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JULY/AUGUST 2011 :: 72(4)
Future of Nursing in North Carolina

The policy forum of this issue takes as its point of departure an April 2011 summit of North Carolina nurse leaders, who met to review and discuss recommendations from The Future of Nursing: Leading Change, Advancing Health, a report recently published by the Institute of Medicine of the National Academies. Commentaries from experts across the state affirm the importance of ensuring that an effective, educated nursing workforce is present; that nursing education involves a seamless process; that nurses can practice to the full extent of their education and training; that nurses are full partners in redesigning health care; and that an effective, comprehensive health care workforce planning system is in place. Also in this issue, original articles address the use Charlotte-area emergency departments for primary care services and the presence of defibrillators in North Carolina public schools.


Escalating the Pathway From the Associate's Degree in Nursing to the Bachelor of Science in Nursing and/or the Master of Science in Nursing: What Is Standing in the Way?

Elaine S. Scott, Helen Brinson

N C Med J. 2011;72(4):300-303.PDF | TABLE OF CONTENTS

For more than 25 years, promoting higher levels of education for registered nurses (RNs) has been a strategic theme in national reports. Yet, only 42.2% of RNs in North Carolina hold a bachelor of science in nursing, a master of science in nursing, or a doctorate in nursing. Creating a seamless educational pathway for RNs is essential for achieving this goal.

For more than 25 years, promoting higher education for registered nurses (RNs) has been a theme in national reports [1, 2]. One reason for this recurring recommendation is evidence that nurses with a bachelor of science in nursing (BSN) more often pursue education at the master’s and doctoral levels, an essential component for sustaining an adequate supply of nurse practitioners, midwives, and clinical nurse specialists, as well as nurse educators [3, 4]. Another justification for increasing education levels of RNs is the growing research that links patient safety and outcomes to the percentage of BSN-level nurses on a unit [5, 6]. Nurses, unlike all other health care professionals, can enter practice via 3 different degrees: a hospital diploma, a community college associate’s degree in nursing (ADN), or a BSN. Graduates of all programs take the same licensing examination to practice nursing. Many historical factors have contributed to this situation, and many political factors make its resolution complex. Historically, nurses—who are predominantly white and female—were educated in hospital diploma programs. As nursing care became more complex and university education became a norm for women, the movement to a baccalaureate was recommended by the profession. At present, 20.4% of nurses in the United States completed a diploma program as their initial education [7]. In North Carolina, only 7.2% of nurses report having received a hospital diploma as their first degree [8]. Since 2004, less than 3.5% of new-entry nurses have graduated from diploma programs [7, 8]. As diploma programs closed, schools of nursing were created in universities; however, supply did not match the demand for nurses arising from World War II, from improvements in medicine, and from an increased use of hospitals [9]. In response to the pressing need for nurses, a proposal for a 2-year, technical nursing degree was created, with the recommendation that the education takes place in community colleges [9]. The initial vision was for technically trained nurses to assist BSN-level nurses in practice, much in the same way that physical therapy assistants work with physical therapists. Instead, nurses with a 2-year ADN gained equal licensure status and soon became the largest pool of US nurses. In North Carolina, during 2004-2009, 21,052 new nurses entered practice. Of these, 14,073 (66.9%) graduated from ADN programs, 6,257 (29.7%) received a BSN, and 722 (3.4%) received a diploma in nursing [8]. On the national level, 45.4% of RNs begin practice with an ADN, compared with 34.2% who begin practice with a BSN [7].

Answering the current call by the Institute of Medicine of the National Academies (IOM) to increase the number of BSN-level nurses to 80% of the nursing workforce by 2020 will require tremendous effort, united vision among nurse educators and leaders, and major strategic commitment by organizations that employ nurses [2]. At present, only 42.2% of RNs in North Carolina hold a BSN, MSN, or PhD in nursing (Table 1). In North Carolina, during 2004-2009, only 2,998 ADN-level nurses used the RN-to-BSN articulation option to achieve a BSN [8]. On average, that is 500 ADN-level nurses per year returning to school, while an average of 2,345 new ADN graduates enter nursing practice. Nationally, only 16%-20% of ADN-level nurses go on to pursue a higher degree [4].

The IOM’s recommendation that a seamless educational pathway be established for RNs has been a vision in North Carolina since 1991, when the University of North Carolina (UNC) president convened a nursing transfer study commission. Yet, only 32.7% of current nurses in North Carolina hold a BSN [8]. The university and community college systems have a comprehensive articulation agreement (CAA) that has existed for many years. However, there is not a statewide nursing articulation agreement. The CAA provides a readily accessible way to evaluate community college courses for university transfer credit. In 2001, the Helene Fuld Health Trust awarded a 2-year grant to the North Carolina Center for Nursing with the goal to create “a seamless articulation plan for North Carolina nursing education programs such that RNs who wanted to further their education were assured that previous learning and work experiences would be valued and recognized.” A project steering committee formed, including representatives from community colleges, universities, the North Carolina Area Health Education Centers (AHEC), the North Carolina Board of Nursing, the North Carolina Nurses Association, and the North Carolina Association of Nurse Leaders. By 2003, the group had drafted a statewide nursing articulation plan; held a meeting to disseminate findings; and, using an RN-BSN consortium, developed a method for fully implementing the work. But funding issues and the dissolution of the North Carolina Center for Nursing challenged the development and continuation of the consortium (J. Kuykendall, personal communication, May 31, 2011).

