Healthcare Employers' Policies on Nurse Education

Healthcare Employers’ Policies on Nurse Education

Patricia Pittman, PhD, associate professor, School of Public Health and Health Services, George Washington University, Washington, D.C.; Carolina-Nicole S. Herrera, director, Research, Health Care Cost Institute, Washington, D.C.; Katherine Horton, RN, JD, research professor, Department of Health Policy, George Washington University; Pamela A. Thompson, RN, FAAN, CEO, American Organization of Nurse Executives, Washington, D.C.; Jamie M. Ware, JD, policy director, National Nursing Centers Consortium, Philadelphia, Pennsylvania; and Margaret Terry, PhD, RN, vice president, Quality and Innovation, Visiting Nurse Associations of America, Washington, D.C.

Executive Summary The 2010 recommendation that the proportion of registered nurses with BSN (bachelor of science in nursing) degrees in the nursing workforce should increase from the current 40% to 80% by the year 2020 has shifted the focus on nurses’ educational progression from state legislatures—where changes in entry-level requirements were debated for decades—to the executive suites of large healthcare providers. The recommendation, contained in the report titled The Future of Nurs- ing: Leading Change, Advancing Health, by the Robert Wood Johnson Foundation Initiative on the Future of Nursing at the Institute of Medicine, suggests that human resources policies for nurses have the potential to double the rates of college degree completions (IOM, 2010). We surveyed 447 nurse executives in hospitals, nurse-led clinics, and home and hospice companies to explore the current practices of healthcare employers with regard to this recommendation. Almost 80% of respondents reported that their institution either preferred or required newly hired nurses to have a bachelor’s degree, and 94% of the facilities offered some level of tuition reimbursement. Only 25%, however, required their nurses to earn a BSN or offered salary differentials on the basis of educational attainment (9%). We conclude that if employers are serious about wanting a more highly educated nurse workforce, they need to adopt requirements for degree completion and wage differentials in the coming years. The likelihood that such policies will be widely adopted, however, is dramatically affected by the dynamics of nursing supply and demand.

For more information about the concepts in this article, please contact Dr. Pitt- man at [email protected].

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Introduction we surveyed nurse executives in three The historic controversy over whether settings—hospitals, nurse-led clin- registered nurses (RNs) should be ics, and visiting nurse care associa- required to obtain a baccalaureate tions—to explore the current practices degree has been laid to rest, at least for of healthcare employers with regard to now, by the 2010 report by the Institute the report’s recommendation. We asked of Medicine (IOM) titled The Future if the healthcare organizations require of Nursing: Leading Change, Advancing or prefer a BSN when hiring nurses, Health. The report recommends, and the and we explored the range of policies nursing community appears to be united they might consider to advance nurse in support of, an incremental approach education. Our findings suggest that to increasing the proportion of RNs with most healthcare employers are already BSN (bachelor of science in nursing) using “soft” incentives (such as tuition degrees from the current 40% to 80% of reimbursement) to encourage nurses the nursing workforce by the year 2020. to continue their education, but the The recommendation places the policies proposed by the IOM (such as onus on healthcare employers, rather pay differential and promotion require- than on individual nurses (many of ments) are infrequently used. whom are mid-career or nearing retirement age and may, therefore, never Background recover the additional costs of returning In healthcare, as in any industry, to school), to ensure that nurses have a employers welcome research that seeks bachelor’s degree. Specifically, the report to define their return on investment recommends that employers (1) encour- in employee education (McMahon, age nurses with associate and diploma 1993). Calculating that return, however, degrees to enter baccalaureate nursing is a methodological nightmare, largely programs within five years of gradua- because the period between the initial tion, (2) offer tuition reimbursement, investment (e.g., tuition reimburse- (3) create a work culture that fosters ment) and the measurable outcomes of continuing education, and (4) provide higher-educated workers may be several salary differentials and promotions to years, making it difficult to control the nurses who advance their education. massive number of organizational-level The rationale for the recommendation and individual-level variables that also rests on two assumptions: (1) Better affect outcomes. Nevertheless, leading health outcomes are achieved by nurses companies around the world have made who have complete a BSN degree, and a leap of faith and openly affirm that (2) if more nurses complete a BSN, offering educational benefits is good then more will continue on to graduate for the company’s bottom line (Bloom school, which will increase the number & Lafleur, 1999; MarketWatch, 2011; of advanced practice nurses and nurses Scramm, 2008). who can serve as faculty. Healthcare appears to be no differ- In September 2011, less than a year ent (Pittman, Horton, Keeton, & Her- after the release of the IOM report, rera, 2012). Research that links higher

