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Committee for Assessing Progress on Implementing the Recommendations of the Institute of Medicine Report The Future of Nursing: Leading Change, Advancing Health ; Institute of Medicine; National Academies of Sciences, Engineering, and Medicine; Altman SH, Butler AS, Shern L, editors. Assessing Progress on the Institute of Medicine Report The Future of Nursing. Washington (DC): National Academies Press (US); 2016 Feb 22.

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Assessing Progress on the Institute of Medicine Report The Future of Nursing.

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3Achieving Higher Levels of Education

According to The Future of Nursing, the current transformation of the health care system and practice environments requires a corresponding transformation of nursing education (IOM, 2011). The report notes that the goals of nursing education will remain the same—preparing nurses to meet patient needs, function as leaders, and advance science. The report suggests, however, that to work collaboratively and effectively as partners with other professionals in a complex and changing system, nurses need to achieve higher levels of education, both at the time of entry into the profession and throughout their careers. The report offers four recommendations that have implications for the education and preparation of nurses throughout their careers:

  • recommendation 4: Increase the proportion of nurses with a baccalaureate degree to 80 percent by 2020;
  • recommendation 3: Implement nurse residency programs;
  • recommendation 5: Double the number of nurses with a doctorate by 2020; and
  • recommendation 6: Ensure that nurses engage in lifelong learning.

These recommendations fall under the Future of Nursing: Campaign for Action (the Campaign) pillar of “advancing education transformation” (CCNA, n.d.-a); each is discussed in turn in this chapter.


Nursing is a unique profession in that there are many different educational pathways to entry. A student may prepare for a career as a registered nurse (RN) in educational programs leading to a master's degree, a baccalaureate degree, an associate's degree, or a diploma in nursing. Some nurses who graduate with an associate's degree or diploma go on to enroll in baccalaureate completion programs, either before or after licensure. And increasingly, some nurses with baccalaureate degrees in other fields begin their nursing education in so-called direct entry master's degree programs, in which the first phase of their education prepares them for the licensure examination. Regardless of the pathway taken, students must pass the National Council Licensure Examination for Registered Nurses (NCLEX-RN) before entering the field. In 2010, when The Future of Nursing was released, only 36 percent of RNs entered the field with a baccalaureate degree (IOM, 2011). However, many nurses who enter the field with an associate's degree or diploma go on to obtain more education, and in 2010, half of the nursing workforce held a baccalaureate or higher degree. The report recommends that this proportion be increased, setting the ambitious goal of increasing the percentage of nurses holding a baccalaureate degree from 50 percent in 2010 to 80 percent by 2020 (see Box 3-1).

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BOX 3-1

Recommendation 4 from The Future of Nursing: Increase the Proportion of Nurses with a Baccalaureate Degree to 80 Percent by 2020.

There are multiple reasons for this recommendation. The Future of Nursing states that more education would give nurses a wider range of competencies in such vital areas as leadership, systems thinking, evidence-based practice, health policy, and teamwork and collaboration (IOM, 2011). The report notes that the growing complexity of care requires that nurses be able to use advanced technology and to analyze and synthesize information in order to make critical decisions, and it posits that a more educated workforce would be better equipped to meet these demands. The report cites some evidence that higher education of nurses is associated with better patient outcomes.


Academic Progression in Nursing (APIN) is a program funded by the Robert Wood Johnson Foundation (RWJF) and led by the Tri-Council for Nursing (comprising the American Association of Colleges of Nursing [AACN], the American Nurses Association [ANA], the American Organization of Nurse Executives [AONE], and the National League for Nursing [NLN]). The APIN program office, located at AONE, has indicated that RWJF will have invested more than $9 million in this program by the end of 2016.1 Nine states currently participate in APIN—California, Hawaii, Massachusetts, Montana, New Mexico, New York, North Carolina, Texas, and Washington. States were selected to receive funding in the amount of $300,000 over 2 years from 2012 to 2014 and again from 2014 to 2016 because of their efforts to make progress at the state and/or regional level on increasing the proportion of baccalaureate-prepared nurses (RWJF, 2012, 2015b). The funding is intended to be used to advance strategies on academic progression and baccalaureate-prepared nurse employment (see Box 3-2).

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BOX 3-2

Academic Progression in Nursing (APIN) Models.

The New Mexico Nursing Education Consortium (NMNEC), established in 2009-2010, has created a model whereby a common curriculum has been established and adopted by all state-funded nursing programs. The idea behind this model is that “a common nursing curriculum would provide the mechanism for seamless transfer between programs and build partnerships between universities and community colleges” (Landen, 2015; Liesveld et al., 2015, p. 16). The statewide curriculum received approval from the associate's and baccalaureate state-funded schools in 2012 (Landen, 2015). Students enroll at both the community college and the university. They complete their prerequisite courses at the community college level and receive their associate's degree from the community college and their baccalaureate degree from the university concurrently (Hoffman, 2015; Landen, 2015). This model allows students to remain in their rural communities rather than incur the time and expense of moving to a large university; while attending a local community college for the majority of required courses, they can complete all additional courses and the final semester for the baccalaureate program either online or in clinical settings (Landen, 2015). Both the New Mexico Board of Nursing and RWJF, through the APIN program, have provided funding to support this model (Liesveld et al., 2015).

Overall, several APIN states have reported that they have successfully increased the percentage of baccalaureate nurses in the workforce beyond the national average increase, although programs and outcomes have varied among states (Gerardi, 2015). The Campaign is coordinating and learning from these state-level efforts with the goal of standardizing and streamlining academic progression at the national level. The Campaign convened leaders in the area of academic progression in 2015 and is developing a strategy for advancing academic progression models. The impetus for these efforts is the belief that “standardizing prerequisites and general education requirements across the nation in all nursing programs is a fundamental step in advancing nursing education and removing barriers that make it difficult for nursing students to move from an associate degree in nursing to a [baccalaureate] program” (CCNA, 2015a, p. 4). The Campaign also has provided technical assistance on academic progression to 25 state Action Coalitions and State Implementation Program grantees.

In a survey conducted by TCC Group for the Campaign, the majority of state Action Coalitions indicated that education goals were their top priority, with 59 percent focusing on the goal of increasing the number of nurses with baccalaureates to 80 percent by 2020 (TCC Group, 2013). The Campaign's most recent biannual operations report showed that 45 percent of all state Action Coalition funding had supported efforts under the education pillar (CCNA, 2015a).

The 2013 TCC Group survey revealed that state Action Coalitions believed they were making progress on this recommendation. All of the states that responded to the survey believed that availability of educational pathways had improved; all believed that nursing schools, universities, and community colleges were working better together; and 74 percent believed that there had been improvements in workplace policies that promoted nurses' educational attainment (TCC Group, 2013).


The Campaign tracks the progress on recommendation 4 from The Future of Nursing (see Box 3-2) by looking at the percentage of employed nurses with a baccalaureate degree in nursing or a higher degree, using data provided by the American Community Survey (CCNA, 2015b).2 According to this data source, the percentage of baccalaureate-educated nurses rose from 49 percent in 2010 to 51 percent in 2014.

Significant growth has occurred in the number of nursing programs over the past decade. Between 2002 and 2012, more growth was observed among 4-year college programs (from 882 in 2002 to 1,413 in 2012, a 60 percent increase) than among 2-year college programs (from 729 to 857 programs, an 18 percent increase) (Buerhaus et al., 2014). The numbers of baccalaureate nursing programs, enrollees, and graduates—including both prelicensure (entry-level and accelerated baccalaureates) and postlicensure (baccalaureate completion) (see Box 3-3)—have increased over the past 15 years (see Figures 3-1, 3-2, and 3-3, respectively).

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BOX 3-3

Educational Pathways to Achieving a Baccalaureate Degree in Nursing.

FIGURE 3-1. Number of baccalaureate nursing programs, 2000-2014.


Number of baccalaureate nursing programs, 2000-2014. SOURCE: Data received from the American Association of Colleges of Nursing (AACN), August 28, 2015.

FIGURE 3-2. Enrollees in baccalaureate nursing programs 2000-2014.


Enrollees in baccalaureate nursing programs 2000-2014. NOTE: Number of enrollees is calculated from responses to American Association of Colleges of Nursing (AACN) surveying. Not all programs in the United States replied with enrollment data. SOURCE: (more...)

FIGURE 3-3. Graduates of baccalaureate nursing programs, 2000-2014.


Graduates of baccalaureate nursing programs, 2000-2014. NOTE: Number of graduates is calculated from responses to American Association of Colleges of Nursing (AACN) surveying. Not all programs in the United States replied with graduate data. SOURCE: Data (more...)