After the work of the North Carolina Articulation Task Force, the North Carolina Institute of Medicine (NCIOM) convened a task force to address the North Carolina nursing workforce shortage. In 2004, the NCIOM task force released a report that included many recommendations and strategies made by the North Carolina Articulation Task Force [10]. Despite a lack of funding, AHEC, North Carolina educational systems, private nursing programs, the North Carolina Board of Nursing, and other organizations have collaborated on many of the recommendations. The AHEC program office and the AHEC Nurses’ Council annually convene directors of RN/BSN/MSN nursing programs located at universities and community colleges to discuss and review program developments. Many regional AHECs have annual advisory meetings to discuss strategies to increase enrollment of ADN-level nurses in BSN and MSN programs. In 2007, the NCIOM reviewed the recommendations from 2004 and provided a detailed update that outlined the legislative and organizational responsibilities needed to meet the recommendations [11]. The report noted that significant progress had been made but that there were still inadequate numbers of BSN-level nurses in North Carolina.

Numerous studies on the educational progression of ADN-level nurses demonstrate the common challenges facing students, including role strain, cost, access, and lack of rewards [12, 13]. Because the nursing workforce consists predominantly of women, role strain stems from competing priorities among the family unit, work, and school [12]. Another challenge is cost. Educational expenses for returning to school vary depending on the number of prerequisites that must be taken before entering the pathway from RN to BSN and/or MSN (hereafter, RN-BSN/MSN). Current economic conditions often make the RN the primary wage earner, and even when organizations provide financial support for education, the RN must find the funds to pay for the courses upfront. Before online education, geographical access was a major deterrent to RNs’ return to school, particularly in rural areas. Even with the increased availability of online education, many nurses reside where Internet access and speed limit the use of this educational mode. A final significant barrier is the lack of rewards in health care organizations for advanced degrees [12, 13]. Offering financial incentives to pursue a higher degree strongly affects the decision to return to school [13]. RNs must consider the costs and benefits associated with continuing education, and often, there is no benefit to offset the cost. Even with the demonstrated improvement in patient safety and outcomes seen with higher ratios of BSN-level nurses, health care organizations rarely offer pay differentials for a BSN or an MSN. In September 2010, Eastern AHEC conducted a regional survey that evaluated nurses’ interest in returning to school. Of 583 respondents, 39% indicated an interest in RN-to-BSN education. Only 3% desired a classroom-only program, with the remaining seeking a 100% online program or a blended (ie, classroom and online) program of study. Of the 122 responses from students who offered suggestions, 21% were related to finances. Sixteen of the 148 ADN-level nurses stated that excessive prerequisites and duplicate courses were major deterrents to returning to school. These findings parallel those in the literature and those determined by the 2001 task force in North Carolina. Barriers and facilitators in the ADN-to-BSN or ADN-to-MSN journey are summarized in Table 2. Despite continued interest in RN-BSN/MSN education and multiple efforts to achieve a seamless progression for RNs to return to school, limited success has occurred.

Creating a seamless pathway for the journey back to school for ADN-level nurses will take concerted effort. Aiken [3] notes that there is a need for education and practice policymakers to develop a unified plan that responds to the growing need for nurses and creates a nursing workforce that addresses chronic disease, health disparities, and patient safety. Unless organizations that employ nurses recognize and reward higher education, many RNs will determine that the benefit of another degree does not exceed the degree’s cost [13]. ADN programs provide an affordable educational experience across North Carolina, and they are our greatest source for an ethnically diverse nursing workforce. ADN programs also provide nursing resources in communities that might otherwise suffer from chronic shortages. But achievement of the ADN must become, for a large number of nurses, only the starting point. Health care organizations must respond to the imperative that a better-educated nursing workforce reduces mortality and decreases the risk of adverse events in health care facilities [5, 6]. If organizations require a BSN or higher degree for leadership positions, and if they reward direct care nurses who invest in educational advancement, then RNs will make the choice to return to school. Once that choice is made, the community college and university system must be prepared to facilitate their education.

To that end, many of the partially implemented recommendations from the NCIOM’s 2007 update must be reexamined and implemented [11]. First, greater priority should be placed on increasing the number of BSN-level nurses, to achieve the overall goal of an 80% ratio in the workforce. This includes basic BSN educational programs and RN-BSN/MSN initiatives in North Carolina.

Second, the North Carolina General Assembly and private foundations need to explore new scholarship support for nursing students, particularly those pursuing the RN-BSN/MSN pathway, as well as support for part-time students who are working full-time.

