1. Lavizzo-Mourey, Risa MD, MBA

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Nearly 18 months after the release of the Institute of Medicine (IOM) report "The Future of Nursing: Leading Change, Advancing Health," it makes sense to ask: what changes are occurring? how can we make the most difference? and where can the report's recommendations take us toward improving patient care?


One of the report's focal points, and a priority for the Robert Wood Johnson Foundation, is ensuring that nurses are educated and trained to excel as 21st century health care delivery becomes more complex and extends beyond acute care settings. The Future of Nursing report emphasizes that if nurses are to maintain their effectiveness in providing high-quality patient care, they will need to be better prepared. Specifically, the report recommends creating a system that produces more nurses educated at the bachelor of science (BSN) level and policies that allow nurses to transition seamlessly from an associate's degree to a BSN or higher degree. From the perspective of the IOM committee that developed the report, increasing the percentage of the workforce holding a BSN to 80% by 2020 is both an achievable goal and a necessary step to meet workforce competency and capacity requirements.1


As a physician, I have seen the tremendous capabilities of nurses-capabilities that are essential to meeting patient needs. But to ensure that they maximize their contributions to health and health care, nurses will need advanced skills and expertise in care management, interdisciplinary teamwork, problem solving, and more. This makes higher levels of education imperative. In addition, having a larger pool of highly educated nurses will be necessary to expand the ranks of nurse faculty, addressing the shortfall that now causes nursing schools to turn away thousands of qualified applicants each year. These advanced degree nurses are also needed to help ameliorate the worsening primary care shortage.


For numerous reasons, employers will benefit from advancing levels of nurse education as well. For one, the advent of value-based payment systems will place an even greater imperative on having a highly trained health care workforce. As payers increasingly focus on hospital readmission rates, nurse-sensitive quality measures, and care coordination, nurses' performance will be even more critical to the bottom line. More BSN-prepared nurses will mean a bigger cadre of nurses prepared to fully participate in interdisciplinary care teams and to take on leadership roles at the staff and executive levels in a transformed health care system.


In a recent survey conducted by AONE,2 51% of nurse leaders said their organizations preferentially hire BSN nurses, although just 32% pay BSN nurses more at the time of hire. Lack of access to BSN nurses and lack of support from organizational leaders were cited as the top barriers to such policies. Ninety-three percent of survey respondents noted that their institutions offer tuition benefits to support associate's degree-to-BSN advancement.


Some of the leading nurse employers favor advanced degree nurses. The well-respected Johns Hopkins Hospital has a stated preference for hiring BSN nurses and requires nurses to obtain at least a BSN before going beyond a certain point on the career ladder. The for-profit Tenet Health Care Corporation has adopted similar policies, and the Veterans Health Administration also links education to career advancement.3


These policies can yield positive benefits, but monetizing the return on investment is challenging. We know that turnover rates are sensitive to human resources policies, including tuition reimbursement and career-ladder programs that provide growth opportunities.3 There is evidence that organizations that earn the Magnet Recognition Program(R) credential for nursing excellence have lower turnover rates among nurses and thus have improved clinical outcomes.4 In Magnet-designated organizations, chief nursing officers and 75% of nurse managers are required to have a BSN degree or higher.5 An important consideration for employers is that education progression policies may yield savings that result from lower nurse turnover and vacancies, estimated to cost from $22,000 to $64,000 per position.6


We cannot wait to take action; failing to grow a better educated nursing workforce risks disastrous results. This is particularly important in light of the aging nursing workforce as well as the coming expansion of health insurance coverage in 2014. Although a recent study shows faster growth in the supply of nurses than anticipated, its authors caution that more progress is needed to meet our aging population's need for highly skilled nurses.7


Around the country, educational institutions are finding creative ways of encouraging and facilitating progression to BSN and higher-level degrees. For example, the Oregon Consortium for Nursing Education has created a shared curriculum across 8 community colleges and the Oregon Health & Science University School of Nursing, which enables students to complete BSN coursework without leaving their home community. Graduates are trained in clinical judgment, patient-centered care, systems thinking, leadership, and evidence-based practice. In New Mexico, leaders will discard 24 separate curricula in favor of a uniform nursing curriculum and a shared faculty pool. Florida is developing RN-to-BSN educational models, including community college transition to state college programs and community college transition to state university regional partnerships. Colorado is developing such partnerships as well.


These are shining examples of the evolution that needs to occur nationwide. To meet our nation's health care needs, we must strengthen the nursing profession at all levels, from the front lines to the executive ranks. That is precisely why we partnered with the IOM to develop the report and why we are actively engaged in facilitating its implementation through the Future of Nursing: Campaign for Action.


Tackling the barriers to educational progression requires a multifaceted approach. Far from being solvable with a single action or within a single arena, realizing full-scale change will take the commitment of many in health care, education, business, and other sectors. A key component of our effort is working with national stakeholders through the Center to Champion Nursing in America, an initiative of the AARP, the AARP Foundation, and the Robert Wood Johnson Foundation.


Because nursing is so critical to improving health care, it is a priority for our foundation and one to which we have devoted more than $300 million over the last 10 years. At the Robert Wood Johnson Foundation, the IOM report is our blueprint for transforming the nursing profession to help ensure that all patients receive the care they need and deserve. We will continue to address its recommendations-and encourage many others to do the same-to fully realize the Campaign for Action's vision: a nation where all have access to high-quality, patient-centered care in a health care system in which nurses contribute as essential partners in achieving success.




1. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Atlanta, GA: The National Academies Press; 2011. [Context Link]


2. Caramanica L, Thompson PA. AONE survey: gauging hospitals' use of preferential hiring policies for BSN-prepared nurses. Voice Nurs Leadersh. 2012;1:17. [Context Link]


3. Pittman P, Horton K, Keeton A, et al. Investing in nurse education: is there a business case for employers? November 2011 (unpublished material) [Context Link]


4. Drenkard K. The business case for Magnet. J Nurs Admin. 2010;40:263-271. [Context Link]


5. Frellick M. A path to nursing excellence. Trustee. 2011;64:201. Accessed January 10, 2012. [Context Link]


6. Strachota E, Normandin P, O'Brien N, et al. Reasons registered nurses leave or change employment status. J Nurs Admin. 2003;33:111-117. [Context Link]


7. Auerbach DI, Buerhaus PI, Staiger DO. Registered nurse supply grows faster than projected amid surge in new entrants ages 23-26. Health Aff. 2011;30:2286-2292. [Context Link]

AACN Advanced Critical Care Web Site


Serena Phromsivarak Kelly, RN, MS, FNP, CCRN


AACN Advanced Critical Care is a peer-reviewed publication intended for experienced critical care and acute care clinicians, advanced practice nurses, and clinical and academic educators. We are working to improve our Web site by expanding content and making it more interactive. As a subscriber, you have access to expanded content on the journal Web site located at:


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