Bridging the Knowledge and Practice Gap Between Diploma and BNSc Prepared RNs

1. Loyer-DaSilva Research Chair in Public Health Nursing| http://www.health.uottawa.ca/chairdasilva/index.htm Bridging the Knowledge and Practice Gap Between Diploma and BNSc Prepared RNs Josephine Etowa RM, RN, IBCLC, BSc.N, MScN, PhD Associate Professor-UOttawa-Canada & Visiting Associate Professor University of Calabar-Nigeria NANNM 6th Biennial/ 5th Quadrennial National Delegates Conference 2012 November 22, 2012

2. NANNM 2012 Conference Presentation Outline • Background • Nursing • Nursing Education • Significance of Higher Education: The Gaps • Drivers of Change • Models of Transitions • New York Model-USA • Canadian Model • Advancing Nursing Education • The Future of Nursing Education • Summary and Conclusions Loyer-DaSilva Research Chair in Public Health Nursing

3. NANNM 2012 Conference Background • Located at the eastern edge of the West African sub-region, Nigeria is the most populous African country with a population of approx. 140,003,542 (WHO, 2008) • The latest estimates (NPC 2007) put life expectancy in Nigeria at 44 years. • Today, there is a 36-year gap in life expectancy between countries. • For example, a child born in Nigeria can expect to live for 47 years while a child born in Japan could live for as long as 83 years Loyer-DaSilva Research Chair in Public Health Nursing

4. NANNM 2012 Conference BackgroundNigeria Health Workforce • There are 128,918 nurses and 90,489 midwives on the register, but only a fraction of these pay the required practicing licensing fee • There are 52, 408 Nigerian Doctors on the medical register. • 13,199 Pharmacists, • 840 Radiographers, • 1,473 Physiotherapists, • 12,703 Medical laboratory scientists, • 19,268 Community Health Officers (WHO, 2008). PrLoyer-DaSilva Research Chair in Public Health Nursing

5. NANNM 2012 Conference Background:Educational Programs • 86 approved schools of nursing • with 17 university-based programs, • 77 approved school of midwifery, • 12 medical laboratory schools, • 6 schools of physiotherapy, • 9 schools of pharmacy, • 19 schools of pharmacy technology, • 5 schools of radiography, • 40 schools of health records, • 13 schools of community health officers, • 43 schools of community health extension workers, • 4 schools of dental technology, • 6 schools of dental therapy, • 3 schools of optometry. Loyer-DaSilva Research Chair in Public Health Nursing

6. NANNM 2012 Conference Nursing • Nursing, as both an art and a science, is a practice profession and a knowledge-based academic discipline concerned with promoting health and healing including care of the sick and dying. • Nursing as a caring practice profession and a discipline is embedded in a social, historical, economic, environmental, and political context. • RNs have the knowledge, skills and understanding for participating within these contexts as leaders and health care providers. Loyer-DaSilva Research Chair in Public Health Nursing

7. NANNM 2012 Conference Nursing ...2 • Nursing is one of the most adaptable professions within the health care workforce, thus it reinvents itself as health care advances and changes. • This leads to new career pathways for nurses which attracts more diverse applicant pool and a broader scope of practice and responsibilities • Nursing has been an enabling force for change in health care including the coordination of multidisciplinary care teams (Aiken et al.,2009). • Over the past decades, nursing has increasingly played a pivotal role as the backbone of health care to the extent that a future without large numbers of nurses is impossible to envision. Loyer-DaSilva Research Chair in Public Health Nursing

8. NANNM 2012 Conference Multiple Roles of Nurses Loyer-DaSilva Research Chair in Public Health Nursing

9. NANNM 2012 Conference Nursing Education • Nursing knowledge is developed through research , education and other practice experiences. • Nursing education responds to societal concerns by developing a curriculum that is relevant and considers future trends in health care. • To best serve the health care needs of the public in the years ahead , a more educated nursing workforce is necessary Loyer-DaSilva Research Chair in Public Health Nursing

