Superficial growth for the sake of change

Superficial growth for the sake of change,Or genuine growth for better patient outcomes?

Sharon Anderson, RN, Jackie Brown, RN, M. Jean Whitaker, RN, Jennifer Henry, RN

Introduction

Changing the education requirements in nursing is inevitable.  The current trend is to require a Bachelor’s of Science in Nursing.  As we move forward in nursing practice and education, nursing leaders look for ways of training nurses to be more competent and more capable of critical thinking upon graduation from nursing school. Some are proposing that a master’s degree should be required.  We do not believe a master’s degree is necessary or appropriate for entry level nursing.  According to an article by Drennan: “…Despite the centrality of critical thinking to educational curricula, achievement of this outcome has not been evaluated.” (Drennan 2010) If the outcome we seek is a better prepared nurse and this outcome’s achievement has not been evaluated, where do we stand on this debate? One cannot assume that more education will make nurses more competent. Rather, it is the individual that seeks to make themselves a more competent nurse. The research is not out there to support the need for a master’s degree as the basis for entry into nursing practice. One must also question whether this would decrease the nursing force. Would potential nurses no longer consider nursing as a profession if they were required to obtain a masters degree? This could leave us with an even bigger nursing shortage than is already in existence. There are no established benefits of requiring this higher degree for entry into practice and there is certainly the potential of producing undesired effects.

                                                         Discussion

One group that has an opinion on nursing education is the American Nurses Association (ANA), started in 1911. “This organization was established when it became apparent that training was necessary to protect the sick and injured from nurses who were incompetent and unable to provide adequate care,” (Smith 2009). The ANA’s mission statement is quite simple: “Nurses advancing our profession to improve health for all.” (ANA 2010) In regards to education, whose ultimate responsibility is it for the nurse being the best possible nurse he or she can be?  Is it the school of nursing, the employer, or the nurses themselves?  The stance of the ANA is as their website states, that the nurse is personally responsible for “maintaining professional competence,” (ANA 2010).  Simply obtaining a Master’s degree in nursing would not accomplish this. 

Looking back into the history of nursing education, we have moved from an “apprenticeship model” to the development of the “partnership model.”  The goal is now the “provision of opportunities for interprofessional learning linked to patient-centered care provided by multiprofessional teams,” (Glen 2009). This is now the basis for most nursing school education. 

Presently, nursing has several programs that allow an RN to gain entry into practice: diploma, ADN, BSN, and Master’s.  In 2004 a study was done to determine the percentages of RN’s that held certain degrees of education: 17.5% 3-year diploma, 33.7% 2-year AND, 34.2 % 4-year BSN, and 13% Masters or PhD. (Glen 2009).

When we consider well-educated nurses to be essential for providing adequate care, we must determine the necessary level of education for nurses to enter into practice.  Right now there is change happening all over the country where specific health care institutions are starting to require that their nurses have more education to be employed.  The diploma and ADN nurses are being asked to seek a Bachelor’s of Science degree in Nursing in order to practice at a specific institution.  Is this the right answer for seeking a more competent nursing force?  Or is it a formality that requires nurses to have a higher degree in order to call themselves “professional?” 

As a profession, one of our main agendas in health care is to provide the best quality health care at an affordable cost.  We must determine an educational standard for entry into practice that will meet the challenges of quality care and cost containment. All states in the United States require that every graduate of nursing schools pass the National Council Licensure Examination (NCLEX) before they can enter into practice.  This standardized test is designed to assess whether or not the candidate is minimally competent for entry into nursing practice.  The American Nurses Association determines what should be included on the NCLEX – RN test and the percentage needed to pass the exam to get licensed. This exam does not test for additional knowledge gained from the higher levels of education, like what a master’s may provide. This test is revised every three years to adjust for changes in practice in the many facets of nursing.

Some studies are showing that it’s not whether or not the student has had a two, three, or four year education in determining competency; it is the nurse who has received the most clinical time, face to face with patients (Finlay, James, and Irwin, 2006). Thus, the approach of adding more classroom time, instead of clinical time, with a Master’s of Science in Nursing would not improve the competency of the bedside nurse who is just entering into practice. 

Currently hospitals are playing a bigger role in determining requirements for the entry level nurse. Hospitals are becoming more competitive in the healthcare industry in order to maintain an adequate market share. In doing so, hospitals are trying to earn Magnet Status and/or similar accreditations. To maintain Magnet Status a hospital must meet certain requirements of their nursing staff and in their role within the hospital setting. One of those requirements is to maintain a certain percentage of nurses who have a bachelor’s degree or higher and provide monetary motivation.