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proportions of BSNs to better patient progression as one component of a outcomes was mixed in the early 2000s, cost-containment strategy. Nursing, on but evidence of a positive relationship average, has represented about 30% appears to be growing. Aiken, Clarke, of a hospital’s total operating budget Cheung, Sloane, and Silber (2003) were (Welton, Fischer, DeGrace, & Zone- among the first to examine the difference Smith, 2006), and nurse turnover has in performance between BSN and ADN cost hospitals $22,000 to $64,000 per (associate degree in nursing) nurses. person (Strachota, Normandin, O’Brien, They found that a 10% increase in the Clary, & Krukow, 2003). The single most percentage of baccalaureate-educated common strategy to improve nurse nursing staff was correlated with a retention has been to provide tuition 5% decrease in both the likelihood of reimbursement and other educational patients dying within 30 days of admis- benefits. Nationwide, between 40% sion and the odds of hospital staff failing and 60% of nurses reported that their to notice or respond to a patient dying employer provided tuition benefits as of preventable complications (known as part of its efforts to attract and retain “failure to rescue”). A significant rela- nurses (Spetz & Adams, 2006). In 2008, tionship between the education level of 90% of healthcare providers in New nurses and failure-to-rescue rates was York offered tuition assistance to their found by Friese, Lake, Aiken, Silber, nursing staff (Zimmerman, Miner, & and Sochalski (2008). Chang and Mark Zittel, 2010). In addition to tuition- (2009) found decreased incidences of related incentives, career ladders have medication errors when BSNs composed often been used to encourage working up to 54% of the nursing staff. Aiken nurses to advance their education. Some et al. (2011) found not only that higher employers have reported using career- proportions of BSNs reduce 30-day ladder programs as the basis for a suc- mortality and failure-to-rescue rates but cessful nurse retention strategy. Flexible also that better nurse workplace environ- scheduling is yet another policy that has ments magnify this effect. Another study, been linked to high retention and has drawing from the same data set used by shown the potential to help nurses who Aiken et al., found that specialty certifica- are seeking to continue their education. tion enhanced the BSN effect on 30-day Under this policy, nurse administrators mortality and failure-to-rescue rates by work with employees to develop shift an additional 2 percentage points schedules that facilitate their education (Kendall-Gallagher, Aiken, Sloane, & progression as well as reduce stress and Cimiotti, 2011). However, at least two burnout from working untenable hours. studies were unable to find a relation- The Magnet Recognition Program, ship between outcomes and the propor- which has a strong educational compo- tion of BSN nurses (Lake, Shang, Klaus, nent, has had an increasingly important & Dunton, 2010; Sales et al., 2008). influence on hospital nurse workforce As the research base on health out- policies. Beginning in 2013, the Mag- comes evolves, many healthcare employ- net program requires all nurse managers have embraced nurses’ educational ers and nurse leaders to have a BSN or

