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Viewpoint: Why nurses will require a stronger back in 2012: Six key challenges facing the nursing community


Editor’s note: Viewpoint highlights the thoughts, opinions, and expertise of well-known nurse leaders. We welcome your comments about these thought-provoking articles.

My grandmother always told me to never pray for a lighter load, but to ask, instead, for a stronger back. Nurses may want to keep this philosophy in mind in 2012 given the long list of challenges facing our profession.

Nurses, perhaps more than any other single occupation, stand at the forefront of major changes in the healthcare industry. But we are not just standing still waiting for changes to happen to us. We are moving toward change as never before, redefining and expanding our roles to be the champions of quality care improvements, research innovations and patient rights, and advancing our skills as leaders to assure our spot at the table with policy makers, hospital executives and other industry leaders.

If ever we were going to, collectively, need that stronger back, now is the time.

As the dean of a major university nursing school, I know first-hand that there is much at stake for us all, both individually and for nursing as a profession. Here are six of the greatest challenges that my colleagues and I will be focused on in 2012. I hope you will join us in advancing these causes.

1. Facilitating advanced education and a culture of learning

Not so long ago, earning a Licensed Practical Nurse (LPN) certificate was considered adequate training for most nurses. But today, with medical knowledge and medical technology increasing exponentially year after year, it is no longer adequate. According to the National Advisory Council on Nurse Education and Practice’s 2010 report to the U.S. Department of Health and Human Services, the medical knowledge base that had previously been doubling every five to eight years is expected to begin doubling every year. Nurses simply will not be able to keep up without advanced education and a system supporting lifelong learning.

Today’s advanced degree programs offer many opportunities for nurses, from master’s and PhD programs to specialized clinician training in fields as diverse as oncology nursing, cardiac nursing and genetics. These programs not only provide a deeper foundational understanding of clinical work and the issues affecting healthcare delivery, but they offer broader career paths, the chance to practice more independently and obtain better salaries. Yet in 2010, only 41% of nurses had bachelor’s degrees and far fewer – 12% – had master’s degrees.

Attracting more nurses to advanced degrees is a profoundly important goal and one that all academic institutions should work toward. We can do this by —

  • fostering a culture of lifelong learning through nursing organizations, schools of nursing, health care organizations and healthcare media.
  • promoting the benefits of advanced degrees to nursing students, including better choices of jobs, higher salaries, broader career path opportunities, and better patient outcomes.
  • expanding the available number of slots for students in advanced degree programs. Many schools are hampered by too few slots for too many eligible and eager students.
  • facilitating access to advanced degree learning through online RN to BSN education modules or evening, after-hours programs.
  • facilitating access to advanced degree funding through scholarships, tuition reimbursement programs, nurse association grants and Federal grants.
  • establishing a firm timeline by which a bachelor’s degree will be the new minimum required to practice nursing. The Future of Nursing Campaign has designated that we try to reach a goal of 80% of nurses having a baccalaureate degree by 2020. I believe that horizon is too far off, and that we must exceed the goal before 2020 in order to meet the demands on our field. The American Association of Colleges of Nursing (AACN) will, by 2015, require a mandatory doctoral degree for those who wish to become advance practice nurses. I believe that we must challenge ourselves to likewise step up our deadline for a bachelor’s degree requirement.

By implementing these changes, we can be sure that the nurses of tomorrow are properly trained with the broad knowledge and skills they will need to best serve their patients and achieve the best outcomes.

2. Development of a National Nurse Residency (Transition-to-Practice) Program

With healthcare reform, hospitals and other health providers are being asked to meet extraordinary demands for better care at a lower cost. In the new regulatory environment, hospitals will be expected to take on more accountability, improve outcomes and better address costly critical and acute care. In many cases, reimbursement will shift to a fee-for-performance model and a hospital’s financial success will depend, at least in part, on its ability to prevent hospital-acquired conditions, reduce unnecessary readmissions and meet rigorous pre-determined metrics. In this environment, hospitals will be demanding the highest caliber nurse professionals with in-depth clinical practice experience, specialization in key areas such as oncology and geriatrics, proficiency with new technology, and the ability to work effectively with colleagues in case management and across all departments.

