437CHAPTER 20

Issues and Challenges for Nurse Educators

Sarah B. Keating

OBJECTIVES

Upon completion of Chapter 20, the reader will be able to:

Chapter 20 summarizes the text and discusses trends, issues, and challenges raised throughout the text. It ends with a sample curriculum that progresses from the lower division level of higher education to the doctorate and features step out points along the way for nurses wishing to enter the workforce at various levels. It integrates some newer prerequisite courses from other disciplines to support the knowledge base for nursing in a complex and ever changing health care system. It continues the career ladder concept of nursing education so that its practitioners can enter subsequent levels of education without repeating previously learned knowledge and skills. At the same time, it promotes a nonstop, progressive curriculum for those who wish to enter at the doctorate level. It is a blueprint for an 8-year prenursing and nursing curriculum that graduates the student in 8 years with either a doctor of nursing practice (DNP) or a research and theory-building doctorate, that is, the PhD or doctor of nursing science (DNS). The author is the first to admit that it is not perfect. Its intent is to raise issues, provoke thought, and generate discussion for future planning.

CHAPTER 1: HISTORY OF NURSING EDUCATION IN THE UNITED STATES

Chapter 1 describes the history of nursing education as it moved from apprentice-type programs into higher education programs. The chapter raises many of the issues related to nursing’s role in academe and its impact on the profession and 438entry into practice. The Institute of Medicine’s (IOM) (2011) recommendation from The Future of Nursing: Focus on Education calls for nurses to be prepared at higher levels of education to meet the health care needs of the 21st century. In response, programs and enrollments in RN to bachelor of science in nursing (BSN) and RN to master of science in nursing (MSN) programs are expanding (American Association of Colleges of Nursing [AACN], 2014a). The explosion of DNP programs for advanced practice (AACN, 2014b), the recognition of the PhD and DNS as the discipline’s research and theory-building degrees, the effect of health care legislation, and the impact of technology on the profession will be the major forces that influence continued evolvement of nursing in the 21st century.

CHAPTER 2: CURRICULUM DEVELOPMENT AND APPROVAL PROCESSES IN CHANGING EDUCATIONAL ENVIRONMENTS

Chapter 2 reviews the processes that schools of nursing undergo to bring about curriculum revision or develop new programs. Several issues related to curriculum development activities are raised including budgetary constraints and faculty shortages that result in turning away qualified applicants. As recommended by the AACN (2012), local and regional partnerships with health care facilities, foundations, and other stakeholders are possible solutions to relieving financial burdens.

The integration of technology into the curriculum challenges faculty to develop newer instructional strategies such as online classes, simulated laboratory experiences, electronic communications, and smart classrooms. The issue of content saturation must be confronted, else the temptation to crowd the curriculum beyond the point of reason will overwhelm students’ learning capacity. Curriculum assessment and content analyses/maps help to identify areas of redundancies or content overload that lead to curriculum revision. Based on the assessment and evaluation, faculty can develop a curriculum that is up to date that guides and facilitates conceptual approaches to learning.

CHAPTER 3: THE ROLE OF FACULTY IN CURRICULUM DEVELOPMENT AND EVALUATION

Chapter 3 reviews the role of faculty in curriculum development and evaluation. Issues raised include the need for new, inexperienced faculty to be oriented to the curriculum and mentored by senior faculty. In the interest of expediency, many part-time and new faculty members are oriented to the particular course in which they teach but not to the total program, thus risking curriculum erosion and failure to meet planned student learning outcomes. The advantages and challenges related to orientation programs and mentorships are discussed and ideas for them are presented. The issue of the lack of pedagogical knowledge for many new master’s and doctorally prepared faculty is raised. To meet this need, opportunities for faculty development through workshops, continuing education, and academic courses in education are discussed.

The importance of the role of faculty in curriculum development and evaluation is discussed. Faculty members have the responsibility to assess the curriculum and its implementation in order to identify need for revision. The necessity to 439include students and colleagues in practice for curriculum evaluation and development processes is discussed. Research topics and opportunities for study related to faculty role and responsibilities are considered.