10. NANNM 2012 Conference Nursing Education • Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression (IOM report, 2011) • Knowledgeable Leader Loyer-DaSilva Research Chair in Public Health Nursing

11. NANNM 2012 Conference Significance of Higher Education • Advances in health science and technology, the changing practice boundaries between medicine and nursing, and the complexity of the health care of a population with multiple chronic health conditions calls for a more educated nursing workforce. • A number of studies have shown the relationship between higher levels of nursing education and improved patient health outcomes (Aiken et al, 2003; Goode et al 2010; Estabrooks, et al 2005 ). • Aiken et al showed that all else being equal, the odds of 30-day mortality and failure to rescue were reduced 5% with every 10% increase in BScN-prepared nurses. • Goode et al longitudinal study of 21 hospitals over 84 quarters5 found that patients cared for by BScN-prepared nurses experienced significant reductions in length of inpatient stay, decreases in hospital acquiredpressure ulcers, and reductions in cardiac mortality. • In the workplace, BScN-prepared nurses report less difficulty in managing complex patients and incorporate critical thinking in their daily practice Loyer-DaSilva Research Chair in Public Health Nursing

12. NANNM 2012 Conference Gap in Knowledge • In the US, it has been shown that when Diploma and BScN prepared RNs sit for the same national licensing exam (NCLEX-RN) and the y both perform equally well. • However, this exam measures minimal competency for safe entry into practice but does not test for the additional knowledge and skills of baccalaureate preparation • These include: • evidence-based practice, • information management, • healthcare policy and finance, • Interprofessional communication and collaboration, • organizational and systems leadership, • population health • Highlighting this curricular differences in has been instrumental in gaining support from various stakeholders especially from clinical administrators. Loyer-DaSilva Research Chair in Public Health Nursing

13. Changing Environment Technological advances Nature of work Growing populations NANNM 2012 Conference Drivers of Change Information availability Loyer-DaSilva Research Chair in Public Health Nursing

14. NANNM 2012 Conference The Tides of ChangeAdapted from Rodgers, 2010 Turbulence is a life force. It is opportunity. Let’s embrace the turbulence and use it’s energy for change. By R. Clarke Loyer-DaSilva Research Chair in Public Health Nursing

15. NANNM 2012 Conference Leading Change Loyer-DaSilva Research Chair in Public Health Nursing

16. NANNM 2012 Conference Changes in Global Standards of Nursing Education • The global community has embraced university preparation for nurses, and standards are quickly changing around the world. The following countries have moved to BSc.N as the entry point to the profession: • Australia, Belgium, Canada, Denmark, • Finland, Ireland, Italy, the Netherlands, • New Zealand, Norway, the Philippines, and Spain • The Bologna Process towards international standardization of the European higher education have been endorsed by over 45 countries and is impacting on nursing education globally. Loyer-DaSilva Research Chair in Public Health Nursing

17. NANNM 2012 Conference Changes in Global Standards of Nursing Education... • The new structure for higher education has improved the competitiveness and status of nursing with a resulting increase in the # of new graduates. • In Canada, the number of nurses entering the profession increased in each province in which the education standard was raised to the Baccalaureate level. • The international impact of BScN education and the accompanying growth in nursing in the countries that have raised their standard have been instrumental in winning the support of nurses, legislators, and healthcare administrators. Loyer-DaSilva Research Chair in Public Health Nursing

18. NANNM 2012 Conference New York Model (Zimmermann et al 2010) • Developed over the course of 7 years, and based on state and national data, extensive consultation with national nurse researchers, leaders and educators. • The model provides for useful, cost-effective education and makes good use of resources. • It is an academia and clinical practice collaboration which has led to this innovative and practical model informed by evidence and has workforce indicators Loyer-DaSilva Research Chair in Public Health Nursing