To keep pace, nursing programs have established accelerated nursing programs to quickly get nurses into practice. But we must do more than simply get nurses out on the floor. We must ensure that they are properly prepared to perform the complex, fast-paced and often overwhelming tasks found in the actual hospital setting. We must assure the safety of every patient by establishing universal nurse residency programs, to begin immediately after the completion of a nursing degree or before transitioning into a new area of clinical practice. This is not a new idea. Schools of nursing and hospitals have been working for years to get such programs into place, but they are costly, and many have been abandoned due to lack of funding and an absence of advocacy by opinion leaders and policy makers. Nurse leaders must continue to rally schools of nursing, nursing coalitions, state boards of nursing, appropriate credentialing organizations and the Federal government to determine a clear path for the development, funding and implementation of these programs.

3. Increased diversity and transcultural/transgenerational training

As our population shifts to include more minorities and as the number of seniors and centenarians doubles and triples, nurses must be better prepared to communicate in more languages, and to better understand a range of cultural and aging issues. At universities like UCLA School of Nursing, not only do we continue to diversify our faculty, students and staff to ensure a true transcultural nursing school, but we also send our students and faculty researchers to other areas of the world to broaden their depth of understanding of culturally sensitive care and to collaborate on key health issues in developing nations. Through an international exchange of ideas and research collaborations, nurses are addressing important health challenges and pushing the scientific and medical boundaries as never before. The results include research collaboration on everything from smoking cessation to HIV/AIDs, the establishment of new international scientific conferences and expanded opportunities for Federal and international grants. Ultimately, the true winners are our patients, as our increasingly global perspective translates to better care for all.

4. Removal of scope of practice barriers

All the advanced degrees and residency training in the world won’t change nursing much or help us meet the growing demands for care unless we eliminate the regulatory obstacles that currently hinder nurses from practicing fully according to their educational capabilities. Do you know of any other profession where professionals are not allowed to practice to the full extent of their skills, abilities and education? Advanced practice nurses must be allowed to act as full partners in health assessment, treatment and care of patients. This is the top recommendation of the Institute of Medicine Report on the Future of Nursing, and should be supported fully by all schools of nursing, nursing organizations, nursing students and other coalitions. States must reform scope of practice regulations to ensure that advanced practice nurses are defined as primary care providers and are thus eligible for clinical and admitting privileges, are accessible to patients through the new state health insurance exchanges (launching in 2014) and are eligible for payment with private health plans as well as Medicare and Medicaid. Now is the time for this to happen, as physician shortages, an aging population and demand for more and better services strain our healthcare system. Nurse practitioners and other specialty care nurses are the answer to this growing concern, but only if they are freed of existing scope of practice limitations and able to act in accordance with the demand and their capabilities.

5. Putting science into practice

Evidence-based practice has been recognized as the “gold standard” of care by the healthcare community, as it attempts to combine the best available evidentiary research with the most appropriate care for the patient’s individual needs. However, nurses have been challenged to implement such practice by barriers due to lack of time, lack of access to the most appropriate research, failure of organizations to adopt a culture conducive to evidence-based care, and lack of nursing autonomy. Hospitals and schools of nursing must find paths to overcome these barriers and put easy-to-follow steps in place which support evidence-based practice.

At UCLA, for example, the School of Nursing and the Ronald Reagan UCLA Medical Center have collaborated to establish a director of evidence-based practice position, designed to institute a structure to engage staff nurses and other clinicians in the constant process of examining their practices to ensure they are backed by the best available scientific evidence. This includes supporting nurses in original research, bringing the findings of relevant studies to the attention of nurses, and helping nurses institute important research-based practice changes at the hospital. This program has facilitated any number of improvements. For example, based on findings that thoracic surgery patients were not consistently prepared for their post-operative experience, one nurse developed a DVD for patients and their families, greatly relieving post-op anxieties and reducing unnecessary readmissions. Tools like this not only improve patient care, but reduce healthcare costs for everyone and further demonstrate the critical role that nurses can play in our evolving healthcare system.

6. Shortage of nursing school faculty

Faculty shortages at nursing schools are limiting student capacity at a time when the demand for nurses is skyrocketing. U.S. nursing schools turned away more than 67,000 qualified applicants from baccalaureate and graduate nursing programs in 2010 due to an insufficient number of faculty, clinical sites, classroom space and budgetary and other constraints. While the American Association of Colleges of Nursing is leveraging its resources to address this issue through focused media attention, data collection and the procurement of federal funding for faculty training programs, we must all focus attention on this crisis by making sure our nurse faculties have the appropriate support and resources they need to not only prevent job burnout, but to encourage potential retirees to stay on the job longer. And, we must continue lobbying policy makers and the Federal government to act swiftly to help fund new faculty recruitment and training.

