Nursing: A Model for New York State

1. Nursing: A Model for New York State Deb Zimmermann, RN, MS, NEA-BC

2. BACKGROUND: Advances in science and increasing patient complexity have accelerated the need for nurses with better skills and knowledge to manage a challenging and increasingly diverse healthcare environment. Researchers have demonstrated a significant relationship between higher levels of nursing education and improved patient outcomes (Aiken, Clark, Cheung, Sloane, and Silber, 2003, 2008; Estabrooks, Midozi, Cummings, Ricker, & Giovannetti, 2005; and Tourangeau et al., 2006, Blegen &Goode, 2009). In 2008, 32 state and national nursing organizations recommended advancing education standards so nurses are well prepared for the future.

3. Deaths per 1000 patients with complications 90 deaths in 1,000 patients 84 deaths in 1,000 patients 76 deaths in 1,000 patients Research and Nurse Surveys Support ChangeAs Nurse Education Increases, Patient Mortality Decreases Aiken (2003) JAMA Education (Percentage of hospital nurses with BS degrees.)

4. Replication of Aiken study in 18,142 patients in 49 hospitals and 6,526 in Alberta, Canada with identical results Estabrooks, et al. (2005). • Hospitals with a higher proportion of BSN RNs experienced lower rates of 30-day patient mortality OR 0.81 [95%CI (0.68 - 0.96]

5. Tourangeau (2007) • Study of 46, 993 patients • Demonstrated 9 fewer deaths per 1000 discharges for every 10% increase in BS prepared nurses

6. Blegen & Goode (2009) • Longitudinal study of 21 US hospitals over 84 quarters • In hospitals with a higher proportion of BS educated nurses: • Lower rates of CHF mortality • Fewer Hospital Acquired Pressure Ulcers • Lower rates of Failure to Rescue • Shorter hospitalizations

7. 2007 NY Nursing StudyRetention and Satisfaction 5,000 RNs: • 47% BSN • 53% AD • 20% received tuition assistance • 40% planned to go back to school • Twice as likely to remain in job with tuition assistance • BS prepared RNs reported higher job satisfaction and lower job stress • BS prepared nurses more than ten years tenure McGinnis S & Martiniano R. (2008), Estabrooks (2005), Ingersoll (2001)

8. 2007 NY Nursing Study 5,007 Practicing RNs • 47% BSN • 53% AD • 20% received tuition assistance • 40% planned to go back to school • Twice as likely to remain in job with tuition assistance • BS prepared RNs reported higher job satisfaction and lower job stress • BS prepared nurses more than ten years tenure McGinnis S & Martiniano R. (2008), Estabrooks (2005), Ingersoll (2001)

9. Education: A sound foundation Much Like Vaccination, there when you need it

10. Causative Theory: Patient and Nursing Outcomesadapted from Kane (2007) Moderating Factors Causal Factors Antecedent Factors Impact Medical staff Hospitalists Intensivists Cultural Background Residents Healthcare Organization Size Volume Specialties Technology Finance Margin Patient Outcomes Morbidity/Mortality Patient Satisfaction Nurse Sensitive Indicators Length of Stay Patient Factors Age CMI Diagnosis Co-morbidity Staffing HPPD Skill mix Community SONs Laws/Regulations Economy Payers Organizational Culture Policies/ Benefits EBP/Research Governance Leadership/Communication Cultural Competence Values and Theoretical Framework Model of Care Delivery Nurse Characteristics Education Age/ Experience Diversity Nurse Outcomes Satisfaction Years of Service Turnover Vacancy Advancement Mediating Mechanisms

11. DEMOGRAPHICS:Total number of New York State Registered Nurses: 257,724New York RN licenses IssuedDemographics 266,029 Registered Nurses in NYS New Licenses Issued RN Vacancy and Turnover New York State Dept of Education ( 2009), Healthcare Association New York (2009)

12. Faculty and Graduates • 47 RN to BSN Programs in NYS • In a June 2009 survey. NYS Deans reported immediate capacity for 5000 RN to BSN students NYS Graduates 4800 AD 3200 BSN 8000 Annually Only 20% go on for BSN Capacity Graduates

13. Statistics • Graduates take NCLEX-RN licensing exam. Tests for minimum technical competency (NCSB,2006) • The average RN salary is $73,000, in rural areas $58,000 (U.S.Department of Labor, 2008) • In Canada, the EU, and Australia enrollment rose after education standards were increased to BSN (Reuters, 2009) • Age of nurses in Canada similar to NYS (Tourangeau, 2009)

14. Nursing: A New Model for New York State The Plan: • Provide seamless transition from AD to BSN programs • Reduce financial barriers for baccalaureate education • Increase the number of nursing faculty • Standardize education requirements

15. The Plan Provide seamless transition from AD to BSN • Standardize admission criteria and application procedures • Endorse common pre-requisites • Develop standard competencies • Concurrently admit students to AD and BSN programs Reduce financial barriers for BSN education • Establish a statewide endowment for nursing scholarships • Require a year of service for every year of education funded

16. More Objectives Increase the number of nursing faculty • Establish nursing faculty scholarships through the endowment • Require recipients to complete a service contract at a New York institution of higher education Standardize education requirements • Standardize education requirements through the passage of Bills A2079B/S4051 • This legislation would require acquisition of a baccalaureate degree in nursing within ten years of initial licensure

17. Why is this important? • The IOM found RNs are the profession to intercept medical errors which cost 3.5 billion dollars a year • RNs prevent hospital acquired pneumonia which increase hospital costs 84% • Cost of RN turnover equivalent to a year of RN salary • Medical errors kill more people than breast cancer, AIDs and MVA’s combined Hassmiller(2009), Institute of Medicine(2004), Jones(2005)

18. Benefits Aiken, 2003; Blegen, 2009; Rambur 2005; Tanner,2007; Unruh, 2008)

19. Work Underway • Statewide meetings between nursing leaders and CEO’s • Implementation of Oregon Model in NYS • Continuation of dialogue with legislators • Pursue regulatory change vs. legislation • Engage national leaders • Engage other states • Recognize the need for resiliency

20. Transformation of Nursing Education Canada: New RNs must be BS prepared European Union: BS required Philippines: BSN Required Since 1988 Thailand: BS required Australia: BSN Required Since 1992 In Canada, enrollment rose after education standards were increased to the BS level. The average age of an RN in Canada is similar to the United States.