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higher degree (ANCC, 2011a). To fulfill recommendation positively (Nurse.com, these requirements, hospitals have 2010). formed partnerships with educational institutions and pursued other creative Methods strategies to develop a workforce that To assess employers’ attitudes and is able to meet the Magnet mandates. practices in the area of nurse educa- In addition, rural hospitals that seek tional progressions, in September 2011 Magnet status have developed new ways we administered a web-based survey to encourage their nurses to pursue to chief nursing officers (CNOs) and continuing education, such as forg- chief nursing executives (CNEs) who ing detailed collaboration agreements are members of the American Organiza- between the organization and area col- tion of Nurse Executives (AONE), the leges and universities. Such agreements National Nursing Centers Consortium allow nursing students to work while (NNCC), and the Visiting Nurse Asso- they pursue their education and dra- ciations of America (VNAA). We invited matically cut down on travel time to and just one nurse executive per facility from school (Murphy, Havener, Davis, to participate, but we did not include Jastremski, & Twichell, 2011). Some of system-level nurse executives in this por- these partnerships have led to a marked tion of the survey. These executives usu- increase in the number of BSN-educated ally have considerable leeway in making nurses on staff (Russell, 2010). decisions about allocating the nursing While disentangling the impact of budget and therefore are the key policy the Magnet program’s 14 Forces of Mag- makers with regard to hiring, retention, netism is impossible, overall, hospitals and promotion of nurses in their facili- with Magnet status have reported higher ties (Anthony et al., 2005). percentages of satisfied RNs, lower RN Of the 2,513 nurse leaders invited to turnover and vacancy, improved clini- participate, 447 responded, representing cal outcomes, excellent nurse autonomy a 17.8% response rate from the eligible and decision-making capabilities, and population, or a 17.1% response rate greater patient satisfaction (AHA, 2011; when considering all surveys e-mailed. Drenkard, 2010; Frellick, 2011). Since Of eligible AONE nurse leaders, 15.7% the first Magnet hospital was desig- responded, representing 353 hospitals nated in 1994, 6.61% of all registered or hospital systems. AONE respondents hospitals have achieved Magnet status represented urban hospitals (45.9%), (ANCC, 2011b). healthcare systems (37.9%), rural hos- It is against this backdrop that the pitals (14.7%), and institutions whose IOM’s nursing recommendation for region could not be determined (1.4%) employers to do more to advance nurse (these nurse leaders did not provide education was released. While some a zip code). For the purposes of this concerns have been raised about the analysis (i.e., to avoid duplication), we recommendation’s impact on older excluded the health system–level nurse nurses (Bensing, 2012; Hader, 2011), executives (because their member hos- most employers have reacted to the pitals were also surveyed), leaving 219

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hospital respondents. We identified the After removing respondents who did hospital subset as “urban” if the nurse- not indicate their facility or institution leader respondent provided a hospital type, AONE members made up 89.6% location zip code within a Core-Based of the weighted analytical survey popula- Statistical Area (CBSA) and as “rural” if tion, VNAA members made up 5.7%, the zip code was not within a CBSA. and NNCC members made up 4.8%. Of eligible VNAA nurse leaders, For analysis purposes, nearly 42% of the 36.6% responded, representing 56 survey population represented urban hos- community-based, nonprofit visiting pitals; 34.5% of respondents were from nurse care, and hospice providers. VNAA multifacility hospital systems, 13.4% were respondents primarily represented a from rural hospitals, 5.7% were from single healthcare institution, such as a visiting nurse care institutions, 3.4% were hospice or a visiting nurse care agency from nurse-led primary care clinics, and (91.1%); the remaining 8.9% of VNAA 1.4% represented wellness clinics.1 respondents did not classify themselves as a visiting nurse care or hospice Findings leader. Of NNCC nurse leaders, 32.2% Across all institutions, 48.4% of nurses responded, representing 27 nurse-led had earned their bachelor’s degree or primary care health clinics (71.1%) and higher (Figure 1). This finding closely 11 nurse-led wellness clinics (28.9%). resembles data from the 2008 National

Figure 1 Highest Educational Attainment (Nursing and Non-nursing) of Nurses Employed in 2011, by Institution Type

Note: There are two types of clinics, primary care and wellness, which have been combined for simplicity. Institutional type excludes healthcare systems; total number of cases = 134. Due to rounding, some totals are greater than 100%.

