Healthcare Employers' Policies on Nurse Education
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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 insti- tution 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]. Photocopying or distributing this PDF For permission, please contact the Copyright is prohibited without the permission of Health 399 Clearance Center at www.copyright.com. Administration Press, Chicago, Illinois. For reprints, please contact [email protected]. JHM58(6).indd 399 11/1/13 1:53 PM JOURNAL OF HEALTHCARE MANAGEMENT 58:6 NOVEMBER/DECEMBER 2013 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 retire- ment 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 Photocopying or distributing this PDF For permission, please contact the Copyright is prohibited without the permission of Health 400 Clearance Center at www.copyright.com. Administration Press, Chicago, Illinois. For reprints, please contact [email protected]. JHM58(6).indd 400 11/1/13 1:53 PM HEALTHCARE EMPLOYERS’ POLICIES ON NURSE EDUCATION 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 manag- ers have embraced nurses’ educational ers and nurse leaders to have a BSN or