The landmark Future of Nursing report published by the Institute of Medicine in 2011 spearheaded a series of initiatives aimed to increase the number of baccalaureate-prepared nurses to 80 percent by 2020. The Robert Wood Johnson Foundation, the AARP, and the AARP Foundation launched the Future of Nursing: Campaign for Action in response to this report, resulting in the formation of nursing action coalitions in all 50 states and the District of Columbia. In the State of Ohio, the Ohio Nursing Articulation Model (ONAM; Ohio League for Nursing [OLN], 2003) had already existed. In 2011, the Ohio Action Coalition (OAC) was formed out of this initiative to increase BSN-prepared nurses in the Ohio workforce.
Ohio received its first State Implementation Program (SIP) grant through the Future of Nursing: Campaign for Action initiative in 2013. This SIP grant supported the development of three regional teams located in the northeast, northwest, and central Ohio regions (Sharpnack et al., 2017). The aim of the regional teams was to develop and promote seamless progression models that reduced barriers for RNs prepared at the associate degree or diploma level to complete the BSN degree, thereby increasing the baccalaureate-prepared workforce. The models provided a framework, while the pathways provided specific educational plans for BSN degree completion.
EVIDENCE FOR BACCALAUREATE PREPARATION
The association between the level of education of a nurse and patient outcomes has been researched and published over the past decade. Greater numbers of BSN-prepared nurses in the workforce correlate with lower mortality rates and decreased odds of failure to rescue as documented in the literature and summarized by the American Association of Colleges of Nursing (AACN, 2019a). Research conducted by Aiken et al. (2014) recognized that employing a higher percentage of nurses with BSN degrees resulted in 30 percent lower probability of mortality in hospitals. In addition, improved patient outcomes in surgery and fewer adverse events were noted with increased ratio of BSN-prepared nurses (AACN, 2019a).
Growth in the pipeline of nursing students with baccalaureate preparation is vital to meet the needs of health care providers and consumers. Hospitals are heeding the call for higher levels of education based on this evidence. Employer preference for BSN-prepared nurses increased from 79.6 percent to 82.1 percent between 2014 and 2019 (AACN, 2014, 2019b). The number of BSN-prepared nurses in the workforce increased following the Institute of Medicine (2011) report, from 49 percent in 2010 to 56 percent in 2017 (Center to Champion Nursing [CCNA], 2019).
Health care reform has been a driver of this preference. Greater emphasis is being placed on population health initiatives and chronic disease management to include improved health care delivery in a value-based system centering on health promotion interventions that require high levels of clinical judgment (Buerhaus et al., 2017). Nurses can facilitate these initiatives by operating at the top of their licensure within the interprofessional team. Top-of-license practices include professional nursing care, critical thinking, interprofessional communication, and patient education with careful attention to delegation of nonnursing care tasks (Buck et al., 2018). These types of practices are expected in RNs with either ADN or BSN degree preparation. However, a qualitative study by Loversidge et al. (2018) exploring differences between how ADN- and BSN-prepared RNs approached top-of-license practices suggested that certain practices that can influence patient outcomes were affected by level of education. In an effort to promote value-based initiatives, nurses can be leaders in the transformation of the health care system through top-of-license practices fostered by increasing the level of nursing education.
Between 2016 and 2026, more than 200,000 nurses will be needed to meet the health care needs of the country (Torpey, 2018). The shortage of faculty, clinical sites, and space has led to the inability to accept all applicants into baccalaureate nursing education programs (AACN, 2019c). Enrollment in programs to complete the BSN degree will help increase the number of BSN-prepared nurses who can operate at top-of-licensure. The creation of more seamless academic progression opportunities for prelicensure students based on established models can help facilitate baccalaureate entry-level goals.
Successful models for seamless academic progression have been established since the initiation of the Future of Nursing: Campaign for Action (Gorski & Polansky, 2019; Sharpnack et al., 2017). These models have moved beyond articulation agreements to include streamlined course pathways, enhanced advising, and higher levels of collaboration between ADN and BSN degree programs (Gorski & Polansky, 2019; Sharpnack et al., 2017). Current data projections suggest a modest increase of BSN-prepared nurses to 63.8 percent by 2025 (Gorski & Polansky, 2019). However, if additional academic institutions implement new models of seamless progression, that rate can potentially increase to 83.9 percent (Gorski & Polansky, 2019). More work is needed across the nation to address the reduction of barriers for the use of seamless academic progression models.