Prelicensure Baccalaureate

The number of entry-level baccalaureate programs increased from 641 in 2010 to 704 in 2014, and the number of accelerated baccalaureate programs increased from 233 to 299 (see Figure 3-1).3 Enrollment in prelicensure baccalaureate programs, including entry-level and accelerated baccalaureate programs, increased by 17 percent, from 161,540 to 189,729 students, during this period. AACN data show a consistent increase in enrollments in and graduations from entry-level baccalaureate programs over the past 10 years.

Postlicensure Baccalaureate

From 2010 to 2014, the number of baccalaureate completion programs increased steadily (see Figure 3-1), and enrollment in these programs increased by 69 percent, from 77,259 to 130,345 students (see Figure 3-2).4 Schools have expanded capacity in baccalaureate completion programs accordingly. Given the tremendous increases in enrollment in and graduation from these programs (see Figure 3-3) and the modest increase in the number of programs in recent years, further exploration is warranted to determine how capacity has been increased, possibly through the use of innovative education delivery approaches, such as partially or fully online programs and programs offered at health care facilities (AACN, 2015a).

In addition to increased capacity in baccalaureate completion programs, some state legislatures have undertaken efforts to require nurses to obtain a baccalaureate within 10 years of entry into practice (known colloquially as “BSN-in-10”) (Larson, 2012). In 2008, ANA's House of Delegates passed a BSN-in-10 resolution that voices support for initiatives that require nurses to obtain a baccalaureate degree within 10 years after receiving their initial nursing license (Edwards, 2012; Larson, 2012; Trossman, 2008). Since 2005, legislation requiring a baccalaureate within 10 years of initial licensure has been introduced in three states—New Jersey,5 New York,6 and Rhode Island (ANA, 2013). In New York, for example, “North Shore–LIJ Health System has required all RNs hired after September 1, 2010, to either have a baccalaureate degree or enroll in an accredited baccalaureate program within 24 months of hire in order to earn the degree within five years” (Hendren, 2010; North Shore–LIJ, 2015).

Despite the increases in numbers of baccalaureate nursing programs, enrollees, and graduates, there were until 2012 more nurses graduating with associate's than baccalaureate degrees (Buerhaus et al., 2014). In 2012, however, the number of nurses with baccalaureate degrees (including those obtained through entry-level, accelerated, and baccalaureate completion programs) surpassed the number with associate's degrees, increasing to 53 percent of the nursing workforce (see Figure 3-4). The increase in first-time takers of the NCLEX-RN with a baccalaureate degree continues, while the growth of first-time takers with an associate's degree has slowed (Salsberg, 2015).

FIGURE 3-4. Number of nursing baccalaureate and associate's degree graduates, 1984-2012.


Number of nursing baccalaureate and associate's degree graduates, 1984-2012. NOTE: Baccalaureate degrees encompass entry-level, accelerated, and baccalaureate completion programs. Data source: Integrated Postsecondary Education Data System (IPEDS). SOURCE: (more...)

Funding for Nursing Education

The Future of Nursing calls on the Health Resources and Services Administration (HRSA) and other federal agencies to “expand loans and grants for second-degree nursing students.” However, HRSA funding for nursing education programs has been relatively flat over the past decade, except for increased investments in the Nurse Corps Loan Repayment and Scholarship Program (formerly called the Nursing Education Loan Repayment Program) and the Nurse Faculty Loan Program, which saw increases in funding between 2008 and 2010. The Nurse Corps programs received an additional investment of $27 million from the American Recovery and Reinvestment Act (ARRA) in 2009, and since then has been funded at a higher level than before that increase occurred. Similarly, base appropriations for the Nurse Faculty Loan Program increased between 2008 and 2009 from $7,860,000 to $11,500,000, but in 2009, this program also received a further investment of $12,000,000 from the ARRA, and it has been funded at that higher level since then (HRSA, 2009, 2011, 2013, 2015) (see Figure 3-5).

FIGURE 3-5. Health Resources and Services Administration (HRSA) Title VIII funding, fiscal years 2005-2016.


Health Resources and Services Administration (HRSA) Title VIII funding, fiscal years 2005-2016. SOURCES: HRSA, 2009, 201120132015.

Comprehensive information on sources of and recent trends in other funding for nursing education programs, including that provided by states and private sources, is lacking. AACN does provide a list of state loan forgiveness programs on its state policy resources page7; some of the listed programs are for practicing nurses, and many are for nurse educators and faculty.


Employer preference for BSN AACN data indicate an increasing preference for hiring baccalaureate-educated nurses. However, a majority of employers do not require nurses to have a baccalaureate (see Table 3-1).

TABLE 3-1. Percentage of Employers Indicating a Requirement or Preference for Baccalaureate-Prepared Nurses, 2011-2014.


Percentage of Employers Indicating a Requirement or Preference for Baccalaureate-Prepared Nurses, 2011-2014.

Other data likewise show that market forces tend to be favoring the baccalaureate over the associate's degree. At the committee's July workshop, the Accreditation Commission for Education in Nursing (ACEN) presented data showing that the mean job placement rate has decreased for nurses with associate's degrees and diplomas while remaining relatively steady for those with baccalaureate and master's degrees (Stoll, 2015) (see Figure 3-6).

FIGURE 3-6. Mean job placement rate by degree type.


Mean job placement rate by degree type. * Data for 2013-2014 are preliminary. SOURCE: Stoll, 2015.

An annual survey of California hospitals showed that in 2014, 9.8 percent of responding hospitals required nurses to have a baccalaureate as a condition for employment, an increase from 8.2 percent in 2013, 7.3 percent in 2012, and 4.6 percent in 2011 (Bates et al., 2015). The percentage of responding hospitals preferring a baccalaureate degree also increased from 52.3 percent in 2011 to 60.5 percent in 2014. In 2014, 11.8 percent of hospitals said they required new hires to complete a baccalaureate within a certain amount of time, typically 2-3 years. While other studies have found that salary differentials between nurses with associate's and baccalaureate degrees are due to factors beyond just educational attainment (Duffy et al., 2014; Spetz, 2002), 69 hospitals in the California survey (32.9 percent of respondents) indicated that they do base salary on the type of degree held, and nearly half use advanced certification as a basis for salary differentials. Likewise, Auerbach and colleagues (2015) found that there has been a consistent $10,000 wage gap between nurses with an associate's degree in nursing (ADN) and those with a bachelor's degree in nursing (BSN) over the past decade, but this gap has not widened as might be expected with an increasing preference for BSN preparation.

In addition to the employment trends described above, as of 2013, ANCC Magnet® recognition required that organizations have a plan for how they will achieve an 80 percent baccalaureate-educated nursing workforce by 2020 (Lewis, 2015). However, ANCC is not prescriptive about how organizations should achieve this goal or what milestones should be reached in the interim. Currently, Magnet hospitals are more likely than other hospitals to employ baccalaureate-prepared nurses. According to ANCC, 55.6 percent of nurses working in Magnet hospitals have a BSN or higher degree (ANCC, 2014). As of January 1, 2013, Magnet recognition also required that nurse leaders have a minimum of a baccalaureate in nursing and that chief nursing officers (CNOs) have a master's or higher degree (ANCC, 2015).

Auerbach and colleagues (2015) report that the unemployment rate for nurses with a baccalaureate degree is lower than that for nurses with an associate's degree, and this gap has widened in recent years; a similar gap in hospital employment also appears to be growing. According to the authors, “the timing of the divergence in unemployment rates between ADN and BSN-prepared RNs, and to some extent, the increase in employment of BSNs in hospitals found in this analysis, appears to have occurred several years before the 2010 Institute of Medicine (IOM) report The Future of Nursing: Leading Change, Advancing Health was released. . . . The IOM emphasized the need for a more highly educated nursing workforce, and its wide dissemination more than likely provided ‘tipping point' information that influenced employers' decisions to prefer the more highly educated BSN” (Auerbach et al., 2015, pp. 11-12). These authors also identify shifts in locations of practice for baccalaureate- and associate's-prepared nurses between 2003 and 2013. The percentage of nurses with baccalaureate degrees in office-based and ambulatory care settings fell from 9.1 percent in 2003 to 7.7 percent in 2013, while the percentage of nurses with associate's degrees in long-term care increased from 13.0 percent to 18.0 percent. Roughly 10 percent of nurses with associate's degrees “shifted from hospitals to long-term care settings over the period” (Auerbach et al., 2015, p. 10). Nurses with baccalaureate degrees bring skills and competencies, leadership capacity, and organizational skills that are needed in all practice settings, including, and perhaps increasingly, those outside of the hospital setting.


The recommendation of The Future of Nursing calling for 80 percent of nurses to hold a baccalaureate degree by 2020 has been described as “aspirational” (McMenamin, 2015). With approximately half of the nation's 3 million nurses currently holding an associate's degree, it will be extraordinarily difficult to achieve this goal by 2020. The effort to build a baccalaureate-prepared nursing workforce is not new, but has been boosted by this recommendation of The Future of Nursing, as well as the efforts of the Campaign and other organizations. As far back as 1965, recognizing the increasing complexity of knowledge needed by nurses, ANA published a position paper recommending that “minimum preparation for beginning professional nursing practice . . . should be baccalaureate degree education in nursing” (ANA, 1965). This position paper was reaffirmed by an ANA House of Delegates resolution in 1978, calling for the baccalaureate degree to be the entry degree for nursing by 1985 (ANA, 1995).