CHAPTERS 4 AND 5: LEARNING THEORIES AND USING CONTEXTUAL CURRICULUM DESIGN WITH TAXONOMIES TO PROMOTE CRITICAL THINKING

Chapter 4 reviews six major categories of learning theories commonly accepted in today’s education system and their application to nursing education. The rationale for analyzing learning theories and their relationship to instructional strategies for enhancing the student’s ability to meet learning outcomes is explained. Combinations of learning theories depend on the faculty’s philosophy of learning, the knowledge and skills to be imparted, the learning environment, and the students’ and faculty’s characteristics. Learning theories provide the foundation for the curriculum and its program goals. Issues that arise when considering learning theories include faculty conflicts related to individual philosophies of teaching and learning and the ability to respond to individual student learning needs when coping with heavy academic responsibilities. The challenge to faculty is to apply learning theories to curriculum designs that prepare nurses to meet the health needs of the people and the future health care delivery system.

Chapter 5 reviews the classic and newer educational taxonomies and domains of learning as they apply to nursing education. It continues with an overview of the development of critical thinking and the major role it plays in clinical decision making in nursing practice. Several models that apply the newer taxonomies to curriculum development and promote active learning are presented. Readers are challenged to use the Contextual Approach to Navigate Delivery of Outcomes (CANDO) when developing the curriculum. The model analyzes several theories including general systems, complexity, adult learning, and constructivism in light of external and internal program contexts. These analyzes result in the development of the end-of-program outcomes with the remaining components of the curriculum developed through the application of a backward design, that is, starting from the expected program outcomes to development of level and course objectives.

CHAPTERS 6 AND 7: A NEEDS ASSESSMENT MODEL FOR CURRICULUM DEVELOPMENT

Section III of this text introduces the Frame Factors model, a conceptual model that describes the major external and internal factors that influence, facilitate, or impinge upon the curriculum. Chapters 6 and 7 review the major components of a needs assessment that include analysis of these factors. While the principal activities of faculty in curriculum development and evaluation are on the curriculum plan and the need for improvement based on evaluation of its implementation and the program outcomes, the needs assessment should become part of the repertoire of the faculty. Even if faculty are not involved in the details of the needs assessment, it should be aware of all of the factors that have an influence on the curriculum. 440These factors can mean the life or death of an education program; thus, faculty members sophisticated in the assessment of external and internal frame factors have an advantage in viewing the curriculum and its place in the scheme of financial security, position within the health care system and the profession, role in meeting the health care needs of the community and industry, and significance to the parent institution.

It is recommended that nurse educators in both the academic and practice settings use the Frame Factors model when evaluating education programs, considering revisions of existing programs, or initiating new programs. While administrators may take the leadership role in conducting needs assessments, faculty should participate in the decisions for what type and how much data to collect and what decisions are made that affect the curriculum based on the analysis of the needs assessment.

CHAPTER 8: FINANCIAL SUPPORT AND BUDGET PLANNING FOR CURRICULUM DEVELOPMENT OR REVISION

Chapter 8 reviews the costs, income, and resources related to the financial support of curriculum development, evaluation, and accreditation activities. Specific costs include faculty released time, administrative and staff support, and office equipment, technology support, and supplies. These are costs over and above the usual budget demands and must be planned for in advance. The challenge is to earmark funds for these activities to avoid unexpected shortfalls and an impact on other program expenditures. Knowledge of possible resources external to the program is useful for generating funds that help to initiate new programs and the chapter reviews several potential funding sources. In addition to a review of budget planning, the roles and responsibilities of administrators and faculty are described and the importance of faculty participation and contributions to budgetary planning is noted.

CHAPTER 9: COMPONENTS OF THE CURRICULUM AND ISSUES ARISING FROM TODAY’S NURSING CURRICULA

Chapter 9 organizes the components of the curriculum in the traditional way, that is, mission, philosophy, goal, organizational framework, student learning outcomes (objectives), and implementation plan. The components of the curriculum provide an organizing framework for initiating or revising an educational program. Major concepts related to the underlying philosophy and the beliefs faculty hold about nursing and education are examined in light of their contribution to and place in the curriculum. Examples include beliefs about teaching and learning processes, critical thinking and its application to nursing, liberal education and the sciences, the health care system, and so on. When revising the curriculum or developing new programs, faculty should initiate the change processes by discussing these concepts and theories and how they apply to the level of nursing education in their program. Most faculty members will agree that these concepts are fundamental to nursing 441education. The challenge occurs when deciding at what level of competency for each concept/essential they expect from their graduates, that is, undergraduate and/or graduate levels.