ACADEMIC PATHWAYS BEYOND ARTICULATION
The regionally located programs in Ohio responded to the national call to increase the number of baccalaureate-prepared nurses (Sharpnack et al., 2017). The OAC called for proposals from all nursing programs and practice sites in Ohio to develop seamless academic progression models. Three regionally located areas of the state responded to the call: the Central Ohio team (COT) in Columbus, the Northeast Ohio (NEO) team in Cleveland, and the Northwest Ohio (NWO) team in Toledo. Although the southern areas of the state did not originally submit proposals to formally participate in the process, representatives from that area later joined the COT effort. The teams collaborated statewide and created the required toolkit for the SIP grant deliverable (OAC, 2015). The toolkit, OPENing Doors: Ohio Pathways for Education in Nursing, outlines the process of developing seamless academic progression models through partnerships based on the Ohio Nurse Competency Model and gap analyses within each region (OAC, 2015).
After completing the toolkit, each team created initiatives specific to regional needs to progress seamlessly from associate (ADN) to baccalaureate (BSN) degree programs. These pathways included 2 + 2 (two years ADN, two years BSN), 3 + 1 (three years ADN, one year BSN), and 1 + 2 + 1 (one year BSN, two years ADN, one year BSN). Each team developed unique partnerships to increase the number of BSN-prepared nurses (Sharpnack et al., 2017). These models, as well as the specific pathways to program completion, have been individualized to the needs of the particular region with a goal to move the needle beyond articulation agreements; this is further described in Table 1.
The COT
The partnerships and pathways created by the COT, described in Table 1, are collectively known as Path2BSN. All students in Path2BSN are provided intense advisement that differs from traditional advisement. Students are counseled about how to progress seamlessly through both programs without taking excess credits with the goal of degree completion in four years or less. Advisors are trained in degree auditing, and nurse educators provide assistance in career development.
Students are provided with an individualized approach that includes assistance with a seamless progression pathway, financial aid, housing, and guidance on the importance of BSN degree completion. The individualized plan addresses the student's needs, regardless of when the student enters a pathway, whether the student is dually enrolled in both an ADN and BSN program, applying for admission to an ADN program, or about to graduate from the ADN program and enter the BSN program. Although a traditional audit may identify specific classes students need to complete, the Path2BSN intense advising moves well beyond a checklist and focuses on individual student needs.
The NEO Team
The NEO team partnerships represent urban, suburban, and rural regions across four northeast Ohio counties. The practice partner represents the largest health care system in the region, and the educational institutions include three ADN, one diploma, and two BSN programs (one private faith-based, one public).
For students who enroll in the ADN or diploma and BSN programs simultaneously using the NEO team pathway, a course audit includes the following: general education courses taken in Year 1 of the ADN or diploma program nursing program courses at the ADN/diploma program; an evidence-based nursing course offered at the BSN program after first-semester ADN/diploma nursing courses are completed; a standardized health assessment competency evaluation in the final year of the ADN/diploma program that permits the student to waive a required health assessment course; and BSN general education and nonclinical nursing courses taken at the BSN program throughout the ADN/diploma preparation until all requirements are completed. Students can obtain RN licensure once they complete the ADN/diploma preparation. Shared academic advising between the ADN program and BSN program supports completion of the BSN in as little as 6 to 12 months.
The faith-based BSN program implemented the seamless dual enrollment progression model more quickly than the state university due to its size, commitment of the nursing faculty, and hierarchical structure. This has resulted in the admission of students dually enrolled in one ADN program and the faith-based BSN program simultaneously. The college's reduced RN to BSN tuition is applied to all dually enrolled ADN students, allowing students to take advantage of receiving private school education at a reduced cost. Furthermore, each student is provided with personalized online and face-to-face advisement for both institutions, a detailed and individualized plan that prevents progression delays, and mentoring opportunities. This high-touch approach to advising provided by the coordinator of the faith-based BSN program and the director of the ADN program has resulted in good student retention. An unanticipated outcome is that dually enrolled RN to BSN students have taken part in the undergraduate honors program, with an opportunity to present at national conferences with a faculty member. The advising and mentoring offered by the small faith-based college is noted as a strength of the model because of this holistic approach. Participating students completed end-of-program surveys providing a feedback loop for future improvement. Students who completed the program found the seamless progression pathway to the BSN degree had fewer barriers, provided for a network of academic mentor connections, and added significant value to their preparation for practice.