19. NANNM 2012 Conference 3 Objectives of NY Model • Standardize Education Requirements • Provide Seamless Transition From Diploma (AD) to BS in Nursing Programs • Address Financing for Baccalaureate Education Loyer-DaSilva Research Chair in Public Health Nursing

20. NANNM 2012 Conference Standardize Education Requirements • The model proposed revision of the Nurse Practice Act, requiring future RNs to attain a BS within 10 years of graduating from a diploma or AD program. • Those who fail to meet the standard will be referred to the State Board of Nursing for further action. The board will then either place the nurse’s license on hold or given an extension based on a given situation. • The bills were specifically crafted to raise educational requirements without displacing the contribution of RNs already in the system and those of community colleges. Loyer-DaSilva Research Chair in Public Health Nursing

21. NANNM 2012 Conference 2. Provide Seamless Transition • More than 660 RN-to-BS programs are offered nationwide, including more than 390 programs that are partially available through distance learning. • Adequate faculty members throughout the country with innovative partnerships. • Healthcare organizations linked with academic institutions for onsite RN-to-BS programs and accelerated fast-track graduate education. • Access to nursing education in rural areas became feasible through online and satellite programs • One plus- two-plus one and two-plus-two programs make baccalaureate education more affordable Loyer-DaSilva Research Chair in Public Health Nursing

22. NANNM 2012 Conference 3. Address Financing for Baccalaureate Education • Funding is a barrier for nurses to return to school, thus must be part of the transition plan. • State level Nursing scholarships were proposed. • In addition, Federal and state nursing scholarships were widely publicized. • Ten year was allowed for attainment of a BS so RNs can work full time while they study part time. Loyer-DaSilva Research Chair in Public Health Nursing

23. NANNM 2012 Conference Advancing Nursing Education • As the nation’s largest healthcare workforce , nurses play a major role in the design, delivery, and transformation of healthcare. • Advancing the profession through an investment in education serves the nation’s health and advances the greater good. • If nursing continues to be the least educated member of the healthcare team, its role and influence will be limited. • Supporting baccalaureate education is an essential next step in the progression toward a more educated nursing workforce committed to lifelong learning. Loyer-DaSilva Research Chair in Public Health Nursing

24. We must increase our visibility in the Global Scene from Ottawa to Bangkok - one chart for 2 Charters GLOBAL Research WHO Commission on the SDoH: Advancing Global Actions Healthy globalization NATIONAL SDOH Healthy international policy across governement Healthy public policy COMMUNITY Community action NURSES Health-Promotion Health Services Global citizenship for health Empowering Environments Personal Skills & Transformation Rio Déclaration-2011

25. NANNM 2012 Conference Collaboration • In collaboration with other health professionals, government and non government agencies, nurses will redesign the system • It takes the combined effort of networks both within and outside the public health system to address population-wide health challenges. Loyer-DaSilva Research Chair in Public Health Nursing

26. NANNM 2012 Conference Leadership • To play an active role in address these pillars, the nursing profession must produce leaders throughout the system, from the bedside to the boardroom. • Be a Trailblazer Loyer-DaSilva Research Chair in Public Health Nursing

27. NANNM 2012 Conference Leadership • Nurse leaders must act as full partners with physicians and other health professionals • They need to be accountable for their own contributions to high-quality health care while working collaboratively with leaders from other health professions • Visionary Leader Loyer-DaSilva Research Chair in Public Health Nursing

28. NANNM 2012 Conference The Future of Nursing Education(Cronenwett,2011) • What to Teach • How to Teach • Where to Teach • Who Teaches: Characteristics of Desired Faculty Members of the Future • Nursing Organizations’ Role • Role of Government and Other Organizations Loyer-DaSilva Research Chair in Public Health Nursing

29. NANNM 2012 Conference What to Teach • Competencies necessary for continuous improvement of the quality and safety of health care —patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics • Mastery of knowledge of systems, interpretations of variation, human psychology in complex systems, and approaches to gaining knowledge in real-world, local contexts •  Skills and methods for leadership and management of continual improvement, for nurse-teachers and nurse-executives Loyer-DaSilva Research Chair in Public Health Nursing

