Iowa Health System 2011
Leadership Symposium
April 19, 2011
Preparing America’s Nursing Workforce for
the Future: Opportunities and Controversies
Presented by:
Jerry Durham, PhD, RN, FAAN
Chancellor and Professor of Nursing
Allen College
Waterloo, Iowa
FACTS ABOUT THE RN
WORKFORCE
Facts About the RN Workforce
RN Growth
The number of licensed registered
2008
nurses (RNs) in the United States
grew to a new high of almost 3.1
5.3%
million between 2004 and 2008--an
increase of 5.3% or 153,806 RNs.
2004
Facts About the RN Workforce
 In 2008, 2,596,599, or 84.8 percent of all RNs were
employed in nursing positions—the highest rate of
employment in nursing since HRSA national surveys
began in 1977.
 RN full-time employment has grown from 58.4 percent of
RNs in 2004 to 63.2 percent in 2008--the first increase in
the percent of RNs working full-time since 1996.
 In 2010, 36,554 (80.5%) of Iowa’s 45,409 RNs licensed
in Iowa were employed in nursing. Almost 60% were
employed full time in nursing
Facts About the RN Workforce
Between 2004 and 2008 in the U.S.
Initial Educational Preparation in Nursing
2004
2008
2010 in Iowa
ADN
42.9%
45.4%
52.0%
Diploma
25.6%
20.4%
20.0%
BSN
31.0%
33.7%
28.0%
In 2008, 0.4 percent of RNs had entered the profession with a
master’s degree in nursing and 0.03 percent had entered with a
doctoral degree.
Facts About the RN Workforce
Percent of American RN’s achieving a baccalaureate or
higher degree in nursing or a nursing-related field as their
highest degree.
1980
2008
2010 in Iowa
27.5%
50%
32.5%
 In Iowa in 2010, 45.2% of RNs reported the ADN as their
highest degree.
 In the U.S., only 21% of nurses who initially earn an ADN
go on to earn a higher nursing degree
Facts About the RN Workforce
 Nurses with advanced degrees
comprised 13.2 percent of all licensed
RNs in the U.S. in 2008.
 There has been marked growth in the
numbers of RNs with a master’s or
doctoral degree in nursing or a
related field.
 There were an estimated 28,369 RNs
(<1%) with a doctoral degree in
nursing or a nursing-related field in
2008—BUT an increase of 64.4%
since 2000.
RN’s with master’s or
doctoral degree in
nursing or related field
2008
404,163
46.9%
increase
275,068
2000
Facts About the RN Workforce
In Iowa in 2010
 4.9% of the Iowa’s RNs held a master’s degree in nursing
as their highest degree.
 2.7% held a master’s degree in another field of study as
their highest degree.
 379 RNs licensed in Iowa (<1%) held a doctoral degree
and 66 of these lived out of state.
 Only 93 RNs (.002%) licensed in Iowa held a doctorate in
nursing and 27 of these lived out of state.
Facts About the RN Workforce
35%
16.8%
Minorities in the US Minority Nurses in the
US
 In 2008, 16.8 percent
of nurses were Asian,
Black/AfricanAmerican, American
Indian/Alaska Native,
and/or Hispanic--an
increase from 12.2
percent in 2004.
 The two largest groups represented were non-Hispanic
Asian (5.5 percent) and non-Hispanic Black/AfricanAmerican (5.4 percent).
Facts About the RN Workforce
RN's 50 Years of Age or Older
45%
2000
1980
25%
2008
33%
Nearly 45 percent of RNs were 50 years
of age or older in 2008, a dramatic
increase.
Facts About the RN Workforce
Estimated RNs Per 100,000 Population
in the U.S.
825
2004
854
2008
(In Iowa in 2009, there were 1,022 RNs per 100,000
population.)
Facts About the RN Workforce
 Federal figures project that if current trends
continue, a shortage of RNs will grow throughout the
next 20 years because of increased demand and
RN retirements.
 Government analysts project that more than
581,500 new RN jobs will be created through 2018.
 By 2020, more than 800,000 RN positions may go
unfilled nationwide.
Facts About the RN Workforce
 The U. S. military requires a BSN for active duty RNs.
 The Veterans Administration--the largest single
employer of RNs—requires a BSN degree for
promotion and has provided financial support for
educational advancement since 2005.
 Several minority nurse associations have been
committed to increasing the number of RNs at the BSN
level.
 Magnet hospitals place a high value on nurses with
BSN and higher degrees.
NURSING EDUCATION
PROGRAMS
Approved Nursing Programs
in Iowa
33
27
19
1 PHD
2 DNP
3
10
5
Nursing Education Programs
In the 2008-2009 academic year
 54% of Iowa’s RN pre-licensure students were enrolled
in ADN programs.