Within the partnership, only the faith-based BSN program used the seamless progression template because of its ability to make rapid changes in curricular audits. The public university partner recently initiated efforts to use this model to facilitate dual enrollment but has not fundamentally altered its original progression pathway.
The NWO Team
The seamless academic pathway created by the NWO team is a 3 + 1 model. Composition of the team originally consisted of a public ADN program, a regional practice partner, and two BSN programs (one private faith-based, one public), but team participation has changed over time. The public BSN and ADN programs are actively securing an agreement wherein students will be dually enrolled in the community college and the university, which will allow core education courses to be taken at either institution. Upon completion of the ADN program and successful completion of the NCLEX-RN, students can seamlessly progress to the university for completion of the BSN degree.
Benefits for students include lower tuition costs offered by the community college and removal of the obstacle of applying to the university after completing the associate program. Barriers to BSN completion in the area include lack of pay differential and lack of hiring preferences for BSN-prepared nurses, which is a difference from other parts of the state. A commitment to educating practice partners on the importance of a BSN education for nurses is ongoing. The dual enrollment agreement is one step that moves beyond articulation agreements and effectively addresses the practice partners' commitment to baccalaureate preparation.
Statewide LPN to RN Transition Team
To further move beyond articulation agreements in Ohio, the OLN created a statewide initiative to address transitions between LPN to RN programs. The ONAM for LPN to RN transitions needed updating to narrow the gap between education and practice, thus enhancing seamless academic progression. The OAC received feedback from nurse educators across the state about revisions identified for the ONAM document in relation to the LPN to RN transition curriculum.
Nurse educators formed an LPN to RN task force, composed of representatives from diploma, ADN, and BSN programs representing all regions of the state. The task force developed a clear mission: to revise the current content of the LPN to RN transition curriculum to reflect higher order thinking, narrow or eliminate disparities from the gap analysis, and enhance the education of LPN to RN students in the state. The new model, entitled Advanced Placement for LPN to RN, was finalized in February 2018 (OLN, 2018). This model uses a concept-based approach, expands the curriculum, and elevates the taxonomy and expectations within program objectives. It is adaptable for all LPN to RN programs and moves beyond articulation agreements between programs, representing seamless academic progression from a statewide perspective beginning at the LPN level. The OLN has posted the model on its website (OLN, 2018), and has shared it with other educators at statewide meetings.
OUTCOMES
All Ohio teams have demonstrated progression toward positive outcomes since the initiation of the OAC project. The State of Ohio data, documenting the increase in baccalaureate-prepared nurses, are a powerful outcome, validating a 30 percent increase in BSN-prepared nurses from 2013 to 2017 (2013, 34 percent, n = 56,737; 2015, 35 percent, n = 65,589; 2017, 64 percent, n = 77,150) (Ohio Board of Nursing, 2013, 2015, 2017).
The state-level data may also be compared to national data from the Campaign for Action (CCNA, 2019). The national data focused on the number of RNs with a BSN or higher rather than on the number of BSN-prepared nurses. For the period 2010 to 2015, Ohio showed a statistically significant 10.4 percent increase (p < .001) in BSN-prepared nurses (2010, 41.8 percent; 2015, 52.2 percent) in contrast to a national increase of 7.1 percent (2010, 48.8 percent; 2015, 55.9 percent). The growth in Ohio was greater in comparison to more than 70 percent of other states (CCNA, 2019). Ohio is moving the needle for higher education of nurses at a faster rate than the average across the nation.
The COT
The COT team demonstrated a steady increase in enrollment through Path2BSN from the ADN partner schools, with increases of 32 percent (2016-2018) and 38 percent (2017-2019). Several factors contributed to the increase in enrollment. One regional consideration was that many employers in the region required BSN preparation within a designated time period after being hired. Intense marketing and simplified advising plans have also significantly contributed to the outcomes, with the Path2BSN including financial aid coordination and seamless transferability of credits between programs.
Enrollment capacity obstacles have evolved since the establishment of the COT. Originally, the focus was on pathway implementation and recruitment; the focus has shifted to more intensive advisement, an increase in faculty reflective of increased enrollment, and admission criteria encompassing a seamless process. A more holistic approach to admission is part of the 2019-2021 phase, along with advisement, both before and during the program. A dedicated nurse educator provides students with career guidance and webinars for academic advancement and career option guidance.