Third, the North Carolina General Assembly should increase funding to the Nurse Scholars Program, to expand the number and types of awards and amounts of support given.

Fourth, the CAA between community colleges and the UNC System (ie, the associate in arts degree), as well as the bilateral articulation agreements involving students with an associate of applied science in nursing degree and the UNC System, should be evaluated and improved so that students wishing to advance from one level of nursing education to another can transition without duplication of courses. This recommendation is critical to the escalation of RN-BSN/MSN programs. If universities accept the associate of applied science nursing degree and transfer ADN-level nurses as juniors, courses would transfer as a block, not individually. In keeping with this, ADN curricula should include nonnursing courses that are part of the CAA. Also, the UNC System and the North Carolina independent colleges and universities with BSN programs should establish (and accept for admission purposes, across the UNC System) general education and nursing education core requirements for RN-BSN/MSN students who completed their nursing education in North Carolina after 1999.

Many ADN-level nurses returning to school must take prerequisite courses at multiple community colleges to prepare for admission into an RN-BSN/MSN program. The lack of centralized systems for course availability and scheduling, the need for redundant community college admission applications and fees, and the lack of advisement for students in between the ADN and the BSN programs create a protracted system for achieving prerequisites and test the endurance of full-time nurses who are juggling a career and a family.

To successfully create a seamless educational pathway for ADN-level nurses to achieve a BSN or an MSN, nursing must receive support from patients, physician colleagues, nurse leaders, and policymakers to implement needed legislation, organizational practices, and simplified systems that successfully promote increases in the number of nurses with a baccalaureate or higher degree in North Carolina. Nurses must educate each other and our communities on the increased competency and capacity that educational advancement brings to patients, populations, and health care organizations. Physicians, realizing the value that educational advancement of nurses brings to the team, need to require that organizations meet the evidence-based standards that demonstrate a need for a higher proportion of BSN-level nurses at the point of care. Nurse executives must advocate for educational advancement, tuition reimbursement, and systems of support within health care organizations that aide RNs in returning to school. Additionally, these nurse leaders must create clinical ladders that require educational progression and reward academic achievement. North Carolina policymakers must promote the highest standards for nursing care delivery in the state, develop funding mechanisms for ADN-level nurses to return to school, and support community college and university system integration and articulation that make achieving a BSN a realistic goal for every ADN-level nurse in North Carolina. Working together, we can make this happen.

Potential conflicts of interest. E.S.S. and H.B. have no relevant conflicts of interest.

1. National Advisory Council of Nursing Education and Practice. Report to the Secretary of the Department of Health and Human Services on the Basic Registered Nurse Workforce. Accessed March 30, 2011.

2. Institute of Medicine of the National Academies. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: The National Academies Press; 2011.

3. Aiken LH. Nurses for the future. N Eng J Med. 2011;364(3):196-198.

4. Aiken LH, Cheung RB, Olds D. Education policy initiatives to address the nurse shortage in the United States. Health Aff (Millwood). 2009;4:646-656.

5. Aiken LH, Clarke SP, Sloane D, Lake ET, Cheney T. Effects of hospital care environment on patient mortality and nurse outcomes. J Nurs Adm. 2008;5:223-229.

6. Friese CR, Lake ET, Aiken LH, Silver JH, Sochalski J. Hospital nurse practice environments and outcomes for surgical oncology patients. Health Services Res. 2008;43(4):1145‐1163.

7. Health Resources and Services Administration, US Department of Health and Human Services. The Registered Nurse Population: Initial Findings from the 2008 National Sample Survey of Registered Nurses. Accessed March 20, 2011.

8. Currently licensed RNs. North Carolina Board of Nursing Web site. Accessed May 31, 2011.

9. Matthias AD. The intersection of the history of associate degree nursing and “BSN in 10”: three visible paths. Teach Learn Nurs. 2010;5:39-43.

10. North Carolina Institute of Medicine (NCIOM). Task Force on the North Carolina Nursing Workforce Report. Durham, NC: NCIOM; 2004. Accessed March 20, 2011.

11. North Carolina Institute of Medicine (NCIOM). Task Force on the North Carolina Nursing Workforce Report: Update 2007. Morrisville, NC: NCIOM; 2007. Accessed March 20, 2011.

12. Delaney C, Piscopo B. RN-BSN programs: associate degree and diploma nurses’ perceptions of the benefits and barriers to returning to school. J Nurses Staff Dev. 2004;4:157-161.

13. Warren JI, Mills ME. Motivating registered nurses to return for an advanced degree. J Contin Educ Nurs. 2009;5:200-207.

Elaine S. Scott, PhD, RN associate professor, College of Nursing, East Carolina University, Greenville, North Carolina.
Helen Brinson, MSN, RN director, Nursing Education, Eastern Area Health Education Center, Greenville, North Carolina.

Address correspondence to Dr. Elaine S. Scott, College of Nursing, East Carolina University, 3138 Health Sciences Bldg, Greenville, NC 27858 (