Radical transformation

 
January 16, 2010 -- Today the Dayton Daily News (OH) ran a fair article by Dave Larsen about a new Carnegie Foundation study by prominent UCSF nursing scholar Patricia Benner and three colleagues calling for U.S. nurses to have at least a bachelor's degree because of the demands of modern nursing practice. Currently, an associate's degree is the minimum requirement. The Daily News piece is balanced, allowing both sides of the debate over the bachelor's idea to present their views, although it does not convey how long the debate has been going on, instead making it sound like the idea is novel. And although the piece spends a lot of time on the particulars of associate's and bachelor's training at local colleges and hospitals, it does not get deeply enough into how nurses will practice in a health care environment in which care technology is increasingly complex and their colleagues increasingly have graduate degrees. Among the unanswered questions:  Does any research suggest that patient outcomes are better when nurses have more formal education? (A: Yes.) Is it fair to expect a nurse with an associate's degree to advocate effectively with a physician with eight years of university education? Should patients' lives depend on the nurse being able to overcome that imbalance? Does any other autonomous health profession require less than a master's degree? On the other hand, how would a move to a bachelor's requirement affect the long-standing nursing shortage? Indeed, the piece does not even mention what may be the most radical recommendation in the study:  that all nurses obtain a master's degree within 10 years of starting practice. Still, we thank the Dayton Daily News for making a serious effort to cover the study; we're not aware that any major mainstream press outlet gave the study any attention at all. But imagine the media's reaction if a major foundation proposed adding 1-4 years to physician training!

The piece is headlined "Nurses now need 4-year degree instead of 2, study finds." So right off the bat, and in the remainder, the article indicates that the nursing associate's degree (AD) is a two-year program. But the prerequisites required for the nursing AD often mean that candidates must take closer to three years of college course work, so this is somewhat misleading. The piece explains that although more than half of U.S. nurses are now AD graduates, the new study "Educating Nurses: A Call for Radical Transformation" says that "today's nurses are under-educated for the demands of practice" and calls for what the article describes as "change to produce nursing graduates who are better prepared to deal with profound changes in science, technology, and the nature and setting of nursing practice." In particular, the study recommends an expansion in nursing program capacities to allow students to  "complete degrees in a reasonable amount of time," and specifically suggests that community college programs "seamlessly articulate their programs at the two-year mark with an affiliated four-year nursing program to enable nurses to complete bachelor's degrees in about 4 1/2 years." It's not clear from the article how that would work, or why it would present any overall advantage over simply getting a 4-year degree. It would seem that because of the limited capacity of existing BSN programs, AD programs would need to continue as feeder schools to universities for some time until all nursing programs could be transitioned to 4-year programs.

The piece notes that the study was written by "Patricia Benner" (right), but does not say that she is a professor emeritus at the University of California at San Francisco who has been a prominent nursing leader for many years, nor that her three co-authors--Molly Sutphen, Vickie Leonard, and Lisa Day--are all doctorally-prepared UCSF nurses as well.

The report quickly gets to a major theme, which is that the BSN entry idea "presents problems and opportunities for local two-year and four-year colleges." The piece gives local associate's degree advocates the first opportunity to react. The president of Sinclair Community College, Steven Lee Johnson, says that "it's an interesting notion, yet it doesn't seem to be congruent with our experience." This gently mocking statement suggests that Sinclair has never heard of this kooky "notion" before--who knows what these zany ivory tower types will come up with next!? Sinclair associate provost Gloria Goldman adds that most of the school's graduates work in the Dayton area, and "we have really good employer feedback." Of course, the debate about the minimum degree for nurses has been going on for many years, and no executive at a community college with a nursing program is likely to be unfamiliar with it. The piece also explains that AD programs "allow students with family or job responsibilities to attend part-time," which is a good point. Presumably, Benner's study is suggesting that four-year programs show similar flexibility if they don't already, though the article does not make that completely clear.