 Iowa’s ADN programs graduated more than two-thirds
(67.5%) of the state’s new RNs.
State’s
New RN’s
BSN/CNL
652
(32.5%)
ADN
1,360
(67.5%)
Nursing Education Programs
 More than 630 RN-toBaccalaureate programs are
available nationwide,
including more than 390
programs that are offered at
least partially online.
 About 160 RN-to-Master’s
degree programs are
available which cover the
baccalaureate content
missing in the other entrylevel programs as well as
graduate level course work.
630+ RN to BSN
programs available
630 RN to BSN Programs
160 RN to MSN Programs
WHY DOES THE BSN DEGREE
MATTER?
Future of Nursing Project
IOM, 2009
 More nurses are working outside of hospitals as care
shifts formally and informally into communities;
 Evidence that could inform practice is growing rapidly,
but is not well-integrated into either education or
practice;
 The need for nurses to effectively work in and lead
teams is increasing; and
 Numbers alone will not fill the widening gap between
the supply of nurses and the growing need for their
services -- additional research and new knowledge will
be required.
Why Does the BSN Degree
Matter?
 Several studies support a significant association
between the educational level of RNs and outcomes
for patients in the acute care setting, including
mortality rates.
 In a widely-cited study published in JAMA in 2003, Dr.
Linda Aiken identified a clear link between higher
levels of nursing education and better patient
outcomes.
 This study found that surgical patients have a
"substantial survival advantage" if treated in hospitals
with higher proportions of BSN nurses. A 10%
increase in the proportion of BSN nurses decreased
the risk of patient death and failure to rescue by 5%.
Why Does the BSN Degree
Matter?
 In a study published in 2005, Dr. Carole Estabrooks
and her colleagues found that baccalaureate
prepared nurses have a positive impact on mortality
rates following an examination of more than 18,000
patient outcomes at 49 Canadian hospitals.
 This study confirmed the findings from Dr. Aiken’s
landmark study from 2003.
Why Does the BSN Degree
Matter?
 A study reported in 2007 of 46,993 patients
conducted by researchers at the University Toronto
found that hospitals with higher proportions of
baccalaureate-prepared nurses tended to have lower
30-day mortality rates.
 The findings indicated that a 10% increase in the
proportion of baccalaureate prepared nurses was
associated with 9 fewer deaths for every 1,000
discharged patients.
Why Does the BSN Degree
Matter?
 In a study released in May 2008, Dr. Linda Aiken and
her colleagues confirmed the findings from their
landmark 2003 study which showed a strong link
between RN education level and patient outcomes.
 These noted nurse researchers found that every 10%
increase in the proportion of BSN nurses on the
hospital staff was associated with a 4% decrease in
the risk of death.
Why Does the BSN Degree
Matter?
Deaths per 1000 patients with complications
As Nurse Education Increases,
Patient Mortality Decreases
100
90
80
70
90
84
deaths in
1,000
patients
60
deaths
in 1,000
patients
76
deaths
in 1,000
patients
50
40
30
20
10
0
20%
40%
Education
(Percentage of hospital nurses with BS degrees)
60%
Why Does the BSN Degree
Matter?
 In an August 2008 article that examined the effect of
nursing practice environments on outcomes of
hospitalized cancer patients undergoing surgery, Dr.
Christopher Friese and colleagues (University of MI)
found that nursing education level was significantly
associated with patient outcomes. Nurses prepared
at the baccalaureate-level were linked with lower
mortality and failure-to-rescue rates.
 They concluded that “moving to a nurse workforce in
which a higher proportion of staff nurses have at least
a baccalaureate-level education would result in
substantially fewer adverse outcomes for patients.”
Why Does the BSN Degree
Matter?
 In December 2009, Dr. Patricia Benner and her team at
the Carnegie Foundation for the Advancement of
Teaching released a new study titled Educating Nurses:
A Call for Radical Transformation, which recommended
preparing all entry-level registered nurses at the
baccalaureate level and requiring all RNs to earn a
master’s degree within 10 years of initial licensure.
 The authors concluded that many of today’s new
nurses are “undereducated” to meet practice demands
across settings.
Why Does the BSN Degree
Matter?
 The Institute of Medicine’s report, The Future of
Nursing: Leading Change, Advancing Health
released in October, 2010, recommends that 80% of
the nation’s RNs be baccalaureate-prepared by
2020.
Why Does the BSN Degree
Matter?
 In May 2010, the Tri-Council for Nursing, a coalition of
four steering organizations for the nursing profession
(AACN, ANA, AONE, and NLN), issued a consensus
statement calling for all RNs to advance their education
in the interest of enhancing quality and safety across
healthcare settings.
