In Nursing Education AACN Shaping A Future Vision For Nursing Education and Call for Change is a struggle for upcoming days of nursing profession. AACN has adopted a new position which recognizes the Doctor of Nursing Practice degree as the highest level of preparation for clinical practice.
Call for Change: AACN Shaping A Future Vision For Nursing Education
The American Association of Colleges of Nursing (AACN) has entertained an ongoing dialogue over the past decade and taken a leadership role in moving toward a preferred future of nursing education. The dialogue began in response to changing global demographics, a health care system plagued with reports of large numbers of medical errors and system breakdowns, and drastic shortages of nurses and other health-care professionals.
The dialogue, including a broad representation of stakeholders internal and external to nursing, has focused on the knowledge, skills, and competencies needed by professional nurses to address the demands of an evolving global society and health-care system. New models of nursing education have emerged from this dialogue. This vision for nursing education does not necessarily represent the vision of the association as a whole.
Rather, this topic represents the vision of one individual who has been actively engaged in this ongoing dialogue within and outside nursing. Where conversations are ongoing and future education models are being explored, this is noted. Where the association has taken a formal position, this is noted as well. Due to political, market, and societal forces, there is no way to predict exactly what form future nursing education will take.
Regardless of its form, nursing education must respond to external forces and evolve if nursing is to remain a viable and important component of the health-care workforce able to make a significant impact on unmet health-care needs. To be successful, this evolution will require a true partnership between nursing education and practice .
Call for Change in Nursing Education
Although not the first indicator of the need to transform the health-care system, the report that first grabbed the public’s attention was issued in 1999 by the Institute of Medicine (IOM). To Err is Human: Building a Safer Health System, which extrapolated data from two previous studies, estimating that somewhere between 44,000 and 98,000 Americans die each year as a result of medical errors (IOM, 1999, p. 1). More recent estimates say that these numbers may be much higher (Leape & Berwick, 2005, p. 2385).
Even at the lower levels, these unnecessary deaths exceed the number of people who die from motor vehicle accidents, breast cancer, or AIDS. Total national costs of preventable adverse events (medical errors resulting in injury) were estimated to be between $17 billion and $29 billion of which health-care costs represented more than half (Johnson et al., 1992).
In addition, medication-related and other errors that do not result in actual harm are not only extremely costly but have a significant impact on the quality of care and health care outcomes. The IOM report focused on the fragmented nature of the health-care delivery system as being a major contributor to the high and inexcusable error rate. This fragmentation leads to a lack of continuity and multiple patient handoffs.
In addition to the growing concern about health-care outcomes, the United States is in the midst of a nursing shortage that is expected to intensify as baby boomers age and the need for health care grows. Dr. Peter Buerhaus and colleagues (2000) reported in the Journal of the American Medical Association that the United States will experience a 20 percent shortage in the number of nurses needed in our nation’s health-care system by the year 2020.
This translates into a shortage of more than 400,000 registered nurses nationwide. The fall 2004 survey of nursing programs conducted by AACN revealed that enrollment in entry-level baccalaureate nursing programs increased by 14.1 percent nationwide since fall 2003 (Berlin, Wilsey, & Bednash, 2005).
Still, this increase is not sufficient to meet the projected demand for nurses. According to Peter Buerhaus and colleagues (2003), enrollment in nursing programs would have to increase at least 40 percent annually to replace the nurses expected to leave the workforce through retirement.
Other recent landmark reports focus on the nursing shortage, the crisis in the health-care system and proposed strategies for addressing these critical issues. The IOM in two follow-up reports in 2001 and 2003 stressed that the health-care system as currently structured does not, as a whole, make the best use of its resources and called on all health-care organizations and professional groups to promote health care that is safe, effective, client-centered, timely, efficient, and equitable (IOM, 2001, p. 6).
The IOM Committee on the Health Professions Education Summit urged that all health professionals be educated to deliver patient-centered care as members of an interdisciplinary team, emphasizing evidence-based practice, quality improvement approaches, and informatics (IOM, 2003). The Joint Commission on Accreditation of Healthcare Organizations (JCAHO, 2002) has been called for transforming the workplace, aligning nursing education and clinical experience.
The Robert Wood Johnson Foundation (Kimball & O’Neill, 2002) has taken a broad look at the underlying factors driving the nursing shortage and urges the reinvention of nursing education and work environments to address and appeal to the needs and values of a new generation of nurses. It is evident…that leadership in nursing…is of supreme importance at this time.
Nursing has faced many critical situations in its long history, but probably none more critical than the situation it is now in, and none in which the possibilities, both of serious loss and of substantial advance, are greater. What the outcome will be depends in large measure on the kind of leadership the nursing profession can give in planning for the future and in solving stubborn and perplexing problems…if past experience is any criterion, little constructive action will be taken without intelligent and courageous leadership (Stewart, 1953, p. 326).
Isabel Maitland Stewart wrote those words more than 50 years ago in her petition for education reform in nursing. Perhaps the most staggering revelation is that despite all of progress nursing has made in recent decades as a profession, nursing remains at the same “critical” juncture that it was at the end of World War II.