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Sample Survey of Registered Nurses, in (both primary care and wellness) were which the 47.2% of surveyed nurses the least likely of any setting to prefer a were educated at the bachelor’s degree bachelor’s degree (51.6%), but they were level or higher. Not surprisingly, we the most likely to require a bachelor’s found that the proportion of nurses with degree (29%). a bachelor’s degree fluctuated across We asked respondents what incen- institution type. Nurses with an asso- tives they provided to nurses to promote ciate’s degree made up a much larger greater educational attainment (Table portion of the nurse workforce at rural 1). Common “soft” incentives offered hospitals (64.3%) than at urban hos- by employers included increased sched- pitals (44.6%). Clinics (both primary uling flexibility (48%), opportunities care and wellness) employed the greatest for promotion postgraduation (45.3%), share of nurses with a master’s degree and loan repayment (41.6%). The most (53.3%) and doctoral degree (18.8%). frequently used policy, however, was When asked about nurse education tuition reimbursement, which was level and hiring preferences, 79.5% of reportedly offered by 93.7% of all insti- respondents reported that their institu- tutions in our survey (Figure 3). Hos- tion either preferred or required newly pitals located in urban areas were the hired nurses to have a bachelor’s degree most likely to offer this benefit (97.5%), (Figure 2). Of these, 70.6% preferred while wellness clinics were the least and only 8.9% required a BSN. Clinics likely to do so (66.7%).2

Figure 2 Hiring Preference for New RNs, by Setting

Note: There are two types of clinics, primary care and wellness, which have been combined for simplicity. Total number of cases = 243. Due to rounding, some totals are greater than 100%.

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TABLE 1 Incentives Provided to Encourage Nurse Educational Progression (%)

Visiting All Rural Urban Primary Wellness Nurse Care/ Incentives Institutions Hospital Hospital Care Clinic Clinic Hospice

Higher salary 34.8 24.4 37.9 10.0 50.0 45.2 upon degree completion Loan repayment 41.6 68.3 36.2 20.0 16.7 19.4 Organized cadre of 18.2 9.8 23.3 0.0 16.7 6.5 student/peer/ support groups Opportunities for 45.3 43.9 48.3 40.0 16.7 32.3 promotion Greater scheduling 48.0 39.0 52.6 40.0 50.0 38.7 flexibility Other 0.6 0.0 0.9 0.0 0.0 0.0

Note: Total number of cases = 204.

Figure 3 Institutions Providing Tuition Reimbursement, by Setting

Note: Total number of cases = 244.

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Results from our survey show that of rural hospitals offered a differential relatively few institutions offered “hard” greater than $3,000, and none offered incentives, such as a salary differential to new BSNs more than $5,000. BSN-degreed versus ADN nurses at the time of hire for new nurses (Table 2). Discussion While 34.8% of respondents indicated The results of our study suggest that providing higher pay upon a nurse’s healthcare employers, as represented completion of a bachelor’s degree (Table by nurse executives, were actively 1), only 25% implemented a salary searching for ways to promote nurse differential between BSN-degreed and educational progression through ADN nurses (Table 2). Urban hospitals soft policies. Nearly 80% of respon- were more likely than rural hospitals to dents said that their institution either offer a salary differential (25.8% versus required or preferred its newly hired 17%). Nevertheless, when institutions nurses to have a BSN, and almost 94% did offer newly hired nurses a salary of all institutions surveyed offered differential on the basis of education, nurses some type of tuition reim- the incentive was likely to be less than bursement. On the other hand, hard $3,000 per year. Table 2 shows this to policies, which put pressure on nurses be the case for 85.1% of all institutions to complete their BSN, were far less that offered salary differentials. Primary prevalent. Only 8.9% of institutions care and wellness clinics offered the required a BSN at the time of hiring, most generous salary differential of the and only 25% provided pay differen- types of organizations surveyed, fall- tials. Moreover, for most of the facili- ing between $5,000 and $10,000 (20% ties that did provide differentials, the and 33.3%, respectively). Only 12.5% amount was less than $3,000 per year.