“Current healthcare reform initiatives call for a nursing
workforce that integrates evidence-based clinical knowledge
and research with effective communication and leadership
skills. These competencies require increased education at all
levels…Action is needed now to put in place strategies to
build a stronger nursing workforce. Without a more educated
nursing workforce, the nation's health will be further at risk.”
Why Does the BSN Degree
Matter?
 Several countries--Canada, Sweden, Portugal, Brazil,
Korea, Greece, Australia, New Zealand, Philippines,
Ireland, Iceland, Cuba—require a four year
undergraduate degree for RN licensure
 In Canada, most provinces limit licensure as an RN to
individuals prepared at the baccalaureate level. None of
the provinces have found that this position has
decreased the number of students applying to nursing
programs; in fact, applications to baccalaureate nursing
program have increased.
Why Does the BSN Degree
Matter?
 For every 1000 nurses who initially graduated from a
bachelor's degree program between 1974 and 1994,
almost 200 eventually obtained a master's or higher
degree. In contrast, only 58 of every 1000 nurses who
initially graduated from an associate's degree program
obtained at least a master's degree.
 Twice as many nurses with an initial bachelor's degree
ultimately obtained a doctorate, a finding that is relevant
to the Institute of Medicine's call for a doubling of the
number of doctoral level nurses by 2020.
Why Does the BSN Degree
Matter?
Why Does the BSN Degree
Matter?
 Of the approximately 72,000 nurses graduating
from ADN programs in 2010, only about 4000
(5.5%) are likely to ever obtain a master's or higher
degree — a yield that cannot produce enough
faculty to replenish the RN workforce.
 Had the proportions of RNs with initial education in
bachelor's and associate's degree programs been
reversed between 1974 and 1994, with the larger
proportion being bachelor's graduates, there would
probably have been 50,000 more nurses today with
master's or higher degrees.
Why Does the BSN Degree
Matter?
 In 1964 the American Nurses Association adopted a
motion that "ANA continue to work toward
baccalaureate education as the educational foundation
for professional nursing practice.“
 Only one state--North Dakota--enacted such a law
(1987) and then overturned the law in 2003 because
various factions fought to have it removed, citing a
nursing shortage.
Why Does the BSN Degree
Matter?
 Initiatives requiring a BSN degree have been
introduced in the New York, New Jersey and Rhode
Island legislatures over the past two years.
 As many as 18 states are considering some type of
initiative requiring newly graduated RNs to obtain a
BSN in order to maintain their licensure.
Why Does the BSN Degree
Matter?
In 2009, a bill was introduced in the New York State
Legislature to require registered professional nurses to
attain a BSN degree within 10 years of their initial licensure--called “BSN in 10.”
 Grandparenting of all currently licensed RNs to exempt them from
ever having to meet the requirements of the bill;
 A 4-year lead-in time frame from the date of passage of the bill, to
permit all students enrolled in non-BSN programs to complete
their studies and be grandparented;
 An RN’s license would be placed on “hold” when the
baccalaureate degree is not obtained in 10 years--similar to the
action taken when a licensee fails to meet continuing education
requirements as a criterion for continued registration--with
extensions for extenuating circumstances.
Why Does the BSN Degree
Matter?
Criticisms of the “BSN in 10” Proposal
 Not all RNs want to return school and will be forced out
of the workforce after ten years, further increasing an
RN shortage.
 BSN programs cost too much. Who will pay for RNs to
complete the BSN degree?
 BSN programs do not have enough capacity to
accommodate all returning RNs.
 Some RNs will not be academically successful in BSN
programs and have to leave the nursing workforce.
The Need for DNP Degree
 Most RNs are women and will find it difficult to juggle
employee, family, and student roles.
 Older RNs with only an ADN or diploma will be
disenfranchised.
 Employers will have to pay more for nurses with BSN
degrees, further increasing healthcare costs.
 Unions will resist any effort to impose a BSN
requirement.
 Community colleges will resist efforts to mandate the
BSN for professional practice.
Preparation of Advanced
Practice Nurses
Four Types of Advanced Practice Nurses
1. Clinical Nurses Specialist
2. Nurse Practitioner
3. Certified Nurse Midwife
4. Nurse Anesthetist
The Nurse Practitioner
Workforce
Number of Nurse Practitioners in 2009:
United States:
157,782
Iowa:
1,265 (0.8% of U.S. total NPs)
Total Nurse Practitioners per 100,000 Population,
2009
United States:
51
Iowa:
42
Preparation of Advanced
Practice Nurses
Current Requirements for Initial Licensure as an Advanced
Practice Nurse
 Master’s degree with a major in nursing
 Evidence of eligibility to take certification examination
 Evidence of passing national certification examination
offered by an approved organization (e.g., ANCC)
Proposal for Doctor of Nursing
Practice Degree
 In 2002 the American Association of Colleges of
Nursing (AACN) convened an 11-member “Task
Force on the Clinical Doctorate.”