The Future of Nursing cites evidence to support the association between higher proportions of nurses with a baccalaureate degree and better patient outcomes, but it characterizes this evidence as inconclusive. Since the report's publication, however, the body of evidence on this association has strengthened (Aiken et al., 2011, 2014; Blegen et al., 2013; Cho et al., 2015; Kutney-Lee et al., 2013; Naylor et al., 2015; Yakusheva et al., 2014a,b; You et al., 2013). Studies show that hospitals with a higher percentage of nurses with baccalaureate degrees have better patient outcomes, and many of the outcomes associated with having a higher proportion of BSN-prepared nurses are associated with cost savings (Yakusheva et al., 2014a,b). With quality of care becoming increasingly important as a determinant of payment for health care services, this evidence suggests that providers may have a financial incentive to have a more highly educated nursing workforce.

Barriers to Nurses' Academic Progression

Despite the long history of the movement toward baccalaureate-prepared nurses and the apparent benefit of an increase in nurses with this level of education, barriers to meeting this recommendation of the Institute of Medicine (IOM) report remain. Schools of nursing report turning qualified applicants away from baccalaureate programs because of faculty shortages, a lack of clinical sites or classroom space, and budget constraints (AACN, 2015b). To advance achievement of this recommendation, both entry-level baccalaureate and baccalaureate completion pathways need to be strengthened. Innovative models of academic progression such as those described earlier (see Box 3-3) need to be expanded upon and implemented more widely.

Nurses continue to perceive barriers and challenges to obtaining higher education both at the entry level and through academic progression programs. These barriers include financial concerns; a lack of time and competing priorities; logistical concerns; a lack of academic support; and a perceived lack of clinical, professional, or economic value in a higher degree (Altmann, 2011; Bates et al., 2014; Duffy et al., 2014; Orsolini-Hain, 2012; Rusin, 2015; Snyder, 2015).

Barriers identified by hospitals and health systems with regard to supporting academic progression for their nurse employees include insufficient funds for incentives (tuition reimbursement, promotions, pay differentials, bonuses) and a lack of baccalaureate programs in the community (Bates et al., 2014). There is evidence that some health care delivery systems do provide incentives and pathways for their nurse employees to work toward higher degrees and certifications, including on-site training programs, partnerships with local colleges, tuition reimbursement, scheduling flexibility, and loan repayment (Bates et al., 2015; Pittman et al., 2013a). Some suggest, however, that these incentives and pathways are not widespread, particularly in nonhospital settings (Pittman et al., 2013a).

Issues of the cost and convenience to nurses of pursuing higher education—whether at the entry level or after entering the workforce—need to be addressed. Expanded use of online methods of delivering education may be one way to address barriers related to cost, scheduling, and convenience. A survey of ACEN-accredited nursing programs found that most now use some type of online delivery and have done so for the past 5 or more years, but that this approach is more common among master's and baccalaureate than among associate's degree programs (Stoll, 2015).

Requirements and preferences for BSN preparation appear to be widespread in hospitals, and incentives for nurses to attain a BSN and the promotion of academic progression are seen predominantly in hospitals and large health systems rather than in community settings. If incentives for an increasingly baccalaureate-prepared workforce and for baccalaureate completion—including tuition reimbursement, pay differentials, and greater opportunities for advancement—are offered mainly in acute care settings, nurses with associate's degrees may be channeled into other care settings, including long-term care, home health, and other community settings.

Quality of New Programs

Tremendous growth has been seen in the numbers of programs and enrollees in all types of nursing education programs over the last decade. This increase in quantity is commendable; however, corresponding attention to the quality of the education offered is essential. As discussed earlier, baccalaureate completion programs and enrollment in these programs, in particular, have increased dramatically in recent years. According to AACN, “Given the dramatic increase in the number of [baccalaureate completion] programs and enrolling students, the need to maintain academic rigor in these programs is growing in importance, including the need for quality practice experiences” (AACN, 2012b, p. 1). A 2014 study found that recent nursing literature and guidance from nursing accreditation bodies lacked information about the content and competencies that are or should be included in the curricula of baccalaureate completion programs (McEwen et al., 2014). Buerhaus and colleagues (2014) note that “worries about the quality of RN graduates extend across all program types, including doctor of nursing practice and traditional doctoral programs” (p. 295).

Implicit in the recommendation of The Future of Nursing to increase the percentage of nurses with baccalaureate degrees is an assumption that the added education would improve nurses' knowledge and skills. As educational institutions respond to the demand for baccalaureate-educated nurses, more attention will be needed to the quality of new programs and emerging models of education to ensure that nurses—and patients—are reaping the assumed benefits of additional education.

Educational Attainment and Diversity

Community colleges and associate's degree nursing programs are an important pathway into the profession for many people, in particular for economically and/or educationally disadvantaged and underrepresented populations (American Association of Community Colleges, 2010; Bell, 2012; Fulcher and Mullin, 2011; Mullin, 2012; Talamantes et al., 2014). Minority students are more likely than their white counterparts to enter the nursing field with an associate's degree rather than a baccalaureate: 40 percent of white new RN graduates held a baccalaureate in 2013, compared with just 36 percent of African American graduates and 26 percent of Hispanic/Latino graduates (CCNA, n.d.-b). However, minority nurses are slightly more likely than their white counterparts to obtain a baccalaureate or higher degree during their career (HRSA, 2010). These data indicate that minority nurses benefit from both associate's degree and baccalaureate completion programs.

Like minority students, students with lower incomes also benefit from associate's degree programs offered by community colleges. Students attending community colleges to earn an associate's degree generally have lower incomes and different economic backgrounds relative to their counterparts attending entry-level baccalaureate programs (Fulcher and Mullin, 2011), and 41 percent of all undergraduates living in poverty are enrolled in community colleges (Mullin, 2012; NCES, 2011).

Minority and disadvantaged students, then, utilize associate's degree programs, baccalaureate completion programs, and community colleges to enter and advance in the field of nursing. Even as the profession pursues the goal of an 80 percent baccalaureate-trained workforce, these pathways will remain important for maintaining or increasing the diversity of the nursing workforce.

Findings and Conclusions


This study yielded the following findings about baccalaureate education for nurses:

Finding 3-1. Between 2010 and 2014, the proportion of employed nurses with a baccalaureate degree or higher in nursing increased from 49 percent to 51 percent.

Finding 3-2. Baccalaureate nursing programs of various types (entry-level, accelerated, and baccalaureate completion) have increased in number, enrollees, and graduates. The number of such programs has been increasing at a faster rate than the number of associate's degree and diploma programs. Since 2012, more nurses have graduated each year with baccalaureate degrees (including degrees from entry-level, accelerated, and baccalaureate completion programs) than with associate's degrees.

Finding 3-3. As baccalaureate programs have grown, some concerns have been raised about the quality of these new and expanded programs.

Finding 3-4. Some APIN states have reported greater increases in their BSN nursing workforce relative to the national average increase, although outcomes vary widely from state to state.

Finding 3-5. HRSA funding for nursing education and workforce programs (Title VIII) has remained relatively flat over the past decade, aside from the Nurse Corps Loan Repayment and Scholarship Program, which saw a boost in funding from the ARRA in 2009 and has received a sustained, higher level of funding since that time.

Finding 3-6. Increasing proportions of schools of nursing are recognizing and employers are showing a preference for BSN-prepared nurses over ADN-prepared nurses, especially in hospital and large health care systems.

Finding 3-7. Employer support for the academic progression of their associate's degree-prepared nurse employees varies, and it appears to be more common in hospitals than in other health care settings.

Finding 3-8. Associate's degree nursing programs and community colleges generally appear to provide entry into educational pathways and careers in nursing for disadvantaged and underrepresented populations.


The committee drew the following conclusions about progress toward a higher proportion of the nursing workforce with baccalaureate degrees:

Market forces are increasingly favoring baccalaureate-prepared nurses, particularly in hospital settings. As the RN population shifts to becoming increasingly baccalaureate-prepared, unintended consequences with respect to the employment, earning power, skills, and roles and responsibilities of those nurses who do not achieve higher education may occur.

New models of education, such as partnerships between community colleges and 4-year universities, show promise for increasing the percentage of baccalaureate-prepared nurses.

The increasing preference for baccalaureate-prepared nurses in hospital settings, as well as the provision of employee educational incentives in these settings, may result in associate's-degree RNs being shifted into nonhospital settings, especially long-term care.


