Recent Trends in Baccalaureate-Prepared Registered Nurses in U.S. Acute Care Hospital Units, 2004–2013: A Longitudinal Study

Recent Trends in Baccalaureate-Prepared Registered Nurses in U.S. Acute Care Hospital Units, 2004–2013: A Longitudinal Study
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First published: 9 October 2017Full publication history
DOI: 10.1111/jnu.12347 View/save citation
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Purpose

To examine the trends in baccalaureate (bachelor of science in nursing)–prepared registered nurses (BSN RNs) in U.S. acute care hospital units and to project the growth in the number of BSN RNs by 2020.
Design

This is a longitudinal study using the Registered Nurse Education Indicators data (2004–2013) from the National Database of Nursing Quality Indicators.
Methods

The level of BSN RNs in each unit was operationalized as the proportion of nurses holding a baccalaureate degree or higher among all the nurses in a unit. Our sample included 12,194 unit-years from 2,126 units of six cohorts in 377 U.S. acute care hospitals. A hierarchical linear regression model was used to examine the trends in BSN RNs and to project future growth in the number of BSN RNs when controlling for hospital and unit characteristics and considering repeated measures in units over time and clustering of units within hospitals.
Results

The proportion of BSN RNs in U.S. acute care hospital units increased from 44% in 2004 to 57% in 2013 (a 30% increase); when combining all cohorts, this rate increased from 44% in 2009 to 51% in 2013. On average, the proportion of BSN RNs in a unit increased by 1.3% annually before 2010 and by 1.9% each year from 2010 on. The percentage of units having at least 80% of their nurses with a baccalaureate degree or higher increased from 3% in 2009 to 7% in 2013. Based on the current trends, 64% of the nurses working in a hospital unit will have a baccalaureate degree by 2020, and 22% of the units will reach the 80% goal by 2020.
Conclusions

There was a significant increase in the proportion of BSN RNs in U.S. acute care hospital units over the past decade, particularly after 2010. However, given the current trends, it is unlikely that the goal of 80% nurses with a baccalaureate degree will be achieved by 2020.
Clinical Relevance

The U.S. nursing workforce is under educational transformation in order to meet the increasing healthcare needs. To help accelerate this transformation, further advocacy, commitment, and investment are needed from all healthcare stakeholders (e.g., policymakers, executives and managers of healthcare facilities, nursing schools, etc.).

Nurses compose the largest healthcare workforce in the United States. There were 2.75 million registered nurses (RNs) working in healthcare settings in 2014, of whom 61% (or over 1.6 million) worked in hospitals (Bureau of Labor Statistics, 2015). Given the dramatic changes within the U.S. healthcare system, such as the aging of the baby boomers and the expansion of health insurance coverage (Department of Health and Human Services, 2015; Garfield, Damico, Cox, Claxton, & Levitt, 2016), nurses will likely have an even greater role in improving quality of care and patient outcomes (National Academies of Sciences, Engineering, and Medicine, 2015). Consequently, it is critical to build a competent nursing workforce to meet the increasing and complex healthcare needs in the United States.

One strategy for preparing a competent nursing workforce is to advance nurse education, particularly by promoting the number of baccalaureate (bachelor of science in nursing)–prepared registered nurses (BSN RNs). Increasing evidence has demonstrated that higher nurse education is associated with better quality of care and patient outcomes (Aiken et al., 2014; McHugh & Ma, 2013). In a seminal study of 168 U.S. general acute care hospitals with 232,342 surgical patients, the researchers found that hospitals with higher proportions of nurses holding a baccalaureate degree (BSN) or higher had significantly lower surgical patient mortality and failure-to-rescue (Aiken, Clarke, Cheung, Sloane, & Silber, 2003). This study was replicated in the United States with more recent data of 665 hospitals and 1.3 million patients (Aiken et al., 2011) and internationally with similar results (Aiken et al.,2014; Ridley, 2008; Van den Heede et al., 2009). The linkage between higher proportion of BSN RNs and lower mortality rates has been further supported by findings from a panel study of 134 hospitals over time (1999–2006; Kutney-Lee, Sloane, & Aiken, 2013). Further complementing the results of large-scale studies, a detailed study of the dose response of care by BSN RNs in a single large U.S. hospital showed that better patient outcomes were associated with more hours of patient care by BSN RNs; and the hospital could financially benefit from hiring more BSN RNs (Yakusheva, Lindrooth, & Weiss, 2014).

Acting on the basis of growing evidence of a linkage between more BSN RNs and better patient outcomes, the Institute of Medicine (IOM) recommended in its milestone report, The Future of Nursing: Leading Change, Advancing Health, that 80% of U.S. RNs should have at least a baccalaureate degree in nursing by 2020 (80/20 goal; IOM, 2011). This recommendation was immediately supported, for the first time in history, by the Tri-Council, an alliance between the main nursing organizations in the United States, including the American Association of Colleges of Nursing, the American Nurses Association, the American Organization of Nurse Executives, and the National League for Nursing (Tri-Council of Nursing, n.d.). Since the report was released, a variety of initiatives (e.g., The Future of Nursing: Campaign for Action) have been carried out to achieve this 80/20 goal, and some changes have been noted. A 2014 survey of nursing schools by the American Association of Colleges of Nursing (AACN) indicated a 4.2% enrollment growth in entry-level baccalaureate programs and a 10.4% increase in “RN-to-BSN” programs for RNs with associate degrees or diplomas from 2013–2014 (AACN, 2015).