 In October of 2004 the AACN endorsed and
published the Position Statement on the Practice
Doctorate in Nursing.
 In October 2006 the AACN member institutions
voted to change the current level of preparation for
advanced practice nursing from the master’s degree
to the Doctor of Nursing Practice [DNP]) by the
year 2015.
The Need for DNP Degree
 The changing demands of this nation's complex
healthcare environment require the highest level of
scientific knowledge and practice expertise to assure
quality patient outcomes.
 The rapid expansion of knowledge underlying practice;
increased complexity of patient care; national
concerns about the quality of care and patient safety;
shortages of nursing personnel which demands a
higher level of preparation for leaders who can design
and assess care; shortages of doctorally-prepared
nursing faculty; and increasing educational
expectations for the preparation of other members of
the healthcare team.
The Need for DNP Degree
 In a 2005 report titled Advancing the Nation's Health
Needs: NIH Research Training Programs, the
National Academy of Sciences called for nursing to
develop a non-research clinical doctorate to prepare
expert practitioners who can also serve as clinical
faculty.
 Nursing is moving in the direction of other health
professions in the transition to the DNP. Medicine
(MD), Dentistry (DDS), Pharmacy (PharmD),
Psychology (PsyD), Physical Therapy (DPT), and
Audiology (AudD) all offer practice doctorates.
Seven “Essentials” that Guide
DNP Programs
1.
2.
3.
4.
5.
6.
7.
8.
Science underpinning advanced practice
Leadership for quality improvement
Clinical scholarship for evidence-based practice
Information systems/technology for improvement of
health care
Health care policy for advocacy in health care
Interprofessional collaboration for improving care
outcomes
Clinical prevention and population health to improve
the nation’s health
Advanced nursing practice
Support for DNP Degree
American Association of Nurse Anesthetists
(AANA) Council on Accreditation will not accredit
new master’s programs for nurse anesthesia after
2015.
Mandates that all CRNA programs transition to the
practice doctorate (“Doctor of Nurse Anesthesia
Practice”) by 2022.
All new CRNA graduates must hold a practice
doctorate by 2025 to be eligible for certification.
Support for DNP Degree
The Nurse Practitioner Coalition Statement
Seven nurse practitioner organizations (AANP, ACNP,
AFPNP, NCGNP, NONPF, NPWH, NPNP) support the
DNP:
“the DNP degree more accurately reflects current
clinical competencies and includes preparation for
the changing healthcare system.”
Support for DNP Degree
National Organization of Nurse Practitioner
Faculties
Endorsed the DNP and developed competencies for
NP practice at the doctoral level.
National Association of Clinical Nurse Specialists
Neutral position on the DNP; has developed DNP level
competencies for CNS graduates.
American College of Nurse Midwives
Recognizes the DNP as an option for some midwifery
programs.
Challenges in Starting a DNP
Program
 Insufficient numbers and type of faculty
 Limited financial resources
 State and accreditation regulations
 Lack of faculty support
 Lack of interest by students (especially post-MSN
programs)
 Insufficient preceptors/mentors for students
About DNP Programs
 72% of schools with ARNP programs (388 schools)
are either offering (120) or planning (161) a DNP
program.
 62% of schools either offering or planning a DNP
program are planning to offer a post‐ baccalaureate
entry option.
 CCNE has accredited 55 DNP programs
 Many additional DNP programs are pursuing CCNE
accreditation
About DNP Programs
DNP programs are now available in at least 36 states
plus the District of Columbia. States with the most
programs (5 or more) include Florida, Minnesota, New
York, Pennsylvania, and Texas.
In Iowa
 The University of Iowa offers a post-BSN/postmaster’s DNP program.
 Allen College plans to open a post-master’s DNP
program in fall 2011.
 Clarke University has been approved to start a DNP
program in fall 2011.
DNP Questions
 How do schools of nursing transition their MSN
programs to DNP programs?
 What credentials do faculty need to teach in DNP
programs?
 Will moving to a DNP program reduce the number of
ARNPs in my school and state?
 Will employers prefer to hire DNP graduates over MSN
graduates?
 Will the increased cost of completing a DNP be offset
by higher salaries for those with the DNP?
 Can DNP graduates earn tenure in the faculty role?
DNP Questions
 Will health care systems have the personnel and time
to supervise students in additional clinical and
independent project activities?
 Will MSN-prepared ARNPs be grandfathered if the DNP
becomes the required degree for ARNP certification?
 How will other practitioners and the public view and
understand the DNP-prepared ARNP?
 Will patients be confused when the NP is called
“Doctor”?
 What new roles will DNP graduates play in a reformed
healthcare system?
 Will the DNP cause a ↓ in PhD program enrollments?
Questions and Comments