The Future of Nursing notes that there is a high turnover rate among newly graduated nurses: some nurses leave their first job to experience a different care setting, but some leave the profession entirely (IOM, 2011). In part to reduce this attrition, the report recommends that nurses be supported in their transition to practice through residency programs (see Box 3-4). These programs would help nurses develop such skills as organizing and prioritizing workflow and communicating with other members of the health care team. The Future of Nursing focuses largely on residencies for postlicensure RNs but acknowledges that going forward, residencies would be useful for nurses transitioning to new care settings or entering practice as advanced practice registered nurses (APRNs).

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BOX 3-4

Recommendation 3 from The Future of Nursing: Implement Nurse Residency Programs.


Residencies at various levels and in different settings have been developed or expanded in the years since the publication of The Future of Nursing. In general, these programs have been established and funded by the institutions that hire nurses, with the aim of enhancing on-the-job training and retention of new hires.

The University HealthSystem Consortium (UHC) and AACN have developed a program for postbaccalaureate residencies (McElroy, 2015; UHC/AACN, 2007). A UHC study conducted in 2000 showed that while many UHC hospitals had a program to prepare new graduates to become competent practitioners, there was little uniformity in the length, curriculum, or content of these programs. The UHC/AACN residency program, which started in 2002, is a year-long program built on an evidence-based curriculum, and it is designed for nurses providing direct care in a hospital acute care setting (Goode et al., 2013; McElroy, 2015; UHC/AACN, 2007). Evaluation of the program has shown that it improves retention; increases nurses' “confidence, competence, ability to organize and prioritize, communication, leadership”; and reduces stress levels (Goode et al., 2013; UHC/AACN, 2007, p. 1). More than 130 hospitals and health systems across the country are currently participating in the UHC/AACN program, and annual participation increased from 362 nurses in 2002 to 3,579 in 2010 to more than 9,000 in 2014 (McElroy, 2015). Overall, approximately 45,000 nurses have completed the program.

Transition-to-practice residency programs for nurse practitioners (NPs) operate in various health care settings, including retail clinics, federally qualified health centers (FQHCs), U.S. Department of Veterans Affairs (VA) primary care centers, and hospitals. CVS MinuteClinic has a 6-month program intended to better prepare new NP graduates for delivering care in the unique nontraditional context of a retail clinic (Gagliano, 2015). The program links new-graduate employees with preceptors who are available to support them and review their charts.

Community Health Center, Inc., an FQHC in Connecticut serving primarily low-income and uninsured populations, operates the nation's first NP transition-to-practice residency program, launched in 2007 (Flinter, 2015). At that time, the goals of the program included attracting and retaining NPs as primary care providers in the safety net setting, as well as preventing attrition by helping NPs attain the skills necessary to practice. The program has shown success in improving competence and clinical performance appraisals. The main challenge to maintaining the program is a lack of funding. Flinter (2011, 2015) notes that while the Patient Protection and Affordable Care Act (ACA) authorized funding for family NP residency programs8 in FQHCs, that funding has never been appropriated. Some organizations have chosen to invest in these programs because of the potential return on investment, but many organizations have the will, need, and capability but not the funding to do so.

In addition to offering residencies for postbaccalaureate and mental health nurses, the Veterans Health Administration has 12-month residencies for NPs that are operated out of its VA Centers of Excellence in Primary Care Education (Gilman, 2015). This program, launched in 2011-2012 in part in response to recommendations of The Future of Nursing (see Box 3-4), involves formal instruction, clinical supervision and interprofessional precepting, and clinical electives. The objectives are to “advance clinical competency in team-based, patient-centered primary care,” and to “advance [the] ability to work in, lead, and improve clinical teams” (Gilman, 2015). In its first 4 years, 42 residents completed the program.

Currently, 21 nurse residency programs are accredited by either the American Nurses Credentialing Center (ANCC) (accredits RN residencies, RN fellowships, and APRN fellowships) or the Commission on Collegiate Nursing Education (CCNE) (accredits postbaccalaureate nurse residencies).9 An additional 11 programs have requested applicant status from CCNE, the first step in the accreditation review process.10 CCNE's accreditation program grew out of recognition that the programs being implemented varied greatly, and it also was encouraged by the work of UHC and AACN to develop a curriculum that would create some commonality in year-long residency programs in acute care settings (although CCNE accreditation is not limited to programs subscribing to the UHC/AACN curriculum) (Butlin, 2015). Standards and procedures for nurse residencies are based largely on concepts of interprofessional education and collaboration. CCNE requires that residencies be built on an academic–practice partnership to bridge the transition between learning and entry into practice, and that programs be 1 year in length. Standards address faculty, institutional commitment and resources, curriculum, and program effectiveness (CCNE, 2008). To date, accreditation has been limited to acute care settings, but CCNE has heard from its communities of interest of the need to extend accreditation to all practice settings, including ambulatory care and home health (Murray, 2015).

The National Council of State Boards of Nursing (NCSBN) began work on transition-to-practice programs in 2007 (NCSBN, 2011, 2015b). In 2011, NCBSN began to study transition-to-practice models for new nurse graduates in hospitals (Phase I) and long-term care, home health, and other settings (Phase II) (NCSBN, 2015c). NCSBN's research shows that residencies in hospitals have better outcomes (in terms of competence, errors, work stress, job satisfaction, and retention) when they

  • are formalized and integrated into the institution;
  • last at least 6 months;
  • include content on patient safety, clinical reasoning, communication and teamwork, patient-centered care, evidence-based practice, quality improvement, and informatics;
  • are customized to specialty areas; and
  • include time for graduates to apply the content and receive feedback (Spector et al., 2015a).

In 2012-2013, NCSBN studied the implementation of its transition-to-practice program in nonhospital settings, including nursing homes and public health and home health settings (Alexander, 2015; Spector et al., 2015b). NCSBN had difficulty finding health care delivery organizations to participate in the program (Alexander, 2015); 34 sites volunteered, but only 23 moved forward with the study and hired nurses during the study period (Spector et al., 2015b). Once settings had been separated into experimental (NCSBN transition-to-practice program) and control (existing transition-to-practice or similar programs), there was not enough statistical power to conduct quantitative analysis. The study did find, however, that NCSBN transition-to-practice sites had higher retention than the control programs, although retention was considerably lower than that seen in hospital settings (55 percent versus 83 percent) (Spector et al., 2015a,b). Qualitative analysis showed that site coordinators, preceptors, and participants held many positive views about the NCSBN program. New nurses indicated that their overall confidence and competence had improved. They did note that the curriculum of the program was too hospital-focused and should be tailored to include topics more related to long-term care and other nonhospital settings. Both participants and preceptors mentioned feeling overwhelmed at times by the added work. Some preceptors also felt that administrative support for the program was inadequate, and site coordinators noted a lack of resources as a barrier to the program's implementation.

Many of the Campaign's state Action Coalitions are working on transition-to-practice nurse residency programs. Nearly three-quarters of states responding to a 2013 survey indicated that they were working toward implementing this recommendation of The Future of Nursing, and 31 percent said it was a main area of focus.11 The Campaign does not have a dashboard indicator for this recommendation, but “percent of hospitals that have new RN graduate residencies” is a supplemental indicator for the recommendation promoting baccalaureate-educated nurses (discussed in the previous section). This indicator uses data from surveys of hospitals conducted in 2011 (N = 214) and 2013 (N = 195) by Pittman and colleagues, which found an increase in the proportion of surveyed hospitals with RN graduate residency programs from 36.9 percent in 2011 to 45 percent in 2013 (CCNA, 2015b; Pittman et al., 2013b).

Several of the State Implementation Program (SIP) grants have residency programs as a primary focus (CCNA, 2013b). Examples include the following:

  • Idaho has evaluated transition-to-practice nurse residency programs throughout the state to identify those that work best and are most appropriate for small, rural hospitals and critical access hospitals (CCNA, 2015c).
  • The Nurse Residency Task Force in the Iowa Action Coalition has developed a competency-based curriculum for a nurse residency program that can be completed using online tools and learning modules (CCNA, 2014a; RWJF, 2014b).
  • The New Jersey Action Coalition received $1.6 million from the Centers for Medicare & Medicaid Services (CMS) to develop an RN transition-to-practice program for long-term care (CCNA, 2013c). The first 1-year program started in spring 2014 and was recently completed (CCNA, 2014b), and a second iteration is currently under way (Boyd, 2015). The New Jersey Action Coalition also has created a curriculum outline for a 6-month APRN residency program in FQHCs (CCNA, 2014b).

In addition to activity at the state level, the Campaign has been working at the federal level to garner continued support for the Medicare Graduate Nursing Education (GNE) demonstration program (CCNA, 2015a). While not defined as a transition-to-practice nurse residency program, the GNE demonstration, which began in 2012, provides funds to hospitals to offset the cost of clinical training for APRNs (CMS, 2012). RWJF, AARP, and the Alliance for Health Reform hosted a briefing on Capitol Hill in 2015 to inform policy makers about the importance of graduate nursing education and training (Alliance for Health Reform, 2015).