30. NANNM 2012 Conference What to Teach...2 • Competencies needed in new care delivery models • Population health and population-based care management • Care coordination • Knowledge based on standardized science prerequisites • Health policy knowledge, skills, and attitudes • Competencies related to emerging health needs—e.g., geriatrics Loyer-DaSilva Research Chair in Public Health Nursing

31. NANNM 2012 Conference How to Teach • Guide students in integrating knowledge from clinical, social, and behavioral sciences with the practice of nursing to enhance development of clinical reasoning skills • Enhance opportunities for interprofessional education • Evaluate and test models of interprofessional education, including timing, determination of what levels of students should learn together, and what content is most effectively delivered with interprofessional learners Loyer-DaSilva Research Chair in Public Health Nursing

32. NANNM 2012 Conference How to Teach...2 • Develop and test new approaches to pre-licensure clinical education, including use of simulation • Involve students in interprofessional quality improvement projects • Develop model pre-licensure curricula that incorporate best practices in teaching and learning and can be used as a framework for community college–university partnerships Loyer-DaSilva Research Chair in Public Health Nursing

33. NANNM 2012 Conference Where to Teach • In baccalaureate and higher degree programs • Increase the number and proportion of new RNs who graduate from basic pre-licensure education with a baccalaureate or higher degree in nursing • Require the BSN for entry into practice • Support community college/university partnerships that increase the number of associate degree graduates that complete the baccalaureate degree • Allow community colleges to provide baccalaureate degrees • In post-graduate residency programs • Develop and test clinical education models that include post-graduate residency programs • Implement requirement of post-graduate residency for initial re-licensure Loyer-DaSilva Research Chair in Public Health Nursing

34. NANNM 2012 Conference Where to Teach...2 • In health care settings that foster day-to-day change and improvement • In programs built on strong academic–practice setting partnerships • At Academic Health Centers, promote governance structures that combine the strategic, rather than operational, oversight for nursing • In settings that are models of integrated care where care coordination skills can be developed Loyer-DaSilva Research Chair in Public Health Nursing

35. NANNM 2012 Conference Who will Teach Characteristics of Desired Faculty Members of the Future Increase the number of faculty members: • Whose criteria for appointment and advancement include recognition of practice-based accomplishments, including engagement in the work of improving health care • Who can move easily during careers between practice and academe • Who shorten their career paths from BSN to doctoral degree Loyer-DaSilva Research Chair in Public Health Nursing

36. NANNM 2012 Conference Who will Teach...2 • Characteristics of Desired Faculty Members of the Future • Increase the number of faculty members: • Who maintain professional certification and/or clinical competence • Who build alliances with faculty in other disciplines (medicine, engineering, business, public health, law) • Who are capable of leading efforts to advance Interprofessional education Loyer-DaSilva Research Chair in Public Health Nursing

37. NANNM 2012 Conference Nursing Organizations’ Role • Ensure that schools produce ever-increasing numbers of nurse practitioners for primary care roles at a time when expanded access to health care will increase society’s need for primary care providers • Challenge current credit-heavy requirements and test teaching innovations that improve competence while reducing program credits • Support the faculty development necessary to bring about the magnitude of reforms in nursing education recommended in the Carnegie study, necessitated by advances in nursing science and practice and guided by advances in the science of learning • Support a learning collaborative of state boards of nursing willing to implement regulatory requirements for transition to practice residency programs as a prerequisite for initial re-licensure Loyer-DaSilva Research Chair in Public Health Nursing

38. NANNM 2012 Conference Nursing Organizations’ Role...2 • Advance post-master’s DNP education, maintaining specialist preparation at the master’s program level • Fund initiative to facilitate professional consensus that DNP programs should be launched as post-master’s program for the foreseeable future • Clarify the expectations for nurse scientists interested in translational research—will both the DNP and the PhD be required? Will the DNP alone be sufficient for tenure-track positions in research-intensive universities? • Identify top ten areas of needed faculty development and provide public recognition for success Loyer-DaSilva Research Chair in Public Health Nursing