While there is mounting evidence demonstrating the significance of promoting baccalaureate education for nurses, empirical evidence illustrating the recent trends in BSN RNs in clinical settings over time is rare. Such evidence is critical for a better understanding of the ongoing educational transformation of the nursing workforce. To address the gap, the purpose of this study was twofold: (a) to illustrate the recent trends in BSN RNs using unit-level data (2004–2013) of U.S. acute care hospitals from a national database; and (b) to estimate whether the 80/20 goal is achievable based upon the current trend and, if not, how far away from it we remain.
Methods
Data and Sample

This was a longitudinal study using the Registered Nurse Education Indicators data (2004–2013) from the National Database of Nursing Quality Indicators (NDNQI). The NDNQI was founded in 1998 by the American Nursing Association with the mission of aiding nurses in efforts to improve care quality and patient safety and has been owned by Press Ganey, Inc. since 2014 (Montalvo, 2007). The NDNQI is a national nursing quality measurement data repository in the United States that enables researchers to compare the quality of hospital nursing and nursing-sensitive patient outcomes at the unit level. Over 2,000 hospitals nationwide were submitting nursing and patient outcomes data to the NDNQI by 2014.

One of the NDNQI's endeavors is to collect data on nurses’ education (RN education indicator) at the unit level from NDNQI member hospitals. RN education data in each eligible unit were collected by trained nursing staff in NDNQI member hospitals and reported quarterly to the NDNQI. Submitted information includes the number of eligible RNs on a unit and the number of RNs at each educational level (i.e., diploma, associate degree, bachelor's degree, master's degree, and doctorate degree). For nurses with multiple degrees, only the highest nursing degree is counted. RNs (full-time, part-time, and per-diem RNs) are eligible for this report if they were unit based, with direct patient care responsibilities for at least 50% of their time, and listed on the staffing roster during the reporting quarter. RNs who were on temporary vocational or medical leave were included, too. However, RNs were excluded if they were contract or agency nurses or not assigned to a specific unit.

In this study, the unit of analysis was the unit-year. We annualized the proportion of BSN RNs across quarters in each year from 2004 to 2013 for each unit. To be included in this study, units must have at least three quarters of RN education data in each year; units must also have at least 5 consecutive years of RN education data to ensure a sufficient amount of data for modeling time trends and projections. Units were categorized into different cohorts based on the first year a unit submitted data to the NDNQI. For example, cohort 2004 included units that submitted three or four quarters of data each year since 2004 and until 2013. In total, there were six unit cohorts (cohorts 04, 05, 06, 07, 08, and 09).

An advantage of the NDNQI database is that units are consistently and systematically classified into a certain type based on the patient population, type of care provided, and patient acuity level. This enables comparative analysis of units across hospitals. For this study, we included five adult unit types: critical care, step-down, medical, surgical, and medical-surgical combined. These units represent the vast majority of adult units reporting data to the NDNQI. They also are the most common units within acute care hospitals. The final analytic dataset consisted of 12,194 unit-years from 2,126 units in 377 acute care hospitals.
Variables

Unit BSN RNs. The level of BSN RNs in each unit was operationalized as the proportion of RNs holding a baccalaureate degree or higher among all the RNs in a unit. A time variable (named t) was generated to reflect the numbers of years from the baseline year, which varied by cohorts. A dummy variable named flag was also created to indicate whether a year was before or after 2010 (i.e., flag = 0 before 2010, flag = 1 from 2010 on). This variable was used to compare time trends before and after the release of The Future of Nursing report.
Covariates

Hospital- and unit-level characteristics at baseline were included as covariates. Hospital-level covariates were ownership, bed size, teaching status, Magnet status, and geographic location. Hospital ownership was categorized as nonprofit, profit, or government-owned. Hospital size was measured by the number of staffed beds and grouped into two categories (small, ≤299 beds; large, ≥300 beds). Teaching status was classified as teaching and nonteaching. Hospitals were also identified based on their Magnet status. Given the geographic locations, hospitals were classified as those located in the metropolitan area versus those out of metropolitan areas. A unit-level variable indicating unit type was included, too.
Analysis