Progress on recommendation 3 from The Future of Nursing is difficult to track for several reasons: the word “residency” is used for a variety of different programs, from simple workplace orientations to year-long intensive training and education programs; there are residency programs offered to nurses at all levels of education (associate's, baccalaureate, and advanced practice); and residencies take place in all practice settings, from hospitals to home health care. The length of nurse residency programs varies greatly, ranging from 6 weeks to 1 year. Because of this variation and because comprehensive data on residencies are sparse, it is difficult to gauge growth in programs overall, within particular settings, and for nurses of different educational levels since The Future of Nursing was released in 2010. Pittman and colleagues (2013c) report that among the organizations they sampled, more were offering RN residencies in 2013 (41.6 percent) than in 2011 (31.7 percent). More than half of these residency programs were created between 2010 and 2013, suggesting that The Future of Nursing may have played a role in the increase. Among these residencies, 67 percent were required for new RN hires, up from 7.7 percent in 2011.


While the educational programs available for nurses provide a solid foundation for the delivery of safe and effective care, rapid changes in the health care environment call for additional training to build on the fundamentals of nursing. Novice nurses need opportunities not only to practice their skills but also to learn how to apply those skills in the real world. Nurses today increasingly must care for multiple patients with complex needs, navigate new forms of technology, and manage the needs of the chronically ill in resource-constrained settings. Transition-to-practice residencies provide an opportunity for novice nurses to understand these complexities and learn how to use their nursing skills for optimal patient care.

While evidence regarding the impact of residency programs on patient outcomes is limited, the available evidence suggests that transition-to-practice residencies for nurses appear to have positive outcomes, including improving nurses' abilities to organize, manage, and communicate, as well as higher retention levels. For example, nurses who completed the UHC/AACN residency were more likely to be retained by their employers and reported improved abilities to organize, prioritize, communicate, and provider leadership (Goode et al., 2013; McElroy, 2015). Likewise, evaluations of APRN residency programs have found that graduates reported improved confidence and competence and strengthened role identity (Flinter, 2011, 2015).

Despite these benefits, information is lacking about whether these outcomes translate into better patient care. Moreover, barriers remain to implementing residencies for every nurse, including cost and a lack of data on the value of these programs. The Future of Nursing offers subrecommendations for addressing these barriers; however, few of these measures have been implemented.

Differing Needs of Residencies for APRNs and RNs

The word “residency” is used for programs for both APRNs and RNs; however, the needs of these nurses are different, necessitating differently designed residencies. RN residencies are generally a transition from student to first practice setting, so the focus tends to be fundamental and setting specific. The newly graduated nurse benefits from supervision and a graded increase in responsibility, and the institution benefits from greater retention. APRN residencies, on the other hand, are related more to professionalization and the establishment of independence for an already experienced clinician; the initial first year of practice provides the “critical foundation on which new professionals build their expertise” (Brown and Olshansky, 1997, p. 46; Bush, 2014). APRNs are expected to come to the work environment ready to care for patients independently, and residencies can give these nurses the opportunity for clinical support in this transition to practice (Flinter, 2005). The funding models for the two types of residencies may differ as well.

The Future of Nursing focuses primarily on the need for RN residencies, although it notes that “the benefit to APRNs of completing a residency is likely to grow,” particularly as more students are progressing immediately from a baccalaureate to an advanced practice degree (IOM, 2011, p. 124). However, the need for NP residency programs is not universally accepted. At the committee's May 28, 2015, public workshop, Sheila Melander, president of the National Organization of Nurse Practitioner Faculties, stated that “the terminology ‘transition to practice' has been picked up by challengers to NP authority and introduced in various state legislations in an attempt to implement more control over NPs. The proposed additional regulatory constraints for NPs are an unintended consequence of the [Future of Nursing] report's [residency] recommendation” (Melander, 2015). Others do not share this view, however. Carolinas Healthcare System's NP postgraduate fellowship program started in October 2013 and now offers fellowships in 16 different specialties. At the committee's July 27, 2015, public workshop, Britney Broyhill, NP fellowship director in the Center for Advanced Practice at Carolinas Healthcare System, supported the inclusion of NPs in the implementation of The Future of Nursing recommendation calling for nurse residency programs (Broyhill, 2015). She said, “we do not agree that these programs challenge the clinical ability of nurse practitioners, but can only enhance their performance.”

Concentration in Hospital Settings

The Future of Nursing notes, and this committee heard in its public workshops and testimony, that residencies are based largely in hospital settings and larger health systems and tend to focus on acute care. A nonexhaustive list of hospital nurse residency and new-graduate programs is available from the Oregon Health & Science University (OHSU) School of Nursing.12 This list, last updated in August 2014, includes 138 programs. These programs vary in their titles (residency, internship, externship, fellowship) and in their length and composition. Some are open only to nurses who have completed a baccalaureate degree, while others are open to all new graduates with an RN license. The nurse residency programs on this list are offered predominantly in hospital settings.


Cost is a major barrier to the development of residency programs for nurses (Flinter, 2015; Wierzbinski-Cross et al., 2015). To lessen the financial burden on health care organizations, The Future of Nursing calls on HRSA, CMS, and philanthropic organizations to fund nurse residencies. Although CMS has not redirected graduate medical education funding from diploma nursing programs to the implementation of nurse residency programs, as called for in The Future of Nursing, it has funded APRN training through the GNE demonstration project. Under the ACA, $200 million was allocated over 4 years for this program, and CMS will use this funding to provide reimbursement for the reasonable cost of clinical training for APRN students (CMS, 2012). While the GNE demonstration is not a residency program, it fulfills a similar goal of providing incoming advanced practice nurses with clinical training. The ACA requires that GNE sites have agreements with a school of nursing and at least two community-based care settings, ensuring the expansion of clinical placement of students beyond hospitals. The GNE program is a current funding source for APRN training, and if shown to be successful, could be expanded to fund similar transition-to-practice residencies for nurses. A similar program, also authorized by the ACA,13 would provide grants for family NP residencies in FQHCs and nurse-managed health clinics (Miyamoto, 2014; Redhead et al., 2014). However, no appropriations have been made for this demonstration project, and there is no requirement for sustained funding for the GNE program after the initial demonstration phase.

Many organizations self-fund their residency programs, and some have turned to outside funding; there remains no standard, sustainable funding mechanism for nurse residencies. In some APRN residencies, participants are licensed and credentialed providers who can bill and continue to generate revenue for the practice (Broyhill, 2015; Flinter, 2011); residents in other programs, however, are considered trainees (Broyhill, 2015). There are other challenges as well. For example, Gilman (2015) notes that electronic medical records have difficulty categorizing NP residents, which impacts supervision, ordering, and billing requirements. As payment systems shift, organizations may develop new business models for residency programs. Anderson and colleagues (2012) note that many administrators measure the success of their residency programs from a purely economic perspective, comparing the cost of the program with the financial savings from increased retention rates. Wierzbinski-Cross and colleagues (2015) assert that the advantages of residencies go beyond improved retention, noting that such benefits as improved job satisfaction, productivity, and competence can affect the quality of care and patient safety and ultimately have a positive impact on the bottom line.

Lack of Data

As called for by The Future of Nursing, organizations that are implementing residencies or promoting residency models are performing self-evaluations of their work. However, because residencies are largely operated by employers, these evaluations tend to focus more on retention and workplace skills than on quality of patient care or patient outcomes. For example, the national programs of UHC/AACN (postbaccalaureate) and Versant (RN) have both published outcome data based on 10 years of data collection (Goode et al., 2013; Ulrich et al., 2010), and NCSBN has published findings from the implementation of its transition-to-practice programs in hospital and nonhospital settings (Spector et al., 2015a,b; see also the Activity section on nurse residency programs earlier in this chapter).

Because of the wide variation in residency programs, it is difficult to gather data across programs. Multiple studies have noted difficulties with the lack of uniformity among nurse residency programs, and variations in content and strategies make comparisons and analysis of best practices difficult (Anderson et al., 2012; Barnett et al., 2014). A few organizations have developed systematic models or standards for residencies, including the UHC/AACN Nurse Residency Program, accreditation through CCNE or ANCC, and NCSBN's transition-to-practice program (discussed in the Activity section). The lack of uniformity among residency programs makes it difficult to determine whether and to what extent residencies affect nurse competencies and patient care. However, these existing models and accreditation standards can serve as a guide for developing more uniform residency programs in the future.

Findings and Conclusions


This study yielded the following findings about transition-to-practice programs:

Finding 3-9. Transition-to-practice residency programs have been shown to improve the efficiency of health care services and retention of new nurse graduates.

