Evaluating national outcomes

Outcomes in advancing the educational level of the nursing workforce must be taken in context.  Researchers have developed and published extensive study data to validate and highlight the need for more highly educated nurses.  Nursing leaders and other stakeholders have been messaging powerfully and consistently to RNs that higher levels of education are important.   APIN and SIP grantees specifically have devoted extensive time and resources to messaging the need for academic progression and have developed a wide variety of tools for this purpose, including publications, podcasts, PowerPoint presentations, student adviser guides, and other content.  Practice partners have had substantial influence on nursing education trends both nationally and regionally.  

Changes in nursing education metrics therefore reflect the combined impact of these efforts and cannot be specifically attributed to any single source, although the Campaign for Action overall has clearly influenced each aspect.  Data displayed through the Campaign for Action dashboard (Campaign for Action, 2017) demonstrate clear progress:

  • More U.S. educated nurses have a BSN or higher degree at their entry into practice than at any previous point in history.
  • Nurses are returning to school in record numbers.  RN-to-BSN graduations have risen dramatically since the onset of the Campaign, from 22,531 in 2010 to 56,059 in 2015.
  • The overall proportion of employed nurses with a BSN or higher degree in nursing is climbing slowly but steadily, from 49% in 2010 to 53% in 2015.

Evaluating individual program outcomes

Nursing leaders and other stakeholders need to assess program outcomes in order to identify the most promising elements of progression pathways.  APIN project leaders created summative reports in January of 2017, and the NPO has distilled those findings.  NPO staff and consultants subsequently reached out to other academic progression program sites who have been included in the national convening to obtain any outcome data available.  Comparative outcomes in particular would be useful to all, however this creates a significant challenge.  Project development sites selected varied metrics for evaluation of progress with no unifying standard.  Projects advancing a defined cohort of co-enrolled students are able to track outcomes differently than those attempting influence on a broad number of schools statewide.  A few projects have not advanced sufficiently for numeric evaluation.  With these caveats in mind, some assessment is still possible and valuable.  All forms substantially reduce the time to progression from the AD to a higher degree from the existing baseline of a 9-12 year delay (HRSA, 2008; California Board of Registered Nursing, 2012).  While all forms of partnership within this continuum improve student progression, outcomes are not equivalent. 

Integrated curriculum models

Early evidence indicates that partnerships in which students complete university coursework concurrently with AD content hold the greatest promise for substantially accelerating the proportion of nurses with a BSN.   Within the relatively small sample of co-enrollment programs with cohorts who have completed the AD portion of the curriculum, the proportion of students continuing to the BSN has increased dramatically, in some cases to over 80% and in all cases evaluated to over 60%.   This substantive increase validates the benefit of this approach, however outcomes still have not matched expectations in some cases.  This is particularly concerning since (with the exception of the MANE program) these cohorts include only those students who self – selected a pathway designed for BSN exit, and they were chosen through a competitive process.  Virtually all were anticipated to complete the baccalaureate immediately after the AD.  The lower-than-expected continuation rate provides the impetus for the fully integrated curriculum, in which students enter at the community college but are not licensed until program completion. Those models are also in early stages for evaluation, but current metrics indicate > 85% of students who begin their nursing education through this pathway will progress directly to successful completion of the BSN.  This measure is inclusive of attrition in the AD content.    

Articulation and transfer models

With the exception of the MANE project, integrated curriculum programs draw from a subset of AD students who have declared an interest in BSN education, and they cannot easily be compared to articulation and transfer models.  Prior to the initiation of APIN, it was clear that simple articulation was insufficient to achieve the needed transformation, as these agreements had been longstanding in many communities with minimal impact on the proportion of BSN-prepared nurses.  Even among schools who have addressed prerequisites, co-requisites, and nursing courses, curricular alignment alone does not provide the needed impetus for students.   Adequate infrastructure for student advising, admission, and financial aid must also be created.  Limited data indicate that in these cases the proportion of students who progress may approach 20%.

Strengthening that infrastructure improves likelihood of success.  Highly developed shared curriculum models using standardized articulation or transfer with solid advising have been shown to triple the proportion of students advancing from the AD to the BSN into the 30% range (Munkvold, Tanner, & Herinckx, 2012).  These students may advance after a delay of some years however.  In one very small sample (22 students) a new direct transfer agreement in Washington resulted in over 40% of AD graduates advancing to the BSN.  For other newer models, comparative evaluation is hampered by lack of standardized metrics, and by the time – lag between program development and students reaching the decision point at which they exit with the AD or continue for the BSN.  For students who do exit, programs have not been in place long enough to evaluate the proportion who return for continuation within a defined timeframe. 

The NPO has compiled a brief overview and summary of academic progression models and their outcomes to date, including those from both APIN and non-APIN funded sites (See Appendix A - Link pending).  More time and additional evaluation are needed to clarify and validate the early findings in evaluation of progression pathways.

Incidental learning and additional benefits

Beyond specifics of academic progression, APIN and the related efforts of the Campaign for Action have resulted in substantial benefits which will continue to influence nursing professional development in the years ahead. In addition to the development of academic progression models themselves, many APIN states used grant funds to complete other substantive projects to advance nursing education.  The NPO has provided a summary of these accomplishments, available with full descriptions Link.

The creation of a national community of nursing educators inclusive of both community colleges and universities is having a profound impact.  The candor and collegial spirit of this group has provided an opportunity for frank discussion of model strengths, shortfalls, and challenges.  Promising practices from all areas have been shared and consolidated. The recognition of common effort toward a common goal resulted in a fellowship and camaraderie which generated a commitment not only to the work but to one another.  This represents transformative change in the nursing education community which can be directly attributed to the Campaign for Action.

New leaders have emerged across the nursing community in relation to the work of education transformation.  The creative and highly complex nature of the work along with the mandate for improved relationships required unique skills, and many individuals rose to the occasion.  Role modeling, mentorship, and team development resulted in identification and fostering of new young leaders.

The NPO itself experienced key learnings which may be useful to others.   Conducting site visits after grants were awarded, rather than before, allowed project staff to accurately assess and support individual grantees.  The relatively poor understanding about outcome measures would have been better addressed earlier, although there was value in teaching grantees to move beyond counting in evaluating impact of their work.  Supporting program leaders who were working with volunteers was challenging.  Identifying sooner the importance for individual project coordinators might have expedited work in some states.   Developing trust between grantees and project staff required time, but ultimately created a safe space to discuss successes and challenges and was key to the progress of individual projects.  Outreach to key national partners beyond the funded grantees greatly expanded both the understanding of promising practices and the sphere of influence of the project.