Baseline characteristics (both hospital- and unit-level) were described first for each cohort. Levels of BSN RNs were then described for each cohort by unit type. BSN RN levels were plotted to show visually how the proportion of BSN RNs changed over time. Given the complex data structure that units clustered within hospitals and measures were repeated within units over time, a three-level hierarchical linear regression model was employed to examine whether there was a difference in the trends of growth in the number of BSN RNs before and after the release of the IOM's Future of Nursing report, when controlling for baseline hospital and unit characteristics. Random intercepts at both hospital and unit level were included to account for the cluster of units within hospitals and repeated measures within units. Our preliminary analysis suggested no significant differences in the overall trends by unit cohort. Therefore, regression models were conducted across all cohorts. Finally, based on the estimates of current trends in the growth in the number of BSN RNs from the above model, we projected the level of BSN RNs by 2020 and compared it with the recommended 80% goal.
Results

Table 1 describes the hospital- and unit-level characteristics at baseline. Of the 2,126 units, there were 547 (25.7%) critical care units, 299 (14.1%) step-down units, 426 (20.0%) medical units, 335 (15.8%) surgical units, and 519 (24.4%) medical-surgical combined units. These units were from 377 acute care hospitals, of which the majority were nonprofit (88.3%) and located in metropolitan areas (87.0%), 47.1% were teaching hospitals, 29.2% had at least 300 beds, and 7.7% were Magnet hospitals. There were some differences in hospital characteristics at baseline across cohort, such as hospital size, teaching status, and Magnet status.
Table 1. Hospital Characteristics and Unit Types at Baseline
Cohort
2004 2005 2006 2007 2008 2009 Overall

Note. A cohort was defined based on the first year that units submitted nurse education data to the National Database of Nursing Quality Indicators (NDNQI). For example, cohort 2004 includes units that submitted nurse education data to the NDNQI since 2004.

Hospital characteristics
Ownership
Nonprofit 59 (88.1%) 59 (91.9%) 67 (93.1%) 47 (97.9%) 45 (86.2%) 56 (88.3%) 333 (88.3%)
Profit 3 (4.5%) 0 3 (4.2%) 0 4 (7.6%) 5 (7.7%) 15 (4.0%)
Government-owned 5 (7.5%) 13 (18.1%) 2 (2.8%) 1 (2.1%) 4 (7.6%) 4 (6.2%) 29 (7.7%)
Bed size (≥ 300 beds) 27 (40.3%) 21 (29.2%) 21 (29.2%) 8 (16.8%) 14 (26.4%) 19 (29.2%) 110 (29.2%)
Teaching hospitals 34 (50.8%) 31 (43.1%) 35 (48.6%) 17 (35.4%) 22 (41.5%) 23 (35.4%) 162 (43.0%)
Location (metro area) 61 (91.1%) 63 (87.5%) 63 (87.5%) 42 (87.5%) 46 (86.8%) 53 (81.5%) 328 (87.0%)
Magnet hospitals 13 (19.4%) 3 (4.2%) 3 (4.2%) 2 (4.2%) 3 (5.7%) 5 (7.8%) 346 (91.8%)
Unit characteristics
Unit types
Critical care 113 (30.6%) 93 (25.4%) 115 (27.3%) 59 (22.5%) 63 (22.4%) 104 (24.4%) 547 (25.7%)
Step-down 52 (14.1%) 48 (13.1%) 54 (12.8%) 34 (13.0%) 40 (14.2%) 71 (16.7%) 299 (14.1%)
Medical 65 (17.6%) 79 (21.6%) 89 (21.1%) 57 (21.8%) 54 (19.22%) 82 (19.3%) 426 (20.0%)
Surgical 55 (14.9%) 58 (15.9%) 62 (14.7%) 42 (16.0%) 55 (19.6%) 63 (14.8%) 335 (15.8%)
Medical-surgical combined 84 (22.8%) 88 (24.0%) 102 (24.2%) 70 (26.7%) 69 (24.6%) 106 (24.9%) 519 (24.4%)

Table 2 presents the unit percentage of BSN RNs at the baseline year for each cohort by unit type. Overall, the percentage of BSN RNs at baseline slightly varied by cohort from 36% (cohort 2005) to 44% (cohort 2004). In each cohort, the percentage of BSN RNs varied by unit types, and critical care units had the highest levels of RNs holding bachelor's degrees or above at baseline. For example, in cohort 2004, the percentage of RNs holding a baccalaureate degree varied from 49% in critical care units to 36% in medical-surgical combined units.
Table 2. Unit Levels of BSN RNs (% of BSN RNs) at Baseline by Unit Types
Cohort, mean % (SD)
2004 2005 2006 2007 2008 2009

Note. BSN = bachelor of science in nursing; RN = registered nurse.