 The Health Maintenance Organization Act of 1973 gave root to managed care which was supposed to help control costs of healthcare (Wooley and Peters 1973).  Managed care has failed in controlling the cost of healthcare.  Since nursing is the largest profession in the healthcare field, pay is kept at a flat rate in order for institutions to be able keep up with technology and pay their bills. It stands to reason that students who begin an educational path where they must obtain a master’s degree will do so in a market where pay is a reflection of educational achievements and not where pay scales remain flat.

If the purpose of the MSN as an entry level for nursing practice is to improve competency and patient outcomes, we must consider the possibility that this measurement can only be achieved on the job.  When there are evidence based practices that are mandated, healthcare facilities provide ways to educate the staff to apply these practices on the job to ensure competency of the staff.  In addition, the licensure of each state mandates continuing education hour requirements before a license can be renewed.  There are many types of certification programs that can help a nurse become a specialist in their field of nursing also. It is up to the nurse to take the initiative to follow through with these offerings beyond the minimum that is mandated.  The responsibility, ownership, and accountability of each individual nurse to remain competent throughout their career is essential in providing quality care to the public (Hallin, 2008). These individualistic traits cannot be taught in any degree program. 

A very important measurement of quality nursing care is the National Database of Nursing Quality Indicators (NDNQI) which look at the nursing sensitive indicators and relate this data to different aspects of nurse staffing. Not only are they evaluating nurse/patient ratios, but they are also looking at the mix of education levels of nurses working on the unit. Experts are also researching staff satisfaction in their job, years of experience, and turn-over rates and comparing it to the quality data. The nursing sensitive indicators are 1) occurrence of urinary tract infections, 2) falls, 3) vascular catheter infections and 4) pressure ulcers. The data is showing that the number one cause of a decline of quality and safety is when the nurse/patient ratio goes up. The education level of the nursing staff had insignificant effect on the quality indicators so far in the research, but it is premature to come to a conclusion at this time (Davidson, 2009). 

However, what some are debating is that right now nurses must recognize the growing challenges that lie ahead in the future of healthcare, and in order to be a part of this, they need a graduate-level degree.  Nurses must be prepared to sit alongside other health care professionals and assume active roles in decision-making opportunities.  It is possible that until nurses take the same accountability and advocate for higher levels of education, they will continue to lack voice and influence on future health care decisions.  This individual accountability could be achieved with a BSN.  There has never been a more challenging time than now for the nursing profession and healthcare as a whole as we see health care reform becoming a true reality. 

The aging population, economics, and complex technologies all contribute to the need for a wider knowledge base that incorporates decision-making, critical thinking and management skills.  Nursing leaders have successfully taken control of establishing Standards for Nursing Education.  However, there is still no single educational standard for entry into the nursing profession (Smith, 2009). The infamous 1965 ANA position paper recognized that the future of nursing is dependent on nursing education moving to a higher level with the recognition that nurses were the least educated of all health care professionals.  Their recommendation was for nurses to acquire a Bachelor’s degree for entry into nursing (ANA, 1965). However, as the demands on the nursing profession have exceeded expectations with the advances in healthcare, we may be faced with extending the requirements to the master’s level in the future.  Nevertheless the healthcare industry is concluding from research that the evidence identifies the bachelor’s degree as quality entry level in the nursing field, not necessarily a master’s. (ANCC, 2008), (Speziale and Jacobson, 2008).

Now is the time for requiring a BSN, not a master’s degree.  As less educated members of the health care team, nurses are not typically invited to participate as members of governing boards.  Some believe that this leads to the situation of nurses having less voice in developments within the healthcare system than do other professions that require higher education levels.  What is truly needed is to band together as the experienced professionals who provide the quality care. As one voice, nurses will be heard loud and clear. We must work together. 

A study was conducted to explore critical thinking as an outcome of a master’s degree nursing program.  This was a cross-sectional cohort study conducted in Ireland.  Graduates of a master’s degree program demonstrated significantly higher critical thinking skills than the students who were beginning a master’s degree.  According to this study, similar scores were also demonstrated in the United States.  The study demonstrated that master’s level study could influence the development of critical thinking ability.  “The development of critical thinking skills is probably best achieved by a cumulative set of mutually reinforcing experiences over an extended period of time. Critical thinking can best be developed by courses that involve problem-solving over role learning, written assignment, multiple choice examinations, class discussions or didactic lectures,” (Drennan, 2010).  Drennan states that there is a need for reinforced experiences throughout a period of time and yet critical thinking can still be learned in the classroom.  For the nurse entering a field where hands-on skills and patient relations is something that can only be learned in the clinical setting, one has to wonder how the nursing student seeking to enter practice can best learn to care for patients and prevent disease and promote health. 