Despite the associate provost's comment, local hospitals seem to favor bachelor's degree graduates. Jayne Lachey Gmeiner, director of Miami Valley Hospital's Center of Nursing Excellence, notes that "health care is becoming more and more complex. Having that bachelor's degree is going to help that nurse continue to be able to practice in probably a better way moving forward." Gmeiner says Benner's "From Novice to Expert: Excellence and Power in Clinical Nursing Practice" has "served as the basis of Miami Valley's internal career ladder for nurses for more than two decades." The article calls this a "study," but it is actually a highly influential 310-page book. Gmeiner explains that all new Miami Valley nurses complete a "pretty intense" orientation "because we have recognized that they are not ready to practice right when they get out of school." This suggests that nurses, like physicians, benefit from substantial clinical orientation before they can practice effectively. The report does not say so, but formal nursing residencies have been shown to help prepare nurses and reduce turnover, though residencies are of course no substitute for academic preparation. Miami Valley helps its nurses get bachelor's degrees with tuition reimbursement and an "on-site bachelor's completion program in collaboration with Wright State University's College of Nursing and Health." Pat Martin (right), Wright State's nursing dean, adds that "there's so much to know, why shouldn't [nurses] be getting the same kind of education that we would expect for an engineer."

Much of the report describes specifics of current local nursing programs. Some "articulation programs" currently enable associate's degree holders to get their bachelor's degrees, and these are reportedly becoming more popular. At least one local institution, Kettering College, is apparently considering starting a four-year degree program and possibly even ending its existing two-year program. Beverly Cobb, the school's director of nursing, explains that "we have an increasing number of employers saying they have a preference ... for baccalaureate-educated nurses, so we are wanting to make sure that we are preparing our nurses." However, "that doesn't mean that they won't be able to get jobs as associate degree nurses."

The piece manages to convey many of the aspects surrounding the important question of what the minimum educational requirement for nurses should be, and it includes good quotes from local college and hospital figures. But it might have delved deeper into the core issues and provided more context. The article fails to explain that the debate has been ongoing for quite a while, and it does not consult the national nursing associations who have long been focused on that debate, the American Association of Colleges of Nursing and the National Association for Associate Degree Nursing. We sometimes wonder whether reporters even know there are national nursing associations, as they are so often ignored in serious articles about health practice. Nor does the piece note that some research, including some by noted nursing scholar Linda Aiken, has suggested that patient outcomes are better when nurses have more education.

The piece includes the comment by Pat Martin about engineers, which is good. However, the report might also have explored how nursing education compares to the education of the professionals with whom nurses work every day, including the physicians with doctorates as well as professionals like social workers and physical therapists, who generally have master's degrees. The piece gives no indication that one of nurses' must important duties is to advocate for their patients, which at times means significant technical discussion with these colleagues and others. Nurses have saved countless lives by catching errors, by carefully explaining the ramifications of health care choices, and even by refusing to allow care plans to proceed. But such activities can be very challenging when there is a large disparity in formal education.

As for the technical aspects of practice, the piece does include some suggestion that nursing practice is complex and requires substantial knowledge. But it might have told readers some of the specific things nurses have to do, such as operating advanced monitoring and therapeutic technology, titrating medications, detecting subtle changes in patient conditions, and explaining complex self-care regimens to patients.

The piece also fails to note that the U.S. has faced a critical nursing shortage for more than a decade, and that this shortage has been a factor in the debate about nursing education. Associate's degree advocates reasonably argue that the nation cannot afford to make it more difficult for nurses to enter practice at this time. Indeed, in recent years there have been efforts to "streamline" nursing education in order to relieve the shortage. And many thousands of qualified applicants are rejected each year from bachelor's programs because of a lack of faculty and other resources. A bachelor's requirement would put even more stress on those programs, and requiring a master's no more than 10 years into practice would require a large additional investment in nursing education. Yet how else can nurses obtain the rough parity with their colleagues that will be necessary for nurses to practice and advocate effectively in the complex health care environment of the future? Of course, lower levels of formal education and associated social status make it harder for nurses to get the resources they need to practice and teach, which exacerbates the nursing shortage. It's a vicious cycle:  a lack of resources and respect fuels a shortage, and the shortage then discourages reforms that might get the profession more resources and respect. But one key step forward is to educate decision-makers about the true value of nursing, so they understand why the profession is worth not just the usual Nurses Week lip service, but significantly increased investment even in a difficult economic climate.

At least the Dayton Daily News covered this story and did a pretty good job of conveying some basic aspects of the debate. We are aware of no significant coverage of the study in a major mainstream publication, despite the fact the Carnegie Foundation is one of the nation's major foundations and that it did issue a press release about the study. This absence of coverage itself suggests undervaluation of the profession among most elite media creators.

When it comes to nursing, even "radical transformation" doesn't necessarily get much attention.

See the study "Educating Nurses: A Call for Radical Transformation" by the Carnegie Foundation.

See the story "Nurses now need 4-year degree instead of 2, study finds" by Dave Larsen, posted on January 16, 2010 on the Dayton Daily News website.

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