Overall (all units) 44.2 (19.4) 36.0 (17.9) 40.4 (17.5) 40.2 (19.5) 41.6 (19.8) 42.7 (18.1)
Critical care units 49.3 (19.3) 44.4 (16.5) 46.5 (17.4) 47.0 (18.5) 50.2 (18.5) 51.8 (17.2)
Step-down units 45.9 (21.0) 37.5 (20.7) 40.2 (17.4) 41.3 (17.5) 36.5 (18.5) 40.3 (18.0)
Medical units 46.5 (18.3) 35.8 (17.4) 37.6 (16.8) 35.5 (17.0) 39.5 (20.6) 40.9 (16.1)
Surgical units 42.9 (19.2) 33.5 17.6) 41.1 (17.3) 37.9 (21.1) 37.3 (18.9) 41.2 (16.5)
Medical-surgical combined units 35.5 (16.8) 28.3 (14.3) 35.8 (17.6) 39.2 (21.0) 41.8 (19.6) 37.8 (18.8)

Figure 1 (also shown in Table S1) illustrates the trends in BSN RNs at the unit level in each cohort from 2004 to 2013. The percentages of BSN RNs increased significantly over time in all cohorts. For example, for units in cohort 2004, the percentage of BSN RNs increased by approximately 30% from 44% in 2004 to 57% in 2013. Despite the differences in percentages of BSN RNs at the baseline years, our preliminary analyses (see Figure 1) indicated that there were no significant cohort differences in the trends in BSN RNs.
Figure 1.
Figure 1.

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Unit percentage of registered nurses (RNs) holding a bachelor's degree or above. BSN = bachelor of science in nursing.

We also analyzed the proportion of units with ≥50% and ≥80% BSN RNs (Table S2). Overall, the percentage of units with ≥50% nurses with a BSN degree increased from 35% in 2009 to 52% in 2013 (a 47% increase); the percentage of units with ≥80% nurses with a BSN degree increased from 3% in 2009 to 7% in 2013 (a 73% increase). Although critical care units had the highest proportion of units with ≥50% nurses with a BSN degree in 2009, it had the lowest increase rate from 2009 to 2013. Medical-surgical combined units had the highest rate of increase (150%) in the proportion of units with ≥80% BSN RNs, from 2% in 2009 to 5% in 2013; and surgical units had the lowest rate of increase (55%) in the proportion of units with ≥80% BSN RNs, from 3.28% in 2009 to 5% in 2013.

Table 3 shows estimates of the differences in trends in BSN RNs before and after 2010 when controlling for hospital and unit characteristics at baseline. There was a significant difference in trends in BSN RNs before and after 2010 as indicated by the interaction term (coefficient = 0.63, p = .000). On average, the proportion of BSN RNs increased by 1.3% annually in the years before 2010; and it increased by 1.9% each year after 2010. In other words, the average increasing rate after 2010 was 1.5 times the rate in years before 2010.
Table 3. Trends in Growth in the Number of BSN RNs Before and After 2010
Coefficient p 95% confidence interval

Note. The interaction is between the numbers of years from baseline year (each cohort had different baseline years) and the variable indicating whether a year is before 2010 or not (variable = 0 if it is before 2010, and variable = 1 from 2010 on); therefore, the coefficient for the annual increase in the proportion of BSN RNs for years from 2010 on is 1.90 (1.27 + 0.63). BSN = bachelor of science in nursing; RN = registered nurse.

Years from baseline year (t) 1.27 .000 1.13 to 1.40
Years from 2010 when current year ≥2010 (interaction term) 0.63 .000 0.40 to 0.86
Cohort 2004 (reference group)
Cohort 2005 −1.23 .334 −3.72 to 1.26
Cohort 2006 0.40 .755 −2.10 to 2.89
Cohort 2007 1.00 .472 −1.73 to 3.73
Cohort 2008 2.98 .032 0.26 to 5.69
Cohort 2009 3.69 .008 0.97 to 6.40
Critical care (reference group)
Step-down −7.63 .000 −8.92 to −6.34
Medical −11.19 .000 −12.37 to −10.02
Surgical −12.17 .000 −13.43 to −10.92
Medical-surgical combined −10.98 .000 −12.13 to −9.82
Non-Magnet (reference group)
Magnet 1.63 .236 −1.07 to 4.32
Nonprofit
Profit −3.59 .334 −10.88 to 3.70
Government-owned −1.59 .561 −6.96 to 3.78
Small hospital (≤299 beds)
Large hospital (>300 beds) 1.80 .227 −1.12 to 4.72
Nonteaching hospital
Teaching hospital 7.40 .000 4.40 to 10.39
Nonmetro area
Metro area 10.61 .000 6.06 to 15.15

Table 4 presents the estimates of proportion of BSN RNs in the future based upon the current trends, both overall (all units) and by unit types. By 2020 there will be a projected 64% RNs that provide direct patient care holding at least a BSN degree; critical care units would have the highest proportion of BSN RNs (72%), whereas medical-surgical combined would have the lowest (60%). The 80% goal will not be reached until at least 2029 (81%); critical care units will likely be the first to reach the 80% goal by 2025, and by 2031 units of all types will achieve the 80% goal. In general, 22% of the units in this study will reach the 80% goal by 2020 and 57% of the units will reach the goal by 2023 (Table S3). Table S3 also displays the predicted proportion of units with ≥50% and ≥80% nurses with a BSN degree by 2020, 2025, and 2030.
Table 4. Projections of Proportion of BSN RNs
% of BSN RNs
By 2020 By 2025 By 2026 By 2027 By 2028 By 2029 By 2030

Note. BSN = bachelor of science in nursing; RN = registered nurse.