While it may seem cumbersome at times, in the long run, examining the curriculum by its major components results in a logical order for planning and evaluation. When faculty members contemplate change in response to a needs assessment of the external and internal frame factors, each component of the curriculum is examined for its congruence with the proposed changes. This may lead to a radical revamping of the curriculum, for it may be discovered that the demands for graduates or from the health care system have so dramatically changed that the mission, philosophy, and goals of the program are outdated or irrelevant.

Approaching the curriculum holistically by viewing all of its components leads to orderly revisions rather than the “Band-Aid” approach that attempts to mend one portion of the program without considering its effects on the other components. Nurse educators are frequently guilty of this maneuver in order to respond to obvious need for changes. The problems associated with this method are their possible detrimental effects on other parts of the program and adding to an already overloaded and content saturated curriculum.

CHAPTERS 10 THROUGH 15: CURRICULUM PLANNING

Chapters 10 and 11 discuss the two current, major curricula for entry into practice, that is, the associate degree in nursing (ADN) and the baccalaureate/BSN. Both of these programs have been in existence since the mid-20th century, replacing the hospital-based diploma programs that continue to exist, but are decreasing in numbers. Chapter 11 describes generic (entry-level) baccalaureate programs as well as fast-track baccalaureate programs for college graduates and RN to BSN programs. The old issue of entry into practice rears its ugly head as the ADN and baccalaureate are examined; however, with the need to produce more nurses as rapidly as possible to meet health care demands and the need for higher education in nursing, the authors of Chapters 10 and 11 describe curricula that embrace both programs and foster career ladder opportunities. Each chapter provides excellent examples of curricula for preparing nurses for the current health care system and can serve in the interim as nursing meets the challenge to educate clinicians, educators, practitioners, scientists, and researchers for the future.

Chapters 12 and 13 examine graduate education at the master’s and professional doctoral degree levels including entry-level master’s programs for nonnursing college graduates. The traditional place for advanced practice roles such as the nurse practitioner, nurse anesthetist, nurse midwife, and clinical specialist has been at the master’s level. However, the DNP degree is replacing the master’s in response to the AACN recommendation that the DNP be the terminal practice degree by 2015 (AACN, 2004). This position and the IOM’s (2011) recommendation for nurses prepared at higher degree levels led to an explosive growth of DNP programs across the nation, starting first with postmaster’s degrees and moving to the BSN to DNP program. Many issues arise from this situation with the profession struggling with where master’s-prepared case managers, clinical nurse 442leaders, nurse managers, administrators, nurse educators, and community/public health nurses fall. Chapters 12 and 13 raise these issues as graduate/doctorate levels of nursing education continue to evolve.

Graduate programs are particularly hard hit by the looming shortage of doctorally prepared teachers as faculty members age and retire and the numbers of new graduates from doctoral programs do not meet the demand. This situation provides the impetus for accelerating access to graduate education for both new entrants into the discipline and practicing nurses and educators who have an interest in teaching. Additional incentives for the faculty role need to be in place to make the educator role competitive with that of practice, administration, and research. Chapter 14 discusses research-focused degree programs and their role as “Stewards of the Discipline” through their research and leadership activities and as faculty members in schools of nursing.

An issue related to doctoral-prepared faculty is the debate that continues about the doctor of nursing practice (DNP) versus the research-focused degrees, that is, the DNS and the PhD and their place in nursing education. It is posed that PhD and DNS-prepared educators are suitable for tenure-track positions in schools of nursing, while DNP graduates are meant for clinically focused teaching positions. However, a counter-argument is that the DNP prepares nurses for applied research, translational science, and evidence-based practice and they could compete in tenure-track roles. It is also argued that DNP graduates are the experts in the practice role and can be role models for the students. There are persuasive arguments on both sides but the majority of those expressing opinions agree that for either degree, nurses planning to teach in schools of nursing need additional knowledge and skills (courses) in education, for example, curriculum development, instructional strategies, educational technology/simulation, and student and program evaluation.