Finding 3-10. There are good models for RN residencies, including the UHC/ AACN program, ANCC and CCNE accreditation, and the NCSBN program. There are fewer models for APRN residencies.

Finding 3-11. Most transition-to-practice residency programs are hospital-based and focus on acute care.

Finding 3-12. Lack of funding has limited the growth of transition-to-practice residency programs. Some APRN residencies have addressed this issue by considering residents to be billable providers so that they can continue to generate revenue while participating in the residency program.

Finding 3-13. The Campaign does not have a major dashboard indicator for recommendation 3 of The Future of Nursing, although a supplemental indicator under the recommendation related to increasing baccalaureate-prepared nurses is “percent of hospitals that have new RN graduate residencies.” This indicator does not track APRN residencies or residencies in nonhospital settings. The data used for this indicator are surveys conducted in 2011 and 2013.


The committee drew the following conclusions about progress toward establishing transition-to-practice residency programs:

Considerable variation among transition-to-practice residency programs makes their evaluation difficult.

Further evaluation of transition-to-practice residencies is needed to prove their value with measurable outcomes; in particular, more attention is needed to determine the effect of these programs on patient outcomes. Although robust evidence on the impact of nurse residencies on patient outcomes is lacking, the available evidence suggests that these programs have positive effects on retention and job satisfaction, both of which have implications for patient care.

Existing residency programs can be used as models for new transition-to-practice residencies for nurses. Use of these existing models could make the design, implementation, and evaluation of these new programs easier and more efficient.

Both RN and APRN transition-to-practice residencies appear to have increased over the past few years, but systematic efforts to track the growth of these opportunities accurately have been limited.


In 2010, fewer than 1 percent of nurses held a doctorate degree in nursing or a nursing-related field (IOM, 2011). According to The Future of Nursing, this number was insufficient to keep pace with the growing need for nurses with a doctorate to teach the next generation of nurses, to perform research, and to serve as leaders in clinical practice and health policy. Nursing doctoral degrees include the PhD—a research-oriented degree—and the doctor of nursing practice (DNP), which was first developed in 2002 and focuses more on clinical practice. The Future of Nursing recommends that the number of nurses with a doctorate be doubled by 2020, but it is not specific about growth in particular types of doctoral programs (DNP, PhD in nursing, PhD in another field) (see Box 3-5).

Box Icon

BOX 3-5

Recommendation 5 from The Future of Nursing: Double the Number of Nurses with a Doctorate by 2020.


Several major initiatives, as well as a number of smaller funding programs, have been undertaken to support students in seeking doctoral degrees in nursing. Three private philanthropic organizations—the Jonas Center for Nursing and Veterans Healthcare, the Rita & Alex Hillman Foundation, and RWJF—have contributed significant funds to the effort to increase doctorally prepared nurses. These organizations' programs encourage nurses to pursue a doctorate earlier in their career and place emphasis, wholly or in part, on increasing the number of nurses with research-focused PhDs in nursing.

The Jonas Center has committed $25 million to doubling the number of nurses with doctorates, and the number of scholars it has funded increased from 6 in 2009 to 600 (400 PhD and 200 DNP) in 2015 (Curley, 2015). As the latter figures suggest, the Jonas Center supports PhD and DNP nurses in a 2:1 ratio. Scholars receive a $10,000 scholarship from the Jonas Center and $12,500 in matching funds from their school of nursing. The program focuses on diversity, with 38 percent of scholars coming from underrepresented groups, and on leadership, requiring scholars to complete a 40-hour leadership project.

The Rita & Alex Hillman Foundation's Hillman Scholars Program in Nursing Innovation was launched in 2011 to support PhD nursing students (Hillman Foundation, 2015). The program is now offered at the University of Michigan, University of North Carolina at Chapel Hill, and University of Pennsylvania, and it incorporates interdisciplinary coursework, clinical practice, research, and mentorship to advance innovation through nursing research and leadership. As with the RWJF and Jonas Center programs, the goal of the program is for nurses to achieve their doctorate early in their career so as to maximize opportunities and contribute to the improvement of health and health care.

RWJF has invested $20 million in the Future of Nursing Scholars program, whose mission is to create “a diverse cadre of PhD prepared nurses” (RWJF, 2013, 2015c). The program awards $75,000 to each scholar over the course of 3 years, and the scholar's school is required to provide $50,000 in support (RWJF, 2015d). Awards were provided to 14 schools to support 17 nurses in 2014, the program's inaugural cohort, and to 25 schools to support 48 nurses in 2015 (RWJF, 2014a, 2015a).

The American Cancer Society also supports nurses seeking graduate study in cancer nursing practice and research through two programs. The Graduate Scholarships in Cancer Nursing Practice program provides a stipend of $10,000 per year for graduate students pursuing a master's degree in cancer nursing or a DNP (American Cancer Society, 2015b). The Doctoral Degree Scholarships in Cancer Nursing program provides a stipend of $15,000 per year for 2 years for students pursuing a doctorate in nursing or a related area to prepare the graduate for a career as a cancer nurse scientist (American Cancer Society, 2015a).

CareFirst BlueCross BlueShield's (CareFirst) Project RN provides stipends to nursing students specifically pursuing advanced degrees to become nurse educators through the company's nurse education partnership program. Project RN was launched in 2007. Between 2007 and 2012, CareFirst invested more than $2 million in the program; it invested another $1 million in 2013 and $960,000 in 2014 (CareFirst BlueCross BlueShield, 2013, 2014, n.d.).

One Campaign state Action Coalition, Georgia, considered the doubling of doctorally prepared nurses to be its top priority (TCC Group, 2013; see Chapter 1, Figure 1-3). Of the states responding to a 2013 survey, 78 percent indicated that they were working toward implementing this recommendation, but only 25 percent said it was a main focus for them (see Chapter 1, Figure 1-2).14

The Campaign tracks progress on this recommendation by using data on the number of students enrolled in doctoral programs (CCNA, 2015b). The recommendation focuses on the number of nurses with doctorates in the workforce; however, progress in the workforce will take considerable time to become discernible because doctoral degrees typically take years to complete. The Campaign also has identified supplemental indicators with which to track progress on this recommendation, including the number of employed nurses with a doctoral degree, the number of doctoral program nurse graduates each year, and the diversity of nurse doctoral graduates.


Since The Future of Nursing was released, enrollment in doctoral programs has risen. Enrollment in DNP programs has grown rapidly over the past 5 years, while enrollment in PhD programs has grown at a slower rate. Since fall 2010, enrollment in DNP programs has more than doubled, from 7,034 to 18,352 students (a 161 percent increase).15 Meanwhile, enrollment in PhD programs has increased by 15 percent over the past 5 years, with 5,290 students now pursuing the research-focused doctorate.

Doctoral programs that confer the DNP degree have grown rapidly over the past 10 years. In 2006, 20 such programs existed; by 2014, this number had grown more than 10-fold, to 262 programs.16 PhD programs also have grown, from 103 programs in 2006 to 133 programs in 2014 (see Figure 3-7). DNP and PhD enrollments and graduations also have grown. Enrollments in and graduations from PhD programs have increased modestly over the past 15 years, while enrollments in and graduations from DNP programs have increased exponentially (see Figures 3-8 and 3-9, respectively). Growth also appears to be occurring among baccalaureate-to-DNP and master's-to-DNP programs (Auerbach et al., 2014). Of 400 schools surveyed by AACN in 2013 that had APRN education programs, 25 percent had baccalaureate-to-DNP programs, and 57 percent had master's-to-DNP programs. A survey conducted in 2013 found that 11 to 14 percent of schools were providing baccalaureate-to-DNP programs without offering a terminal master's program, but more were planning to do so in the future. In 2010, by comparison, this was the case for only one school (Auerbach et al., 2014).

FIGURE 3-7. Numbers of nursing PhD and DNP programs, 2000-2014.


Numbers of nursing PhD and DNP programs, 2000-2014. SOURCE: Data received from AACN, August 28, 2015.

FIGURE 3-8. Enrollments in nursing PhD and DNP programs, 2000-2014.


Enrollments in nursing PhD and DNP programs, 2000-2014. SOURCE: Data received from AACN, August 28, 2015.

FIGURE 3-9. Numbers of nursing PhD and DNP graduates, 2000-2014.


Numbers of nursing PhD and DNP graduates, 2000-2014. SOURCE: Data received from AACN, August 28, 2015.


As noted, both DNP and PhD nurses are critical to fill the need for faculty positions and for leadership roles in academics, health care delivery, health care planning and policy, and other arenas. In addition, nurses with doctoral degrees in fields outside of nursing, including public policy, business, health administration, public health, and other fields, will be especially well prepared for important leadership and educational roles in an evolving health care environment.