Overall 64.40 73.88 75.78 77.67 79.57 81.47 83.36
Critical care units 71.64 81.12 83.02 84.91 86.81 88.71 90.60
Step-down units 63.63 73.11 75.01 76.91 78.80 80.70 82.60
Medical units 63.78 73.26 75.16 77.05 78.95 80.85 82.74
Surgical units 61.00 70.48 72.38 74.27 76.17 78.07 79.96
Medical-surgical combined units 59.93 69.41 71.31 73.21 75.10 77.00 78.90
Discussion

In this study, we examined the recent trends in BSN RNs in U.S. acute care hospital units between 2004 and 2013 using data from a national nursing quality database. Our findings provide empirical evidence illustrating the ongoing educational transformation of the nursing workforce, particularly in hospital care settings.

Our study shows that there is a consistent increase in the proportion of BSN RNs in acute care hospital units, and this increase appears to have begun several years before the 2010 IOM report of The Future of Nursing was released. In our study, for example, we found that in cohort 2004 approximately 44% of the nurses providing direct patient care on a unit had BSN degrees in 2004, and this number reached 57% in 2013; across cohorts, 51% of RNs held a baccalaureate degree or higher in 2013. Our finding is similar to that of the National Sample Survey of Registered Nurses (NSSRN). The NSSRN is a national survey conducted by the Health Resources and Services Administration (HRSA) between 1977 and 2008 and aimed at examining the characteristics of U.S. registered nurses. Data from the NSSRN indicated that approximately 45% and 50% of the RNs held a bachelor's degree or higher in 2004 and 2008, respectively (HRSA, n.d.). Data from the National Nursing Workforce Survey showed that there were about 61% RNs holding a baccalaureate or higher degree (Budden, Zhong, Moulton, & Cimiotti, 2013). Using data from the Integrated Post-Secondary Education System, Buerhaus, Auerbach, and Staiger (2016) estimated that the proportion of nursing graduates with baccalaureate degrees increased from 45% in 2002 to 53% in 2012; in 2011, there were more BSN graduates than associate degree in nursing (ADN) graduates for the first time. Despite slight differences in the estimates of proportion of BSN RNs, which are mainly due to the different sampling strategies employed in each study, a common theme of a consistent and significant increase in the proportion of BSN RNs is conclusive across studies.

Our findings also suggest that the increase in the proportion of BSN RNs in acute care hospital units accelerated from 2010 on. In our sample, we found that on average the proportion of BSN RNs on a unit increased by 1.3% annually before 2010 and 1.9% annually in 2010 and after. In 2010, the IOM published the milestone report of The Future of Nursing. Although we cannot claim a causal relation between the publication of this report and the accelerated increase in the number of BSN RNs, our finding does suggest that the publication of The Future of Nursing report may have contributed to this change. This report has drawn extensive media coverage that raised national attention to improving nurse education nationwide and resulted in various initiatives nationwide for promoting nurse education. For example, shortly after the report was published, the American Association of Retired Persons and the Robert Wood Johnson Foundation jointly initiated the Future of Nursing: Campaign for Action. One of its aims is to promote more efficient articulation between associate degree and baccalaureate nursing programs and help state action coalitions develop local and regional strategies to increase the number of nurses with BSNs (Campaign for Action, n.d.). Another example is the Magnet Designation Program, which recognizes healthcare organizations for high-quality patient care, excellent nursing practice, and innovations in professional nursing practices. It now requires hospital applicants to provide evidence documenting progress or effort toward achieving a nursing workforce of 80% BSNs. In addition, hospitals also show increasing and strong preference in hiring BSN RNs (AACN, 2016; Bates, Chu, & Spetz, 2016), and nursing schools have demonstrated their commitment by implementing new models to educate more BSN RNs (Close & Orlowski 2015; Gaines & Spencer 2013). These changes well demonstrate the influence of national initiatives on nursing workforce development.

Despite the consistent and significant increase in the proportion of BSN RNs, our findings suggest that the goal of 80% BSN RNs by 2020 is unlikely to be achieved in acute care hospitals. Based on the current trend, our estimates indicate that it will be 2029 that 80% of hospital RNs will be BSN prepared, and that nurses on critical care units will reach this 80% goal first (by 2025), compared to other unit types. There are many reasons that challenge the achievement of this 80/20 national goal. One of them is the shortage of faculty and other resource constraints of nursing schools to enroll more BSN students. According to the AACN, there was a nurse faculty vacancy rate of 8.3% nationwide in 2013; 79,659 qualified applicants were turned away from nursing baccalaureate and graduate programs in 2012; on average, doctoral-prepared and master's degree–prepared nurse faculty holding title of “professor” were 61 and 57 years old, respectively (AACN, n.d.). The small difference in wage premium of BSN RNs and ADN or Diploma RNs also discourage AND or Diploma RNs from pursuing a baccalaureate degree (Spetz & Bates, 2013). In addition, some hospital executives and administrators are reluctant to invest more money and resources to hire BSN RNs. However, researchers have estimated that, in addition to better quality of care and patient outcomes, increasing BSN RNs can be cost saving by improving patient outcomes such as reducing readmissions (Yakusheva et al., 2014).

