and equipment, using video equipment to record activities for debriefing, and conducting a debriefing conference.  This process requires faculty to become skilled in teaching these models.  Faculty collaboration through Web sites is being promoted to share information and research about this technique. 

Traditional education was a place-bound classroom experience, based on structured didactic learning using face-to-face instruction.  Interactive and Internet-based instruction transform that model to one that facilitates access, interaction, and convenience for students through the use of distributed classrooms, electronic universities, computer-mediated technology, and interactive video teleconferencing.  With distance learning, students are physically separated from classroom resources, faculty, and other students.  This physical distance is bridged by an artificial communication medium that delivers information and access to learning resources and communication networks.  In a study of 43 RNs enrolled in a semester-long core course taught via interactive video teleconferencing and the Internet, DeBourgh (2003) found that students acclimated to the educational modality.  The quality and effectiveness of the instructor and instruction, not the instructional modality, was the most important predictor of course satisfaction.

Halstead and Coudret (2000) urged educators to consider instructional design concerns, faculty-student interactions, time and technology management skills, and student outcome evaluations when implementing Internet-based instruction.  While benefits of this type of instruction include increased flexibility, improved computer skills, decreased travel time, increased access to information, and independent learning, some of the disadvantages noted were technological difficulties, decreased contact with faculty and peers, increased time demands, the need for self-discipline, and the cost of the technology (like computer hardware and software) required to take the course (Halstead & Coudret, 2000).

Internet-based courses have increased in popularity in recent years.  However, competing demands in terms of curricular content and lack of prepared nursing informatics faculty have undermined efforts to include computer and information literacy in nursing curricula.  About half of the respondents to a national online survey of baccalaureate nursing education programs reported not having access to informatics education.  There is a lack of clarity among nursing faculty about essential informatics content and how to effectively integrate this content into the nursing curriculum (McNeil, Elfrink, Pierce, Bickford, & Averill, 2005).  The National Advisory Council on Nurse Education and Practice recommends increasing support for efforts to improve nursing education by funding programs, projects, and/or efforts that create shared regional clinical simulation centers, technology centers, and virtual skills labs to complement clinical rotation and provide access to evidence-based practices.