Although, as discussed above, there has been significant growth in enrollment in DNP programs in recent years, the relatively small increase in enrollment in PhD programs for nurses is concerning. According to testimony at the committee's July 2015 workshop from Darlene Curley, executive director, Jonas Center for Nursing and Veterans Healthcare, “PhD numbers are growing too slowly to fill the vacant faculty positions and impending baby boomer retirements.” More emphasis is needed on increasing the number of PhD nurses through expansion of programs, incentives for nurses to return to school, and more scholarships for baccalaureate-to-PhD programs. Students also need to be encouraged to pursue a PhD early in their career so they can practice for a longer period of time in the research, faculty, and leadership roles that a doctorate enables.

Studies and stakeholders have noted that the progress seen in enrollments in and graduations from doctoral programs, primarily DNP programs, puts the field on track to achieve the goal in The Future of Nursing of doubling the number of nurses with doctorates by 2020 (Curley, 2015), despite some identified barriers. However, simply doubling the number of nurses with doctorates is not sufficient. An assessment of the mix of doctorally prepared nurses is needed. It should be noted that a DNP typically takes less time to complete than a PhD. A DNP usually takes 3-4 years to complete, while a PhD usually takes 4-6 years, including years spent on academic work and years spent conducting research and producing a dissertation (AACN, 2006; Ellenbecker, 2010; Johnson, 2014).

Role of the DNP

Despite rapid growth in DNP programs, enrollees, and graduates and schools' plans for continued expansion of BSN-to-DNP programs (Auerbach et al., 2014), some concern and confusion have been expressed regarding the role of the DNP-prepared nurse in certain settings. Understanding and awareness of and demand for the DNP varies considerably among nurses, students, nursing schools, and employers (Auerbach et al., 2014; Lee et al., 2013; Martsolf et al., 2015; Swanson and Stanton, 2013; Udlis and Mancuso, 2015). For example, Martsolf and colleagues (2015) heard from schools of nursing that “some employers were not familiar with the different capabilities of DNP-prepared APRNs and were unsure how to use them compared with MSN-prepared APRNs in a clinical setting” (p. 223). Cronenwett and colleagues (2011) state, “The confusion surrounding doctoral degrees is exacerbated if the meaning of master's education changes fundamentally” (p. 12). In August 2015, AACN acknowledged that “the national dialogue about the DNP has amplified the need to clarify” advanced nursing practice and the preparation and role of the DNP with regard to research and knowledge generation, leadership, and advanced practice (AACN, 2015c, p. 1). Despite recent rapid growth in DNPs, master's preparation remains the predominant entry into advanced practice (Auerbach et al., 2014), although AACN recommended in 2004 that the DNP become the terminal degree for advanced practice nursing by 2015 (AACN, 2004).

Faculty Considerations

Many schools need more faculty before they can enroll more qualified applicants at all levels, as evidenced by data showing that 40 percent of schools said they had no faculty vacancies but need additional faculty (Li and Fang, 2014; NCSBN, 2015a). Barriers to improving the faculty vacancy situation include insufficient funds, unwillingness to commit to hiring full-time employees, noncompetitive salaries, an inability to recruit qualified individuals or those with the right specialties or research or teaching interests, the limited number of doctorally prepared nurses, and a lack of qualified applicants in the school's area (Li and Fang, 2014; NCSBN, 2015a). The projected future faculty vacancy rate is of great concern (Berlin and Sechrist, 2002; Williamson et al., 2010). In 2009, NLN found that 30 percent of all full-time nurse educators were aged 60 or older (NLN, 2009), and state boards of nursing have highlighted as an emerging issue the expected high turnover due to faculty retirements (NCSBN, 2015a).

Nurses with doctorates are needed to fill these faculty positions. The educational attainment required for these positions varies among schools and program types (AACN, 2008; Bednash et al., 2014); however, 89.6 percent of the faculty vacancies at nursing schools are for positions for which a doctoral degree is required or preferred.17 For nurses to be prepared to educate the next generation of nurses, AACN has called for nurses who plan to be educators to have “additional preparation in the science of pedagogy” (AACN, 2006, p. 7, 2010, p. 4). Instruction that prepares PhD and DNP nurses to teach about and in an evolving health care system that is less focused on acute care will be beneficial to these future faculty and their future students.

Findings and Conclusions


This study yielded the following findings on doctorally prepared nurses:

Finding 3-14. The recommendation of The Future of Nursing calling for a doubling of the number of nurses with a doctorate by 2020 is not specific about growth in particular types of doctoral programs (DNP, PhD in nursing, PhD in another field).

Finding 3-15. The number of DNP programs has increased more than 10-fold in the last decade, but expansion of PhD programs has been much more modest.


The committee drew the following conclusions about progress toward increasing the number of nurses with doctorates:

The number of nursing students pursuing a PhD needs to be increased. There are barriers to meeting the demand for PhD programs for nurses, including issues of insufficient faculty.

Additional efforts are needed to clarify the roles of PhD and DNP nurses, especially with regard to teaching and research.

As nurses are increasingly looked to for leadership in health care, advanced education in clinical care, research, education, and other areas (including public policy and business), advanced degrees will be more useful than ever. Information exists and is readily available about the number of nurses with higher degrees in the workforce. However, the breakdown of nurses with these degrees (particularly those with non-nursing advanced degrees), the settings in which they practice, and the types of work they do is less accessible.


The Future of Nursing states that a single initial degree cannot “provide a nurse with all she or he will need to know over an entire career” (IOM, 2011, p. 202). It suggests an emphasis on “continuing competence” rather than “continuing education” and recommends that health care organizations, schools of nursing, and accrediting institutions do their part to ensure that lifelong learning—which “encompasses both continuing competence and advanced degrees” (IOM, 2011, p. 202)—gives nurses the skills necessary to provide quality care (see Box 3-6).

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BOX 3-6

Recommendation 6 from The Future of Nursing: Ensure that Nurses Engage in Lifelong Learning.


The Campaign has not focused a significant amount of activity on this recommendation. There is no Campaign dashboard indicator in this area, and the Campaign noted that it has worked on this broad recommendation but has not worked toward the second or third subrecommendation.18 A 2013 survey of state Action Coalitions conducted by the Campaign's external evaluators asked Action Coalitions to identify the level of focus and effort in 15 major topic areas relating to the recommendations of The Future of Nursing and Campaign goals, none of which concerned lifelong learning (TCC Group, 2013).

Beyond the Campaign, the Joint Accreditation for Interprofessional Continuing Education, established in 2009 as a collaboration among the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and ANCC, provides a streamlined accreditation process and standards for interprofessional continuing education for these fields (Joint Accreditation for Interprofessional Continuing Education, 2013). Joint accreditation allows organizations to develop innovative programs to further build the competency of clinicians working in health care teams. “To be eligible for Joint Accreditation, an organization needs to demonstrate that for the previous 18 months its structure and processes to plan and present education by and for the healthcare team have been fully functional; and that at least 25% of its educational activities have been designed by and for healthcare teams” (Joint Accreditation for Interprofessional Continuing Education, 2013).


In the most recent NCSBN member board profile report, produced in 2014, 11 of the 49 responding jurisdictions (Colorado, Connecticut, Guam, Hawaii, Iowa, Maine, Maryland, Mississippi, Missouri, Oregon, Wisconsin) reported having no continuing competency requirements for licensure maintenance; 36 jurisdictions have such requirements (NCSBN, 2014).19 Various methods can be used to meet these continuing competency requirements, including competency examinations or assessments, minimum practice hours, and continuing education. The content and quantity of continuing education requirements for RN licensure and NP credentialing also vary significantly across the United States (AACN and AAMC, 2010; NCSBN, 2014).

A few states have instituted continuing competency requirements for nurses since 2010:

  • In Washington, continuing competency requirements were instituted for RNs and licensed practical nurses (LPNs) in 2011 (Washington State Department of Health, n.d.).
  • In Georgia, Governor Nathan Deal signed a continuing competency bill into law on May 6, 2013, requiring that all RNs and LPNs meet continuing education competency requirements by January 1, 2016, and March 31, 2017, respectively (Georgia General Assembly, 2013).
  • In Oklahoma, continuing competency requirements for RNs and LPNs were instituted effective January 1, 2014 (Oklahoma Board of Nursing, 2014).


The Future of Nursing cites several contemporaneous reports covering continuing education (IOM, 2011). A 2010 IOM report, Redesigning Continuing Education in the Health Professions, states that there are “major flaws” in the way continuing education is “conducted, financed, regulated, and evaluated”; that the science behind continuing education is “fragmented and underdeveloped”; and that continuing education should bring health professionals together for interprofessional learning “with a common goal of improving patient outcomes” (IOM, 2010, pp. 2-3). The report notes that although some states have long required nurses to complete continuing education programs, these programs do not always increase competence. A 2010 report from the Association of American Medical Colleges (AAMC), AACN, and the Josiah Macy Jr. Foundation recommends that continuing education evolve away from classroom learning and toward action-oriented, site-of-care training; that education be focused on the development of key competencies rather than mere knowledge acquisition; and that health professionals be educated together in an interprofessional setting (AACN and AAMC, 2010).