Findings from our study have several implications for accelerating the progress of achieving the goal of 80% of RNs holding a baccalaureate degree. First, further efforts are needed to promote national recognition of the importance of advancing nursing education in health care, as well as policy and financial support from federal, state, and local government. Both findings from our study and previous research have suggested that such support can have a significant impact on the transformation of the nursing workforce (Aiken, Cheung, & Olds, 2009). Second, administrators in hospitals and other healthcare facilities should commit to more investment in hiring BSN RNs or support employed AND or Diploma RNs to obtain a baccalaureate degree. Researchers have shown that RN-to-BSN is the fastest growth pathway for RNs to obtain a baccalaureate degree (e.g., a 10% increase from 2013 to 2014) (AACN, 2015). It was also found that in hospitals that provided tuition and other benefits (e.g., more flexibility in scheduling) or value and respect higher nursing education, RNs were more likely to enroll in RN-to-BSN programs (Spetz & Bates, 2013). Last but not least, researchers need to provide more evidence demonstrating the business case of having more BSN RNs providing care to patients.

Our study has some limitations. Although the NDNQI collects data from a large sample of hospitals nationwide, participation of hospitals in NDNQI data submission is voluntary. Therefore, hospitals with certain characteristics may be overrepresented or underrepresented. Specifically, there are a higher proportion of large (>300 beds) and not-for-profit hospitals in our sample, when compared to 2011 American Hospital Association data (Choi, Boyle, & Dunton, 2014). In addition, only data from NDNQI-affiliated hospitals were used; thus, one should be cautious when generalizing the results from this study to other hospitals or other healthcare settings (e.g., nursing homes, rehabilitation centers, and home care agencies). Our projections of the proportion of BSN RNs in acute care hospital units were based on the current trends; thus, it is conservative.
Conclusions

To our knowledge, this is the first longitudinal study using unit-level data from hospitals nationwide to examine the trends in BSN RNs over a decade (2004–2013). Our findings provide unique insights into the current ongoing educational transformation of the nursing workforce. Despite the significant increase in BSN RNs, results from our study suggest that further efforts and commitment from healthcare stakeholders (e.g., policymakers, executives and managers of healthcare facilities, nursing schools, etc.) are needed to advance nursing education and promote the use of BSN RNs, which in turn will result in superior quality of care and better patient outcomes as researchers have suggested.
Acknowledgments

We would like to thank Dr. Nancy Dunton and Dr. Emily Cramer for their support to this project, and Press Ganey, Inc. for providing access to NDNQI data.

This research reflects the views of the authors and should not be construed to represent the views or policies of the U.S. Food and Drug Administration. Dr. Lili Garrard completed this work as a statistical analyst at the National Database of Nursing Quality Indicators.
Clinical Resources

American Association of Colleges of Nursing. Advancing healthcare transformation: A new era for academic nursing. http://www.aacn.nche.edu/AACN-Manatt-Report.pdf
Campaign for Action. The future of nursing: Campaign for action. http://campaignforaction.org/
Institute of Medicine. The future of nursing: Leading change, advancing health. http://www.nationalacademies.org/hmd/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health.aspx

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Volume 50, Issue 1
January 2018
Pages 83–91
PROFESSION AND SOCIETY

Challenges Facing Nursing Students Today by Michele Wojciechowski

Challenges Facing Nursing Students Today

Dec 12, 2017 | Blog, Magazine, Nursing Mentorship, Nursing Students

There have always been challenges facing nursing students. What are the biggest ones today, and how can students deal with and overcome them? Some experts weigh in.

Frederick Richardson, a BSN student and the Breakthrough to Nursing director for the National Student Nurses’ Association, had no doubt about how much of his time would be taken up when he began attending nursing school. Yet, he says, this seems to be one of the toughest aspects of attending nursing school that students struggle with.

“One of the biggest issues that nursing students face is time—making time for everything,” explains Richardson. “Nursing school is very demanding, and when you add in the coursework, reading for homework, and the clinical work, there usually isn’t time for anything else.”

Richardson says that he was fortunate enough to learn about this before choosing to attend nursing school. His older brother had attended nursing school, and Richardson saw firsthand how often he didn’t see his brother during that time. “He would be at the library studying, at class, or at clinicals,” recalls Richardson. “When I’d see him, it would be late at night. And he would be out of the door first thing in the morning. At the time, I recognized that when I would get to nursing school, I would probably have a similar schedule, and sure enough, it’s been exactly the same way.”

To overcome this, Richardson says that students need to have perspective and be realistic regarding what they can accomplish in their lives while attending such vigorous programs. “Our schedules can get really hectic. But I think that when you get into nursing school, you have to recognize that you’re going to devote the majority of your time to your nursing program. A lot of students don’t realize that,” he says.