Despite the promise of university-based education for professional nursing, the health-care system is in yet another nursing shortage with yet another call for “intelligent and creative leadership” requiring insight and innovation. Nursing as a profession must look beyond what currently exists and think beyond personal experience to what could be. The good news is that nursing can provide many of the answers to the predominant health care dilemmas of the future, including:
- The problems associated with normal human development, particularly aging
- Chronic illness management in all ages
- Health disparities associated with socioeconomic dislocations such as global migration, classism, and sexism
- Strategies for health promotion and disease prevention
Each of these prevailing health problems is suited to the nursing paradigm. Their amelioration is what nursing students are educated to do. The advancement of medical science and technology has changed the landscape of health and illness. Not only are people living much longer, they are living with chronic illnesses that would have been fatal 20 years ago.
This is true in adults and children, resulting in the need for providers who can manage the ongoing health needs of persons of all ages. The need for practitioners who focus on the promotion of health and wellness and the prevention of disease has emerged. Such a focus addresses escalating medical costs and improves the health of the nation and global community (AACN, 2003).
Although there is ample evidence for the need to produce many more nurses to meet the pressing health-care needs of society, this is not just a matter of increasing the volume of the nursing workforce. Nurses, particularly those working in hospitals, are dissatisfied with their work (41 percent), and an inordinate number, particularly young nurses, plan on leaving their job (30 percent) (Aiken et al., 2001).
Further, research by Linda Aiken and others also has shown that hospitals with a higher percentage of nurses with baccalaureate and higher degrees demonstrate lower mortality rates and lower failure to rescue rates (Aiken et al., 2003). One of the natural responses to the changes in health care, new technologies, and calls for a better educated workforce has been to expand current educational requirements.
Course requirements, clinical hours, and credit hours required for graduation from associate degree (ADN), baccalaureate (BSN), and master’s degree in nursing (MSN) programs have grown exponentially. The result has been an increase in expectations for each of these degrees far beyond expectations and requirements for equivalent degrees in many other disciplines.
Despite the growth in these requirements, graduates and employers still identify additional content and experiences needed to practice in today’s health-care environment, including business principles of health care, evidence-based practice, and emerging areas of science such as genomics and environmental mental health.
The Institute of Medicine, American Hospital Association , the Robert Wood Johnson Foundation, and other groups external to nursing have called on all the health professionals to change the way future health professionals are educated. New ways of educating health professionals, including inter-professional education and practice, and new practice models must be developed.
AACN Actions Shaping the Future of Nursing Education
In response to the calls for change within nursing education, AACN, over the past several years, has taken a leadership role in shaping the future of nursing education.
Recent AACN Actions Affecting Baccalaureate Nursing Education
In 2004, the AACN Board of Directors reaffirmed its position that baccalaureate education is the minimum education required for entry into professional nursing practice in today’s complex health-care environment. Despite articulation mechanisms between associate degree programs and baccalaureate or master’s degree programs in almost every state, only 16% of nurses educated in ADN or diploma programs continue their education beyond their entry-level degree (Spratley, Johnson, Sochalski, Fritz, & Spencer, 2001).
Therefore, the AACN Board also reaffirmed the need for strong articulation mechanisms between ADN and BSN and MSN programs. The board urged the nursing community to create opportunities and incentives for nurses to pursue higher degrees in nursing, citing the Department of Veterans Affairs (1998) as one outstanding example of an organization that has provided such incentives and opportunities.
Recent AACN Actions Affecting Master’s Nursing Education
In 2004, the AACN Board voted to accept the recommendations of a task force and to pilot a new professional nursing role at the master’s degree level (AACN, 2004a). This new role, the Clinical Nurse Leader sm (CNL), grew out of several years’ work by two task forces charged with examining the future needs of the health-care delivery system and potential education models. See section on the CNL for additional detail.
Recent AACN Actions Affecting Doctoral Education in Nursing
The AACN task force charged with revising the position statement on the Quality Indicators for Research-Focused Doctoral Programs in nursing recommended further examination of the history of, need for, and criteria for practice doctorate programs in nursing. In October 2004, the AACN membership passed the Position Statement on the Practice Doctorate in Nursing (AACN, 2004b).
This position statement sets the doctorate of nursing practice (DNP) as the highest level of preparation for clinical nursing practice. Nursing practice is broadly defined as “any nursing intervention that influences health care outcomes for individuals or populations, including the direct care of individual patients, management of care for individuals and populations, administration of nursing and health care organizations” (p. 3).
AACN member institutions also voted to move the current level of preparation necessary for advanced nursing practice roles from the master’s degree to the doctorate level by the year 2015. See the section on the DNP for additional detail. To facilitate the transition within nursing education to the practice doctorate by the target date of 2015, the AACN board created two task forces with representation from various nursing specialties and institutions.
The first task force was charged with creating an “Essentials” document for practice doctorates, which outlines the basic competencies that must be built into these educational programs. This document is similar in nature to the other Essentials documents originated by AACN for baccalaureate and master’s degree education.
The second task force, the roadmap task force, is focused on implementation of the new position statement and issues related to this transition, including moving existing Advanced Practice Nurse (APN) programs to the doctoral level and providing efficient bridge programs for master’s prepared nurses interested in pursuing a DNP degree.
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