Degree audit tracking throughout the programs helps students avoid excessive credit hours, which is also recognized as a concern nationally (Giddens & Meyer, 2016). At the state level, utilization of the Ohio Transfer Module has provided a way to streamline transferability of credits between public programs in the state. The advisor works between programs to provide a distinct path for students and to track student progression. Curriculum plans change frequently when working with seven schools, and the advisor needs to stay abreast of all changes.
A future challenge relates to the restructuring of the general education requirement at the larger public university. The entire general education requirement is being revised, which will entail an intense level of adjustments to the pathways to ensure acceptance of applicable credits between the ADN programs and the university. Advisors will be available to assist students as they adapt to these changes.
Future direction of the COT will include the work of nurse educators for pathway refinement, curricular gaps, and the facilitation of communication to students. The COT will continue to address housing challenges associated with attending college or leaving the university and going to an ADN program, as in the 1 + 2 + 1 pathway. The strong collaboration and ongoing communication among the nurse educators on the team have helped overcome challenges; each member of COT is deeply committed to the Path2BSN pathway refinement. The university maintains the infrastructure; the funding obtained from the Ohio Board of Nursing Nurse Educator Grant Program has provided support to continue this work.
The NEO Team
The NEO team created seamless progression plans for dual enrollment that can be readily transferable to programs throughout the state. This transferability is one distinguishing factor for the NEO team and an important component to the goal of improving the time frame for baccalaureate completion. Plans are made available through the OAC website.
Since implementation, the NEO region has seen an increase in students dually enrolled in ADN and BSN programs. The RN to BSN coordinator meets with students prior to enrollment in the ADN program. Open access to the community colleges promotes seamless progression, avoids delays due to inappropriate advising, and connects students to the four-year institution at the onset of their nursing education journey. Students dually enrolled do not take clinical courses at the BSN degree-granting college until they become licensed RNs, but they do participate in dialogue with students in the RN to BSN program, whether pre- or postlicensure.
As the major health care systems in this region require completion of the BSN within two to five years of hire, the dual enrollment framework allows for baccalaureate completion in as little as six months after passing the NCLEX-RN. Thirty-one students have entered the dual enrollment program at the faith-based college; two dually enrolled students who graduated from the partner community college were able to complete the baccalaureate degree in six months, with another two students scheduled to graduate in 2020. The remaining students are actively taking courses in both programs.
Currently, more students are enrolled in prelicensure dual enrollment than in the postlicensure portion of the program. The online delivery format, reduced tuition cost, the ability to maintain the autonomy of the community colleges, and the college's reputation and high-touch, small-program appeal have resulted in several programs across the state expressing interest in using this model.
Engagement in designing strategies to reduce the gap between education and transition to practice caused the NEO team to explore the competency of graduates from the ADN programs in health assessment skills. The purpose was to identify ways to measure competency that would allow for transfer of course credit into the BSN program. A subcommittee developed competency assessments that allowed RN to BSN students from across ADN programs with integrated health assessment content to receive credit in the RN to BSN progression plan, thereby reducing barriers to earning the baccalaureate.
Finally, the NEO team continues to meet consistently to further develop competency testing in other areas identified in the gap analysis. Broader academic and practice partner outreach is taking place as many of the leaders who were influential in the region have changed since 2015. The team continues to emphasize ways to close the gap between the new nurses' competency levels and expectations of the practice community. Ongoing efforts to assess clinical judgment skills through testing strategies continue, and results are shared with the broader academic community. The NEO team has disseminated its work at national and international conferences to assist other academic and practice partners in reproducing the outcomes for use in other institutions.
Challenges to the team's work include significant changes in executive leadership in both the academic and practice organizations external to the NEO team partnership. In addition, while the seamless progression model was posted on the OAC site for use by all programs, there are a few schools in Ohio that have not utilized this resource, resulting in disconnected progression between the community colleges and baccalaureate programs. Finally, because of lack of funding, the infrastructure for ongoing recruitment and support does not exist in this region. Plans for the future are to increase support through grant funding to jointly support the academic programs that use this model.