Students need to set their priorities straight and decide how they are going to organize their time. Richardson, for example, says that he had to learn how to plan his time, organize his life and tasks on a calendar, and then follow that calendar every single day. From his perspective, quite a lot of students expect to attend nursing school and still have an active social life and do everything they did before, like watch all their favorite television shows.

“I think that the trouble students run into is they believe they can have everything—do well in nursing school, have an active social life, et cetera. If they go in with that kind of view, I don’t think they’re going to survive nursing school,” says Richardson. “They’re going to have to sacrifice a lot of that time, but once you get into it, it gets a bit easier.”

Martha A. Dawson, DNP, MSN, FACHE, assistant professor and coordinator of Nursing and Health Systems Administration at the University of Alabama at Birmingham School of Nursing, as well as the current historian for the National Black Nurses Association, agrees that having enough time can be an issue for nursing students. Traditional nursing students still face challenges that relate to study time, finances, and part-time work. In addition to the challenges of traditional students, however, second degree nursing students, such as those in a BSN to MSN bridge or other accelerated degree program, may also have immediate family obligations, explains Dawson. For instance, some may be primary caregivers for older parents. “Many students in these new and emerging programs are older, and these added life demands can lead to both high stress and exhaustion,” she adds.

Money, Money, Money

Richardson and Dawson agree that financial issues can also be a big challenge for nursing students. Dawson says that with the varying nursing programs and the older student population in them, these students may have greater financial obligations besides school, like a mortgage. “The current economic climate is making it more difficult for students to gain access to scholarships, trainee grants, and other forms of funding without going further into debt,” says Dawson.

In addition to taking out loans to attend nursing school, Richardson says that there are a number of scholarships available for students. Believe it or not, though, not a lot of students are applying for them. “There are a good number of scholarships available,” says Richardson. “After speaking with some people who have scholarships or who fund scholarships for students, I’ve discovered that they’re not getting a lot of applications. One reason is because of the time. A lot of students don’t know that the scholarships exist, and a lot who know they exist feel like they don’t have the time to fill out the applications because of the high demand of nursing school.”

The reality, Richardson says, is that studying takes up so much of the students’ days that many don’t think they could take the time to do what some scholarships may require in their applications—like get a letter of recommendation, write three essays, get transcripts, and the like.

Recently, Richardson had a heart-to-heart talk with a student who was frustrated because of going to school, clinicals, and a part-time job. “I said, ‘If you took about three hours applying for a scholarship, you would get more money to help you out with your school fees,’” says Richardson. He continued to explain to the student that he was working twice as hard and putting in twice as many hours at his part-time job to make the same amount of money that he could get if he applied for a scholarship—which would ultimately free up more of his time. “It would help the student more in the long run,” says Richardson.

Family Support

Along with not getting enough financial support, some nursing students don’t have as much family support, says Rebecca Harris-Smith, EdD, MSN, BA, dean of Nursing and Allied Health at South Louisiana Community College. “Nursing classrooms across the nation are filled with an intergenerational, multicultural group of students that range from millennials to baby boomers,” explains Harris-Smith. “This nontraditional classroom of students has many that are parents who frequently do not have siblings, parents, or other relatives to assist them with child care. The expense of child care, transportation, and after-hours coverage often impacts the nursing student’s classroom, clinical, and study time.”

Richardson says that family support and encouragement is often needed, but not every student has it. “I noticed immediately that I needed a lot of support,” says Richardson.

Communication

“In my personal experience, soft skills as they relate to interpersonal people skills have become an issue for nursing students. The ability to communicate both verbally and in writing appears to be a challenge,” says Harris-Smith. She says that because Gen Xers and millennials have grown up with a lot of technology, they have spent a lot of their early years communicating that way.

“Basic socialization has changed in that the younger generations would prefer to text over having a verbal conversation. The lack of appropriate communication skills has an impact on the students’ ability to work collaboratively with physicians, fellow nurses, and other members of the health care team,” explains Harris-Smith.

“Effective communication is essential due to the intra- and interprofessional team collaboration essential in the health care arena,” Harris-Smith explains. “Additionally, nursing students must learn flexibility, professionalism, and a strong work ethic—which are essential to the development of the new nurse graduate. Being able to adapt to an ever-changing environment is important as health care facilities have staffing issues often requiring nurses to work beyond their shifts.”

Challenges for Minority Students

Although the challenges for nursing students are often the same for students of color and those who aren’t, “students from underrepresented groups in the nursing profession and in society . . . have them on a much larger scale,” says Dawson. “There are barriers and biases that these students experience such as academic skills, perceived perceptions about their abilities, lack of faculty role models, limited peer support, and major financial issues that ‘majority’ students do not have to deal with on a daily basis. Many minority students also struggle with the very basics of housing and food.”