39. NANNM 2012 Conference Nursing Organizations’ Role...3 • Accreditation criteria for nursing education programs should include: • Substantive nursing education–service partnerships, e.g., in shared teaching and clinical problem solving • Interprofessional education • Development of competencies in health policy • Student/faculty participation in or leadership of teams that work to improve health care • Student competency development related to health policy • Require proof of a nurse’s participation in or leadership of teams that work to continuously improve the health care system for renewal of certification • Urge testing of interprofessional teamwork and collaboration and health policy competencies in licensure exams Loyer-DaSilva Research Chair in Public Health Nursing

40. NANNM 2012 Conference Role of Government and Other Organizations • Increase scholarships, loan forgiveness, and institutional capacity awards to increase the number and proportion of newly licensed nurses graduating from baccalaureate and higher degree programs • Increase scholarships, loan forgiveness, and institutional capacity awards for graduate nurse education at master’s and doctoral levels • Redirect nursing education funds from hospital-based pre-licensure programs to postgraduate residency programs Loyer-DaSilva Research Chair in Public Health Nursing

41. NANNM 2012 Conference Role of Government and Other Organizations ...2 • Promote innovation and evaluation of novel approaches to improving preparation for the practice of nursing through expanded funding • Invest in nursing education research, related particularly to the evaluation of multiple pathways to licensure • Use research facilitation structures to promote knowledge development at the point of care, translation of knowledge into practice, practice improvements, and interprofessional education Loyer-DaSilva Research Chair in Public Health Nursing

42. NANNM 2012 Conference Role of Government and Other Organizations ...3 • Create a federal health professions workforce planning and policy capacity in the Executive Branch • Expand authorities for funds to support development and evaluation of interprofessional education innovations • Expand Nurse Faculty Loan Programs and other loan forgiveness/scholarship programs that produce more faculty • Encourage public and private resource investments that incentivize students and nursing programs to expedite production of qualified nurse faculty by shortening the trajectory from entry into basic nursing programs through doctoral and post-doctoral study • Create incentives to motivate community college nursing programs to increase the proportion of their nursing students who complete their initial education with a BScN Loyer-DaSilva Research Chair in Public Health Nursing

43. NANNM 2012 Conference Role of Government and Other Organizations...4 • Increase programs that support greater production of nurse practitioners for primary care (and remove legal barriers to interprofessional education and practice) • Fund studies to track state-based data on number and proportion of new nurse graduates from ADN vs. BSN/higher degree programs • Advance media attention to states that exemplify “best practices” in the distribution of new nurse graduates from ADN vs. BSN programs • Include health services research (in addition to drug and treatment intervention trials) in initiatives to enhance comparative effectiveness research • Require universities and colleges (presidents, provosts, deans) to support infrastructures and mandates for interprofessional education Loyer-DaSilva Research Chair in Public Health Nursing

44. NANNM 2012 Conference In Summary • Growing evidence suggests that the shortage of nurses with BSN and higher education is negatively impacting on various aspects of health care delivery at the preset time and the problems will worsen in the future • Nurses’ scientific understanding of care processes give them a unique ability to lead the improvement and redesign of the health care system IOM Report (2011) Loyer-DaSilva Research Chair in Public Health Nursing

45. NANNM 2012 Conference Conclusions • The time is ripe for nurses in Nigeria to join the rest of the world to embrace this reality of contemporary nursing-Change • We must be creative as we are confronted with the challenges in a changing world • Taking the pulse of health care Loyer-DaSilva Research Chair in Public Health Nursing

46. Loyer-DaSilva Research Chair in Public Health Nursing Thank YouQuestions Email: jetowa@uottawa.ca Website: http://www.health.uottawa.ca/chairdasilva/index.htm