Chapter 15 applies the principles of curriculum development and evaluation to staff development in the practice setting. Nurse educators in academe and in the practice setting have much to offer each other. Nurse educators who focus on staff development can provide faculty with their perspectives on the knowledge and competency expectations for students and graduates. Their wisdom is valuable in helping faculty prepare new graduates for practice in the reality setting. Nursing faculty members, on the other hand, have expertise in instructional strategies and program development, which they can share with nurse educators in the practice settings. They also have clinical specialty knowledge and skills for offering in-service opportunities for nursing staff in health agencies. Faculty also provides orientation and educational services to nurse preceptors and mentors for students and new graduates.

Research partnerships between nursing service and education benefit nursing faculty members as they earn promotion and tenure and keep abreast of changes in health care, while students can carry out their graduate theses or dissertations in the practice arena in collaboration with staff. All levels of students apply the newest knowledge from research to evidence-based practice, which in turn, is shared with nursing staff members who reciprocate with their knowledge and clinical skills in the latest advances in health care.

443There are increasing instances of industry and education partnerships, with industry working with schools of nursing to develop quality clinical experiences for students and to assist with the costs for additional faculty members to meet faculty shortages (Burns et al., 2011; Jeffries et al., 2013). Qualified staff members from the agencies serve as instructors, while continuing in their practice roles in the agencies. It is imperative that instructors from the service area are well oriented to the curriculum and its goals and objectives in order to protect the integrity of the curriculum. There must be opportunities for new instructors’ participation in faculty and curriculum meetings as well as for their responsibilities to the curriculum. Experienced faculty members act as mentors to share the curriculum plan and the knowledge and skills necessary to the learner-centered teaching role.

CHAPTERS 16 AND 17 PROGRAM EVALUATION AND ACCREDITATION

Chapter 16 reviews common definitions, concepts, and theories in evaluation that apply to nursing curricula and programs evaluation. Nursing education evaluation is evolving from an emphasis in the past on the use of models of evaluation in education to the adaptation of business and health care models to measure productivity, outcomes, cost-effectiveness, and quality. Issues that are raised in Chapter 16 relate to the increasing emphasis on outcomes and benchmarks to measure quality and the possible loss of equal attention to the processes that lead to the outcomes. Owing to many accreditation standards, educational programs usually have master plans of evaluation in place to facilitate the process of collecting and analyzing data. These data relate to the standards expected for accreditation and the goals and objectives of the program. One flaw in many of the master plans is the lack of specific plans to follow-up on the analyzes and their recommendations. Implementing strategies to act on the recommendations closes the loop between data collection and actions for change in the curriculum, thus maintaining an up to date and vibrant program.

Chapter 17 discusses in detail accreditation agencies, their purpose, and their role in total quality management. Included in the chapter is a description of the process for undergoing accreditation. While accreditation is voluntary, it carries certain advantages for the institution and its students and graduates. For example, an accredited institution demonstrates to the public that it meets quality standards or criteria set by education and the profession, and therefore increases its marketability. For students and graduates, an accredited program signifies that they are eligible for certain financial aid programs and, in most cases, admission to an institution of higher education for the next degree level(s).

Two major issues are raised regarding accreditation. The first is the question of these agencies keeping their standards and criteria up to date. With the expansion of technology-driven distance education programs and rapid changes in the health care system, it becomes difficult to make changes in the curriculum in response to the changes and at the same time, ensure that the program continues to meet program approval standards and accreditation criteria.

Many state boards of nursing and accreditation agencies require notification of any major (or even minor) changes in the existing program. Although this ensures quality and maintenance of approval or accreditation, it can hamper 444creativity and a speedy response to external changes and demands on the program. The advantage of notifying program approval and accreditation agencies of pending changes is the preservation of quality, while the disadvantage is a lowered motivation for creating change. In these cases, the wise strategy is to consult with the agencies when the idea for change begins to form and to continue the consultation throughout the planning stages so that the appropriate paperwork and visits, if necessary, are ready for timely approval processes.

Educators have a responsibility to participate in accreditation processes including review of standards and criteria, becoming site visitors, and becoming members on review boards and committees of the agencies. These kinds of activities contribute to faculty’s professional development and the ability of the approval and accrediting agencies to keep abreast of changes occurring in education and the profession that call for modifications of standards and criteria.