An additional burden that minority students face, says Harris-Smith, is that of access and equity in education. “A selective admission process is used by schools of nursing across the nation, and this very process can serve as a barrier for students of color. Academic profiling of students ensures admission of the most academically prepared students that rank highest among their peers, but students from underrepresented populations are often the first-generation college students that struggle with the issues of being the first in the family to attend college. This situation places a heavy burden on the student because s/he may be dealing with the pressure of being the ‘savior’ for the family. These students are generally not savvy enough to apply for multiple college programs, have difficulty completing financial aid forms, and generally come to college with limited resources,” says Harris-Smith.

“Nursing programs tend to address diversity in their mission statements but fail to explain how this is accomplished. Merely placing the statement in the mission statement does not explain how the school of nursing addresses the issue. To ensure transparency, each school of nursing could better address this issue by providing information on the way in which this mission is accomplished,” says Harris-Smith. For example, she says, schools could use a statement that’s more explanatory: This school of nursing addresses diversity via academic profiling of students but is careful to admit a diverse student body that resembles the demographics of the community in which we live.

“There is a need for schools of nursing to restructure their admission process to address the lack of the underrepresented students in attendance at their colleges and universities,” Harris-Smith adds.

Richardson says that’s why he is a part of the Breakthrough to Nursing committee because its goal is to increase diversity in the nursing profession. Another challenge he’s seen is that some minority students don’t last in nursing school because they have different ways of learning. “Culturally, students from different backgrounds learn differently. I’m a kinesthetic learner. If you show me how to start an IV, I will know how to start an IV more efficiently than reading three chapters about how to start an IV,” Richardson explains. “A lot of nursing school is geared toward your textbook. But a lot of students are visual, auditory, and kinesthetic learners.”

He says that there are also students from various cultural backgrounds who don’t know how to study. “For students who come from the other side of the world to America to learn, their views are different from yours, and when you have a different perspective, you’re able to become more aware. You’re able to see a different view. It actually makes us stronger and allows us to become smarter to look at the way that other people do things,” suggests Richardson.

“With diversity, we need to recognize and communicate to understand what the other person’s thinking is and allow them to realize that though their culture is different, it’s not a bad thing,” says Richardson. “It’s just a different view and perspective for them.”

Michele Wojciechowski is an award-winning writer and author of the humor book Next Time I Move, They’ll Carry Me Out in a Box.

What #MeToo means for nurses

What #MeToo means for nurses
February 2018 Vol. 13 No. 2
Take action; be the change.

Will the worldwide response to the recent disclosures of sexual assault and harassment cases in entertainment, music, sports, and politics shed light on related issues in healthcare?

The #MeToo movement has taken the world by storm, and many say it’s been a long time coming. The New York Times revelation last fall seemed shocking at the time—famed Hollywood producer Harvey Weinstein was accused by multiple women of sexual misconduct in what appeared to be an alleged pattern of psychological manipulation and strategic harassment spanning decades. Apparently, some victims were paid for their silence. Most reactions I heard about the “Weinstein phenomena” from news reporters and colleagues agreed about one key point: It was wrong.

metoo nurseI remember thinking about the impact the Weinstein revelation might have on nursing. In my view, the victims who bravely came forward with their stories had clearly been bullied in the workplace and had experienced psychological and physical assault at the most egregious level. Sadly, nursing shares a similar reality. Just consider this statement on the American Nurses Association (ANA) website: “ANA recognizes that incivility, bullying, and violence in the workplace are serious issues in nursing. Currently, there is no federal standard that requires workplace violence protections.”

ANA has been addressing this issue for many years. As a chief nursing officer, I’ve often used ANA’s materials, books, slides, and talking points on the subject and now incorporate them into the academic courses I teach. However, I have no way of knowing the true numbers of nursing staff affected since current measures and ways of reporting these incidents are inadequate at best.

How many nurses have encountered similar issues but kept silent thinking that nothing would be done or that no one really cared? How many nurses are among the millions of women who have responded #MeToo?

At least the enormous scale of the bigger problem is coming to light. The sheer numbers of those affected have been revealed, but not as a formal call to action with protests and marches. Instead, the hashtag seems to have given voice to the secluded silent.

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The #MeToo movement is exposing a dark past (and present). Let’s do what nurses do best: Advocate for a better future. Could we flood the media with ideas about how to counter the negativism and be the change we want to see? The idea came to me when I heard three great suggestions from a colleague: Pay close attention to how we (all of us) welcome new staff to the unit; during interprofessional training, teach physicians and other disciplines how to value nursing (what to say, what to do, how to contribute positively to a healthy work environment); and emphasize to nurses over and over and over again to not be intimidated. And if intimidation does occur, what to do.

What would happen if we focused more on what we’re doing to change and not concentrate on the “it’s awful, what happened” scenario? The #MeToo movement has shown us that massive impact is possible, if it’s done together on a large scale. #BeTheNursingChange anyone?



Lillee Gelinas, MSN, RN, CPPS, FAANlillee gelinas msn rn cpps faan editor in chief

Editor-in-Chief