Unfortunately, little progress has been made over the past 5 years on either the recommendation of The Future of Nursing or the findings of these other reports. While there have been some efforts toward interprofessional learning, such as the Joint Accreditation for Interprofessional Continuing Education, continuing education has not kept pace with the needs of the increasingly complex, team-based health care system.

One obstacle that stands in the way of achieving progress on the recommendation of The Future of Nursing related to lifelong learning is a lack of data on lifelong learning and continuing education for nurses. Information about requirements for licensure or accreditation is collected by individual organizations through member surveys, and thus there is no single, comprehensive source of such data. In addition, evidence is lacking with regard to whether nurse certification and credentialing lead to better patient outcomes (Hickey et al., 2014; IOM, 2015; Johantgen, 2013; Newhouse, 2014).

Recognizing this gap in knowledge, the IOM convened the Standing Committee on Credentialing Research in Nursing and held a public workshop in September 2014 to discuss priorities for research and knowledge in this area (IOM, 2015). Workshop speakers highlighted various barriers to understanding the impact of nurse credentialing, including the lack of common terms and data points, and limited and inconsistent data collection by multiple credentialing and certification organizations and through national datasets. Further, speakers noted the importance of connecting more comprehensive credentialing data with metrics on performance and outcomes. They also identified the need to align research in nurse credentialing with changes in health policy and health care systems, including greater emphasis on integrated and coordinated care, team-based care, and value-based payment. Specifically, participants noted that the shift toward global and quality-based payment schemes may make it more likely that organizations and nurses will obtain credentials, but only if strong evidence can show that credentials improve skills and outcomes. In talking about the maintenance of credentials, “[Jody] Frost [from the American Physical Therapy Association] added that ongoing assessment strategies have to consider that professions are changing, and individuals need to be measured against competencies relevant today, not when they graduated from their educational institution” (IOM, 2015, p. 62). Presenters Susan Hassmiller from RWJF and Robin Newhouse from the University of Maryland School of Nursing both noted that advances in nurse credentialing research could have implications not just for The Future of Nursing recommendation related to lifelong learning and continuing competencies but also for nurses being able to practice to the full extent of their education and training and nurses partnering with other health care professionals in the improvement and redesign of the health care system. Yet despite the potential for nurse credentialing to improve knowledge and practice competencies as suggested by the workshop participants, barriers exist for individuals and organizations, including the cost of initial and sustained certification and a lack of support for or perceived value of certification (Haskins et al., 2011; Perlstein et al., 2014).

AACN has said that it “would like to see more data collected about the full spectrum of educational experiences completed by RNs” and that it is “ready to work with the Health Resources and Services Administration, National Council of State Boards of Nursing, and other stakeholders to develop a plan to collect this data.”20

A bullet under The Future of Nursing recommendation on lifelong learning calls for updating curricula to “ensure that graduates at all levels are prepared to meet the current and future health needs of the population” (see Box 3-6). In a changing health care environment, nurses and other providers will increasingly require skills necessary to be comfortable in providing care in both hospital and community-based settings. As Tanner (2010, p. 347) puts it, “As care continues to shift from hospitals to community-based settings, as the population ages and care management in the community becomes more complex, and as new health care needs emerge, a new kind of nurse will be needed. Educational programs must be redesigned to better prepare this nurse.” Yet health professions education is still highly oriented toward acute care, despite some efforts to change this paradigm (Paterson et al., 2015; Spector, 2012; Thibault, 2013). Thibault (2013) acknowledges the important roles of competency-based educational models, technology, clinical education, and interprofessional education (see Chapter 5) and notes that “future needs will require more clinical experiences that are longitudinal, integrated, immersive, and community based” (p. 1930).

Findings and Conclusion


This study yielded the following findings on lifelong learning:

Finding 3-16. A single source of information about states' lifelong learning requirements for nurses is lacking, and health care settings impose varied requirements on their clinical staff for continuing competencies and education.

Finding 3-17. Efforts are being made to promote interprofessional continuing education.


The committee drew the following conclusion about progress toward ensuring that nurses engage in lifelong learning:

The current health care context makes interprofessional continuing education more important than ever. Current efforts by health care delivery organizations, accreditors, and state regulatory boards to promote these programs need to be expanded and promoted.


Recommendation 2: Continue Pathways Toward Increasing the Percentage of Nurses with a Baccalaureate Degree. The Campaign, the nursing education community, and state systems of higher education should continue efforts aimed at strengthening academic pathways for nurses toward the baccalaureate degree—both entry-level baccalaureate and baccalaureate completion programs.

  • Efforts to expand and encourage partnerships between community colleges and 4-year universities, as well as other models for establishing these pathways, should continue to be promulgated. Employers play a critical role in promoting educational progression and should be encouraged to provide financial and logistical support for employees pursuing a baccalaureate degree.
  • In addition, the quality of new programs should be monitored to ensure consistency in effective educational practices and to ensure the ability of nursing graduates to qualify to attend other accredited schools as they pursue advanced studies. This monitoring could be conducted through a national accrediting body such as the Commission on Collegiate Nursing Education or the American Commission for Education in Nursing.

Recommendation 3: Create and Fund Transition-to-Practice Residency Programs. The Campaign, in coordination with health care providers, health care delivery organizations, and payers, should lead efforts to explore ways of creating and funding transition-to-practice residency programs at both the registered nurse and advanced practice registered nurse levels. Such programs are needed in all practice settings, including community-based practices and long-term care. These efforts should include determining the most appropriate program models; setting standards for programs; exploring funding and business case models; and creating an overarching structure with which to track and evaluate the quality, effectiveness, and impact of transition-to-practice programs. With respect to funding models,

  • government agencies, philanthropic organizations, and foundations should support these programs on a temporary basis to help better understand how the programs should be designed; and
  • health care organizations should support these programs on a permanent basis as they can be beneficial in the evolving value-based payment system.

Recommendation 4: Promote Nurses' Pursuit of Doctoral Degrees. The Campaign should make efforts, through incentives and expansion of programs, to promote nurses' pursuit of both the doctor of nursing practice (DNP) and PhD degrees so as to have an adequate supply of nurses for clinical care, research, faculty, and leadership positions. More emphasis should be placed on increasing the number of PhD nurses in particular. To maximize the potential value of their additional education, nurses should be encouraged to pursue these degrees early in their careers. DNP and PhD programs should offer coursework that prepares students to serve as faculty, including preparing them to teach in an evolving health care system that is less focused on acute care than has previously been the case.

Recommendation 5: Promote Nurses' Interprofessional and Lifelong Learning. The Campaign should encourage nursing organizations, education programs, and professional societies, as well as individual nurses, to make lifelong learning a priority so that nurses are prepared to work in evolving health care environments. Lifelong learning should include continuing education that will enable nurses to gain, preserve, and measure the skills needed in the variety of environments and settings in which health care will be provided going forward, particularly community-based, outpatient, long-term care, primary care, and ambulatory settings. Nurses should work with other health care professionals to create opportunities for interprofessional collaboration and education. The Campaign could serve as a convener to bring together stakeholders from multiple areas of health care to discuss opportunities and strategies for interdisciplinary collaboration in this area.




Personal communication, B. Hoffman, Academic Progression in Nursing, July 21, 2015.


The Campaign also uses several supplemental indicators, such as annual RN graduates by degree type, and the number of current RNs who return to school to receive a baccalaureate degree (CCNA, 2015b).


Data received from AACN, August 28, 2015.


Data received from AACN, August 28, 2015.


See http://assembly​.state​.ny.us/leg/?bn=A03945 (accessed September 18, 2015).


Section 5316 creates a “training demonstration program for family nurse practitioners to employ and provide one-year training for nurse practitioners who have graduated from a nurse practitioner program for careers as primary care providers in federally qualified health centers (FQHCs) and nurse-managed health clinics (NMHCs).”


Personal communication, K. Locke, TCC Group, September 3, 2015.


Section 5316 of the Patient Protection and Affordable Care Act of 2010, Public Law 111-148, 111th Cong., 2d sess. (March 23, 2010).


Personal communication, K. Locke, TCC Group, September 3, 2015.


Data received from AACN, August 28, 2015.






Personal communication, D. Herrera, Robert Wood Johnson Foundation, May 14, 2015.


Ten jurisdictions did not respond to the survey: Alabama, American Samoa, California (vocational nursing), Indiana, Louisiana (practical nursing), Nebraska, Nebraska (advanced practice registered nursing), New York, Rhode Island, and South Carolina.


Personal communication, R. Rosseter, AACN, August 13, 2015.

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Copyright 2016 by the National Academy of Sciences. All rights reserved.
Bookshelf ID: NBK350161


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