CHAPTER 18: EFFECTS OF INFORMATICS AND TECHNOLOGY ON CURRICULUM DEVELOPMENT AND EVALUATION

The growth of technology and informatics and their impact on nursing education is explored in Chapter 18. A major concern about the integration of nursing informatics and technology into the curriculum is the lack of planning in advance and the lack of using standards developed by nursing informatics experts (TIGER, 2014). Many times, classes on technology and informatics such as its application to electronic records, utilization of literature and health information databases, and experiences in simulation labs are developed without analyses for their relationship to the curriculum. It is necessary that faculty reviews the curriculum for the student learning outcomes and the organizational framework that relate to informatics and technology, utilize nursing informatics standards as guidelines, and plan for their placement into the program accordingly.

The information age and high technology require faculty to keep abreast of changes and gain the knowledge and skills required for facilitating learning, transmitting new knowledge to students, and conducting research and other scholarly activities. In some cases, faculty preparation does not keep pace with the rapid growth of the utilization of technology. Studies demonstrate the need for faculty development to not only meet the application of technology to instructional strategies but to prepare students to meet the needs of the health care system that utilizes informatics and technology for the delivery of care. Faculty and their student and clinical partners have tremendous opportunities for research that measures the effectiveness of technology and nursing informatics in education and the health care systems.

CHAPTER 19: RESEARCH AND EVIDENCE-BASED PRACTICE IN NURSING EDUCATION

Chapter 19 discusses the need for research in nursing education for evidence-based practice. It reviews Boyer’s (1990) and AACN’s (2014c) statements on the 445scholarship of teaching that serve as guiding principles for faculty to conduct research and produce scholarship that deepens our understanding of education and learning processes. The temptation for faculty is to rely on tried and true strategies for developing curricula and instructional strategies. However, with the rapid changes in the health care delivery system and the impact of technology, educators must provide curricula that are responsive to changes and prepare nurses for the future. Nurses must be able to think critically and creatively, use and generate technology for safe and quality patient care, collaborate with other health professionals and the clients they serve, provide leadership for health care policies, and participate in or conduct research that, in the end, produces high-quality health care. Each chapter of this text reviews the classic and recent literature related to curriculum development and evaluation in nursing. Chapter 19 summarizes the literature review from previous chapters, and using National League for Nursing’s (NLN) Priorities for Nursing Education (2014), suggests topics for further study and research. It is hoped that many studies are replicated for their generalizability and usefulness to nursing educators and that new research findings lead toward evidence-based practice in education and practice.

FROM WHENCE WE CAME AND WHERE TO GO

Chapter 1 reviews the history of nursing education from the mid- to late 1800s to the 21st century. It is interesting to see the visions of nurse leader educators over the centuries that called for a unified approach to curriculum development in nursing and placement of nursing as a discipline and science into academic institutions of higher learning. It is equally interesting to see the influence that international wars and the major changes in the health care system and society had on nursing education. Nursing education programs found that with government help, they could accelerate nursing programs in institutions of higher learning and produce graduates for high demand eras. Advanced practice roles at the master’s level came about as high technology and managed care systems began to change the health care delivery system and research-focused doctoral programs came about as nursing sought its professional identity and began to build the scientific body of knowledge. The explosive growth of the DNP in less than a decade’s time after AACN’s (2004) position paper on the DNP as the terminal degree in nursing for advanced practice is remarkable. As the graduates of these programs increase and impact the health care system at the same time that the Affordable Care Act (ACA) for reform takes place, the role of nursing becomes even more crucial (U.S. Department of Health and Human Services, 2014). Some of the major challenges facing nursing education for the future are discussed below.

THE FUTURE EDUCATIONAL PREPARATION FOR NURSING

The IOM’s recommendations regarding nursing’s future had an impact on nursing education along with the AACN (2004) statement on the DNP as the entry for advanced practice nurses and they might be called the “tipping points” for change 446in nursing education in the 21st century. Gladwell (2002) introduced the concept of tipping points as “little things that happen that result in making a big difference.” Although the IOM recommendations and AACN’s position are not “little things,” they have influenced change. Lane and Kohlenberg (2010) review the rationale for a nursing workforce prepared at the baccalaureate or higher degree levels. They list the various professional organizations and health care systems that endorsed the need for a better prepared nursing workforce and some of the initiatives that occurred on the state legislative levels. Associate degree and baccalaureate nursing programs’ collaboration for curricula that provide seamless entry into the bachelor’s degree for associate degree students/graduates are increasing exponentially. As a by-product of these collaboratives, practice colleagues participate in the planning of curricula and development of the expected practice competencies of graduates (Nielsen, Noone, Voss, & Mathews, 2013; Sroczynski, Gravlin, Route, Hoffart, & Creelman, 2011). Out of these project comes a spirit of colleagueship that overcomes decades of intra-professional resentment and unhealthy competition. Nielsen et al. (2013) and Sroczynski et al. (2011) describe two recent major collaborative undertakings on the West and East Coasts of the United States and provide models for the growth of similar programs throughout the nation.