The NWO Team
An outcome for the NWO team was the implementation in fall 2019 of a competency-based education (CBE) option for students completing their BSN degree. The CBE RN to BSN program option at the University of Toledo (UToledo) is the first among Ohio institutions. This program option allows students to finish in as few as two semesters, is entirely online, and is self-paced by the student. According to the National Survey of Postsecondary Competency-Based Education, the CBE option is ideal for nontraditional learners because it measures student learning through competencies as opposed to traditional credit hours and grades (Mason & Parsons, 2019).
Program advisors work closely with students who apply for RN to BSN admission to evaluate their potential for success in the CBE option. In addition to an academic advisor, students are assigned a mentor who monitors student engagement and communicates with both the faculty and student. To be successful in a CBE curriculum, students need to be self-motivated, familiar with online learning, and be independent learners (Mason & Parsons, 2019). At UToledo, the CBE option allows students to begin a course within the first nine weeks of any semester; however, they must complete the course by the end of the traditional 15-week semester. Students can move quickly through a course by passing the required competencies at their own pace. If students require more time to master the required competencies, they can take the full 15 weeks. This nontraditional, student-centered approach is ideal for working nurses. Preliminary data indicate that once students are given the option of the CBE program versus the traditional online option, the majority choose the CBE option. In fall 2019, 15 students chose the CBE enrollment option and 15 chose the traditional option. In spring 2020, 23 students selected the CBE option, and only one selected the traditional option.
A major barrier unique to NWO is that there is little incentive from practice partners to encourage earning the BSN degree. To combat this issue, the NWO team partnered with the OAC to develop an online educational tool to educate the community on the advantages of increasing the number of BSNs in the region. Upon partnering with the Center for Creative Instruction at UToledo, the project transformed into a virtual gaming experience in which potential nursing students can create an avatar inclusive of their personal attributes, academic strengths/weaknesses, and financial situations to help them predict which nursing career pathway option will best facilitate their success. A prototype and a business model were developed and tested internally; however, the team ran short of funding to move to production. The team is continuing to search for funding to make this innovative educational tool a reality.
DISCUSSION
The data and regional efforts presented demonstrate the tremendous efforts and positive outcomes related to baccalaureate preparation in the State of Ohio. The regionally located teams have responded enthusiastically since the initiation of the SIP grant over five years ago. The teams were efficient and prompt in their response to the needs of their communities and continue to address challenges and barriers throughout the state. Implementation issues have included challenges with advising, practice site requirements for the baccalaureate degree, and lack of funding to continue with initiatives. The teams have collectively addressed these barriers and are moving forward with strategies to increase the number of nurses prepared at the baccalaureate level.
The seamless progression models created by each team are a reflection of the initial gap analysis and provide a way to foster seamless progression from the ADN to the BSN degree. The teams demonstrated a significant commitment to the aim of improving the student experience and partnering to meet the regional needs for nurses to complete the baccalaureate degree. The focus of the models has evolved over time, but the primary framework and composition are still intact. Each team has either strengthened the original models and/or developed variations to meet the site-specific needs of the programs, students, and practice sites. In addition to the models developed within the teams, the statewide Advanced Placement LPN to RN Transition Model was created to further seamless progression efforts in Ohio. All of this collectively has contributed to the positive outcomes across the state.
CONCLUSION
With health care systems becoming increasingly complex, it is vital that nursing education keep up with the rapid changes experienced across the nation. The role of the nurse is shifting, and BSN preparation is fundamental to meet the needs in the workplace environment for operating at top-of-license practice. Consistency of educational programs for baccalaureate completion and continued momentum toward this initiative are a priority at this time. A wide amount of variability in educational preparation exists between basic licensure education as an RN and baccalaureate preparation. National accreditation standards for ADN and BSN completion help maintain stability and credibility of programs across the nation.
Seamless academic progression models should further delineate the competencies and curriculum integration between ADN and BSN programs. As discussed, teams in Ohio performed a gap analysis involving partner schools that helped inform the streamlining of educational competencies between associate and baccalaureate partner schools. Further analysis of the outcomes related to the seamless academic progression pathways will allow nurse educators to provide educational experiences unique to both ADN and BSN programs.
In addition to the demands of the nurse in the hospital setting, the need is extending well beyond the acute care environment to outpatient and primary care settings. Nurses can effectively address population health initiatives, chronic disease management, and disease prevention in an autonomous manner through these community settings. Nurses need to be an integral part of transforming health care. Baccalaureate preparation allows for enhancement of the ability to operate at the top of license in any health care setting.
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