TABLE 2 Salary Differential Offered as an Educational Progression Incentive, by Setting (%)

Visiting Rural Urban Primary Wellness Nurse Care/ All Institutions Hospital Hospital Care Clinic Clinic Hospice

Higher BSN salary 25.0 17.0 25.8 23.8 33.3 38.0 <$3,000 85.1 87.5 89.7 80.0 33.3 75.0 $3,000–$4,999 7.9 12.5 3.5 0.0 33.3 18.8 $5,000–$10,000 7.1 0.0 6.9 20.0 33.3 6.3 Salary same for 68.7 80.9 71.7 23.8 22.2 54.6 ADNs and BSNs Unknown/ 6.3 2.1 2.5 52.4 44.4 6.8 indeterminate

Note: Number of cases = 242, except for the salary differential amount, for which the number of cases = 61.

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Our findings shed light on previous important drivers of the market’s studies reporting that tuition reimburse- preference for a BSN degree. However, ment and career ladder programs are not this preference may also have been sufficient to persuade most ADN nurses facilitated by the current surplus of new to complete their BSN degree. Access to nurse graduates who report having diffi- a four-year college in rural areas may be culty finding jobs (Auerbach, Buerhaus, an impediment to completing a BSN & Staiger, 2011). If the surplus continues, (Brewer, Zayas, Kahn, & Sienkiewicz, healthcare employers essentially have 2006; Megginson, 2008), and the return the luxury of employing the highest- on investment for nurses themselves— educated nurses while paying them the in particular, older nurses—continues to same amount that less-educated nurses be low (Carnevale, Rose, & Cheah, 2011; earn. This conclusion is borne out in Graf, 2006). The policy relevance of this our data, which suggest that the prefer- analysis is twofold. First, from the per- ence for BSN-degreed nurses among spectives of healthcare employers, the respondents representing rural hospitals implicit rationale for pro-educational (where fewer BSN-degreed nurses are progression policies appears to be the found) was significantly lower than that reduction of turnover costs, as opposed in urban hospitals. to quality improvement or an increase If, on the other hand, a perfect- in quality-based payments. This implica- storm scenario were to develop—the tion is suggested by the fact that most simultaneous occurrence of an eco- institutions offer tuition reimburse- nomic recovery; the expansion of ment—which is a well-proven retention healthcare coverage; an aging patient strategy—regardless of whether nurses population; mass retirement of the actually use the program or complete aging nurse workforce; and new pay- their studies. On the other hand, salary ment models that reward providers for differentials—which are, by definition, nurse-related work, such as care coor- linked to achieving educational progress dination—most analysts agree that a rather than achieving lower turnover severe nursing shortage could return rates—are far less commonly applied. If (Graf, 2006). Under that scenario, this trend holds true, in order to achieve preferences for BSNs may become less an 80% BSN-prepared workforce by relevant as employer competition for 2020, more healthcare employers will nurses intensifies. The return of a nurs- likely need to adopt the hard policies ing shortage would, in effect, be the real recommended by the IOM, such as test of healthcare employers’ interest in requiring a BSN degree within five years nurse educational progression. of hiring and providing salary differentials by degree. CONCLUSION The second relevant point is that In the coming years, many nurse lead- employer policies must be monitored in ers will be tracking the IOM’s goal of an the context of the supply of and demand 80% BSN nurse workforce by 2020. An for nurses. Both the IOM report and important explanatory backdrop to this Magnet designation are undoubtedly story resides at the level of healthcare