Another phenomenon is the growth of community colleges that offer baccalaureates in nursing. Daun-Barnett (2011) reviewed community colleges that offer them and found that the majority of these types of programs can be found in Florida, Texas, and Washington. The growth of these programs did not seem to affect enrollments in baccalaureate, private, and other types of nursing programs and produced more nurses for the workforce than if they not been in existence. The question as to the original purpose of community colleges remains, that is, to offer higher education opportunities at lower costs for transfer to upper division programs and to prepare graduates for technical-based careers. If these programs become more numerous, what effect will they have on these original purposes of the community colleges? And are these degrees equivalent to the baccalaureates from traditional 4-year institutions? These are the issues that will need investigation.

The growth of DNP programs and the increase in enrollments in research-focused doctorates indicate an expansion of the nursing workforce prepared at the doctorate level who will be the scientists, faculty, advanced practice heath care providers, and nurse leaders (Kirschling, 2014). It is a forecast of the role that nursing will play in leading health care policy changes for the benefit of the population and providing evidence-based practice built upon collaborative translational science and research.

A key component of professional education is the faculty members who are responsible for developing and implementing curricula that prepare nurses for the future. It is agreed that over the recent past, the focus of instruction changed from teacher-centric to participative, learner-centric modalities. As mentioned previously, nursing is in the process of producing additional doctorally prepared nurses who will serve as faculty members for the newer models of education. Some will be advanced practice nurses/leaders who focus on translational science, while others will be researchers exploring and identifying new knowledge for the science of 447nursing. They will encounter the same challenges facing current educators to fulfill the role of academic faculty, that is, teaching, service, and scholarship/research. The enigma to be solved is how faculty roles are defined to, first, provide high-quality instruction that prepares professionals who meet current and future health care needs and, then, to meet the other faculty expectations, that is, remain current in practice, provide service, and maintain research and scholarship. Roberts and Glod (2013) discuss these dilemmas and stress the need for nursing to find a solution that maintains quality education and research in academe and, at the same time, prepares competent professionals for the health care system.

NURSING INFORMATICS AND TECHNOLOGY

Throughout the chapters of this text, nursing informatics, clinical simulations, and technology applications are discussed as they apply to curriculum development and evaluation. Previous reviews in this chapter alluded to the need for alignment of these advances to the curriculum plan (organizational framework and student learning outcomes). Many of yesterday’s technological advances such as personal digital assistants (PDAs) rapidly become outdated as smartphones and tablets with additional features provide rapid access to databases for health care information. It is hard to imagine the future and additional expansions of technology and their application to nursing and education. Thus, it becomes the responsibility of nursing educators to become or remain sophisticated in the use of informatics, clinical simulations, and other applications. While there are numerous studies on the application of these strategies in nursing education (Brewer, 2011), there remains the need for replication of studies and comparisons of programs across the country to validate their effectiveness and to provide information on best practices. Brewer, in her review of the literature, found several similarities of strategies that produced the most effective learning in simulated clinical experiences; they included student preclass assignments so they were prepared to participate in scenario/case studies, clear clinical evaluation criteria, postconferences for reflective thinking activities, cooperative team work, and linkages to didactic content.