Nursing care has always been directly linked to patient safety.  Some studies say that patients need access to nurses and to better educated nurses.  Every 10 percent increase in nurses holding a bachelor’s degree or higher, is associated with a 5 percent decline in mortality and failure to rescue after common surgical procedures (Aiken, 2005).  However, the challenges that faced healthcare in the 1990’s created situations where hospitals were forced to restructure as they faced financial constraints.  Many nursing positions were reduced or eliminated. These included positions of direct patient care as well as positions of consultation, education, and administration.   As a result, following these acts we saw an increase in patient morbidity and mortality (Long, 2004).  What the studies do not clarify is the position of the nurse with a master’s degree.  Are they at the bedside or are they unit educators?  There is unarguably a need for graduate level nurses; their ideal position for best overall patient-outcomes may not be at the bedside. Further studies need to be done to determine the best entry level for nursing education. Studies do not indicate that a master’s level nurse performed better than a BSN nurse.    

What would be the effects on the nursing shortage if the educational requirements were raised? Today’s nursing shortage is much more complex than supply and demand.  The complexity of this shortage should overpower any call to raise the requirements of entry level nursing to a master’s degree. In 2008, nursing was, without a doubt, the largest profession in the healthcare field. Nurses held approximately 2.6 million jobs, in a variety of capacities and settings. According to the U.S. Bureau of Labor and Statistics, new positions for nurses will grow another 22 percent by 2018. This is only one aspect that would be further reason to maintain that a master’s degree should not be required for an entry level nurse, (OOH, 2010).

In March, 2010 the federal Division of Nursing released the findings of the 2008 National Sample Survey of nurses. This survey projected that the average age of nurses to be 44.5 years old by 2012 with the largest portion of the workforce to be in their 50’s. The nation must face the fact that the largest percentage of nurses are part of the baby boom generation and will soon be facing retirement and many will become part of the population that require more care. These staggering demographics further emphasize that an increased requirement of a master’s degree to enter the field of nursing would only serve to decrease the number of nurses that will be able to care for the health needs of our population (HHS, 2010).  With these facts looming in our future, we need to encourage entry into nursing rather than add another layer of educational requirement for entry level nurses.

                                                         Conclusion

Just as every profession has a natural progression from novice to master, nursing has a natural progression. As nurses enter the workforce, they are able to view all that is available and needed. Many options are available for today’s entry level nurses and with an impending nursing shortage on the horizon we need to encourage and develop the natural progression of novice nurse to master.

While studies have shown that a BSN education is linked to patient safety and improved patient care, there have not been sufficient studies that would indicate a master’s degree for entry level nurses is needed or desired. When a national (and global) shortage of nurses is expected, we need to focus our attention on getting quality nurses at the bedside. Forcing novice nurses to make premature choices on career pathways only serves to decrease the number of qualified nurses entering the workforce. (Baurhaus, Donelan, Ulrich, Norman & Ditmus, 2006)

“Health promotion and disease prevention” is starting to become a catch phrase within the healthcare community, and it is becoming the role of the registered nurse to promote this view.  Do we become a part of this simply by having more nursing school education?  Or is it something that cannot be taught in a classroom?  If the ANA believes that the nurse is personally responsible for “maintaining professional competence,”  (2010) then the prospect of adding more letters behind your name, (what one of my ADN professors referred to as “alphabet soup”), should purely be optional for the RN practicing in acute care settings such as hospitals and outpatient clinics.  As we gain more understanding from the perspective of seeking to have the most competent nursing force possible, we glimpse into the future of the nursing profession, wondering what other changes may come. Forty-four years ago the American Nurses Association took a position declaring that nurses enter the practice with at least a bachelor’s degree in nursing.  Only now are employers starting to adopt this view, even without state laws declaring it be mandatory.  This century may be one of great growth and change and the bedside nurses will be the ones that feel the effects.  We have come very far in our profession.  One has to wonder if there is, at times, superficial growth for the sake of change, or genuine growth for better patient outcomes. 

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