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employer behaviors. Measures to be respondents where their healthcare monitored include (1) employer pref- organization was located; they could erences for BSN-degreed nurses, (2) provide a state, a zip code, or both. Al- most 95% (94.3%) reported that their the use of soft policies that provide an healthcare organization was located incentive for educational progression, in only one state, 4.5% reported that and (3) the use of hard policies that their healthcare organization served require educational progression and more than two states, and 1.2% did not reward it with increased salaries. Health- indicate the state in which they were care employers’ attitudes and practices located. Most hospitals served only one state, as did most clinics and visiting will, in turn, need to be examined in the nurse care providers. Visiting nurse care context of the evolving supply of and providers reported the greatest geo- demand for nurses. graphic diversity, with 11.7% serving two or more states. Notes 2. This finding is likely due both to the 1. Of the rural and urban hospitals, 69% high percentage of wellness clinics that were nonprofit, 13% were for-profit, did not hire nurses and to a dispropor- 10% were public institutions, and tionate number of employed nurses 8% were in a university setting. This with master’s and doctoral degrees. percentage breakdown is similar to the percentages of community hospitals ACKNOWLEDGMENTS that were members of the American The authors would like to acknowledge Hospital Association in fiscal year and thank the Robert Wood Johnson 2011—58.4% were nongovernmental Foundation for funding this research. nonprofits, 21% were publicly owned, and 20.6% were for-profit institutions. Of the nurse-led clinics, approximately References 55% were university based, 37% were Aiken, L. H., Cimiotti, J., Sloane, D. M., Smith, nonprofit, 5% were for-profit, and H. L., Flynn, L., & Neff, D. (2011). The effects of nurse staffing and nurse educa- 3% were owned by “other.” All visit- tion on patient deaths in hospitals with ing nurse care/hospice organizations different nurse work environments. Medi- reported as nonprofit. cal Care, 49(12), 1047–1053. Most responses (79.4%) came Aiken, L. H., Clarke, S. P., Cheung, R. B., from representatives of hospitals, of Sloane, D. M., & Silber, J. H. (2003). which 40.1% were medium sized (i.e., Educational levels of hospital nurses and 100 to 399 beds). Representatives of surgical patient mortality. Journal of the visiting nurse care and hospice institu- American Medical Association, 290(12), tions made up approximately 8.5% of 1617–1623. respondents. Of nurse leaders, 7.3% American Hospital Association (AHA). (2011, represented a clinic, 4.9% of respon- March 22). Magnet status: Is it worth it? [Blog post]. Retrieved from http://ahare dents represented hospitals, and visit- sourcecenter.wordpress.com/2011/03/22 ing nurse care agencies did not select a /magnet-status-is-it-worth-it/ category. American Nurses Credentialing Center We divided the institutions into (ANCC). (2011a). History of the Magnet five categories: rural hospitals, urban program. Retrieved from http://www hospitals, nurse-led primary care clin- .nursecredentialing.org/Magnet ics, wellness clinics, and visiting nurse /ProgramOverview/HistoryoftheMagnet care/hospice organizations. We asked Program.aspx

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PRACTITIONER APPLICATION

Linda J. Knodel, FACHE, vice president and chief nursing officer, Mercy Health Springfield Communities, Springfield, Missouri

he voice and the role of the nurse leader are vital for articulating to other health- T care leaders, governing board members, and peers in the industry that a baccalaureate-prepared nursing workforce has a significant positive impact on patient outcomes and an organization’s financial stability. Therefore, the needs of nurses who choose to continue their education and serve in advanced practice roles or as faculty must be accommodated. As noted in the article by Pittman et al., the majority of hospitals and healthcare systems prefer to hire baccalaureate-prepared nurses; however, the reality of doing so depends on access to nursing education. Even with the increase in online courses, the geographic location of the school of nursing plays a significant role in whether a registered nurse (RN) returns to school for a bachelor of science degree in nursing (BSN). Many nurse leaders know of nurses who have graduated with a BSN degree only to be unable to find employment. As Pittman et al. have done, studying those organizations that require a BSN and experience upon hire could lend additional insight on the needs surrounding our profession. Today, more than ever, organizations must develop and maintain a nursing workforce profile, which provides a means by which to anticipate issues related to nurse staffing, retention, academic progression, and salary administration. Furthermore, nurse leaders need to partner with their human resource (HR), finance, and information technology colleagues to ensure that systems and processes are in place to con- tinuously assess that profile. Adopting practices such as salary differentials for those with a BSN degree may elicit challenges from HR, such as the expectation of equal

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