CAREER PATHWAYS AND PROMOTING PROFESSIONAL DEVELOPMENT FOR THE FUTURE

Career Ladder Pathways in Nursing

Nursing, as a profession, prides itself on providing career ladder opportunities through experience in the workforce and progression of degree opportunities from the licensed practical nurse/licensed vocational nurse (LPN/LVN) through to the doctorate. Entry into practice as RNs remains multilayered with graduates of diploma, ADN, BSN, and entry-level master’s degrees eligible for licensure. These multiple pathways continue to confuse the public and those seeking education to become RNs. However, according to the report on the nursing workforce by the Health Resources and Services Administration (HRSA) (2014), there are trends 448toward higher education that give credence to the IOM (2011) recommendations. From 2001 to 2011, the growth in the nursing workforce exceeded that of the general population for the first time and increased in diversity from 20% non-White to 25%. Fifty-five percent of the nursing workforce was prepared at the bachelor’s or higher degree level with many of those receiving an ADN as the first degree. Both the number of bachelor’s prepared nurses taking National Council Licensure Examination (NCLEX) and the number of nonbachelor’s degree nurses doubled. Positive trends in higher education were demonstrated from 2007 to 2011 with an 86% increase of RNs earning a BSN. Also, there was a 60% growth of nurses earning their master’s, and the number of doctoral graduates tripled (HRSA, 2014). While these trends are promising, there remains a concern about the preparation of nurses for today and tomorrow’s far more complex health care demands that require providers prepared at higher levels of knowledge and skills. Although 86% of ADN nurses returned for their BSNs during 2007 to 2011, the ADN-prepared general nursing workforce remains at 60%.

Orsolini-Hain (2012) conducted a study of ADN-prepared staff nurses with years of experience to identify their reasons for not returning for the BSN. Reasons cited were the absence of a salary differential, their perceptions that their competencies were equivalent to or better than BSN-prepared nurses, and through their employer, they participated in research and projects to help improve patient care systems. They viewed master’s prepared nurses as those who were not engaged in direct care but, rather, provided staff development, patient education, and management services. On the other hand, RNs who were graduates of an RN to BSN program viewed the upper division level of nursing education as adding to their communication skills with patients, a gain in cultural competence, and providing an academic background for growing professionally (DeBrew, 2010).

Baccalaureate schools of nursing have a long history of offering user-friendly programs for RNs, doing away with past practices of requiring the RNs to repeat lower division nursing courses and integrating them into classes with generic BSN students. The RN to BSN or RN to MSN programs are for the most part accelerated, usually with 1 year of full-time study to earn the baccalaureate and for the RN to MSN programs, 2 to 2.5 years of full-time study. Courses are geared toward adult learning strategies with classes scheduled 1 day a week, while others offer the program totally online, or a combination of both. The majority of programs have part time options as well.

Brown, Kuhn, and Miner (2012) describe a successful accelerated ADN to BSN program with a 10% attrition rate, a 95% rate of student/graduate satisfaction with the program, and 83% of the students reported they would pursue graduate education. Other successful programs reported in the literature include Wagner’s (2013) study that described a program that introduced RN students to activities involved in professional activities such as attending legislative sessions, board of nursing meetings, and so on. Cobb (2011) discusses the influence of social presence (interactions with peers and faculty) in an online course and its positive contributions to the students’ perceived learning and satisfaction with the program. Robbins and Hoke (2013) conducted a qualitative study of RN to BSN students to identify factors influencing their academic success. The study examined various 449ethnic groups, particularly Hispanic, as the study took place in a university with a high Hispanic population. The major positive themes identified included the faculty’s belief in the potential for student success, a transparent curriculum (program of study), and a commitment to respect of the students. Student factors that had a positive influence were family support, individual resources, and employment considerations. While additional studies to replicate these findings are indicated for generalizability, they provide useful information for programs offering RN to BSN or MSN programs.

For some time, ADN and diploma graduates did not have an incentive to return to school for their baccalaureate or higher degrees owing to, among other factors, the absence of differentiation of practice in the worksite. However, some health care systems moved in that direction. For example, the VA system and hospitals seeking or having magnet status prefer the BSN for their RN staff and have tuition assistance programs for nurses to continue their education by obtaining a baccalaureate and/or higher degree.

Preparation of Interprofessional and International Providers for the Future

Although this text focuses on curriculum development and evaluation in nursing in the United States and as we contemplate the future with its promise and challenges, there is a need to envision a broader, global perspective about nursing and the education required for its professionals. Cyberspace communications give us the ability to share knowledge and expertise with colleagues in health care and discover commonalities and differences that enrich the profession and lead to improved delivery of health care. International colleagues share the same concerns of U.S. nursing educators for preparing quality health professionals to meet the needs of the world’s populations from the poorest nations to the richest. Garrett (2012) likens the issues facing nursing education on an international level to the IOM’s (2011) recommendations on The Future of Nursing in the United States. He summarizes the needs as follows:

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