These challenges nurses face are not for the faint-of-heart, or for those without conviction. But, I know of no other profession more capable of meeting tough challenges than nursing. Our specialty was built by individuals who have broad shoulders, a strong back and perseverance. Nurses will, as they have done always, continue to transform healthcare in ways that will have an immeasurable impact on the nation’s health.

Courtney H. Lyder is dean and professor of the UCLA School of Nursing, professor of Medicine and Public Health as well as Executive Director of the UCLA Health System Patient Safety Institute and Assistant Director of the UCLA Health System.


  • I agree that we need our nurses more highly qualified. But as nurses we need a better benefits package. America needs to recognize that nurses are human beings also. We need better maternity benefits, tuition/scholarships and a better pension plans like our counterparts in other parts of the world. Do some research on nurses in other developed countries and see how they are treated! Plus the daily threats of being sued is a reality we live with in our daily practice.

  • nurse thats disgusted
    January 22, 2013 9:58 am

    I have been a LPN for over 14 years. I have been lucky enough to learn many different areas of nursing from working in a rural hospital. Maybe we should look outside the box, have clinicals and procedural classes and with a certain amount of experience have them to test out for the NCLEX-RN. It’s what one knows, and the care they give and experience has much learned skills in it. I am able to do alot of what RN do (within scope)but there needs to be other ways to look at this shortage problem.

  • Peter DiGiuseppe
    June 18, 2012 5:50 am

    Thanks Dot. Let me lay out some more truth for nurses out there. I took the liberty of researching the IOM (Institute of Medicine). Surprise, surprise; just about every one of its officers and board members are in some way affiliated with a four year college or university. It is no wonder they’d like to have all nurses run back to school for baccalaureate and graduate degrees. They could make it so nurses can earn a BSN the same way CEUs are earned. But the four year schools wouldn’t profit.

  • Peter has some very accurate points. Nurses who have been ADN’s for several years are very good nurses, often much better than their higher degreed managers. There is too much emphasis on what the entry degree should be, instead it should be on how to get the experienced ADN’s a BSN. Statistics show that at the rate our country is aging & the rate staff nurses and nursing instructors are retiring is dramatically increasing, we won’t be able to survive w/o ADN’s. Help us get where we need to be

  • rwjf rn report 2010
    May 13, 2012 6:34 pm

    Please why is apa style, paper writing, citing references, all going to make an adn or diploma nurse a better caregiver. All the bsn/msn and certified rns I work are all ready to move on away from bedside and they are all under 30, so who will take care of the iom/rwjf/ana folks when they are sick?

  • Peter DiGiuseppe
    April 11, 2012 7:27 am

    In looking over the content in RN-BSN and MSN programs, I see courses such as Theoretical Foundations, Current Issues, Research Methods, Leadership and Professional Ethics. This is covered in all basic A.S., Diploma and BSN nursing programs. Taking them at higher levels will not impact patient care. Believing colleges are not a business; now that’s short-sighted. “Put an advanced-degreed nurse manager on a floor with 10 patients and you’ll really see mortality rates increase”. (MD, PA 2012)

  • Going back to school is about advancing each persons individual education while advancing the profession, and improving patient care outcomes. It is not about writing papers, Yes that is one mechanism but that is not the reason to be there, those of you that believe this are short sighted. Our profession of Nursing is not recognized by other profession. We all need to broaden our learning and understanding and then use that knowledge to improve patient outcomes.

  • The comment by CJ gets at the largest reason for the drive to push RNS to BSN and MSN degrees. You see, Peter is right. Most RN-BSN/MSN programs focus on theory and papers, not “the BEST” or even improved care for patients. no, the push is so nurses will be seen as professionals. Why, it is ever so embarrassing to admit that plenty of nursing jobs don’t require theory courses, or advanced paper producing skills. No, great nursing CAN be attained w on the job learning and application of reading!

  • It’s a burden for those who are seeking nursing careers,to stay in school, when they can get a quickie degree, and be out in the profession earning a living. I believe strongly, however, that the entry level degree for most nursing positions is a BSN. I worked with nurses from all backgrounds, and the extra effort it took to supervise LPNs in an acute care med/surg unit was taxing on the rest of the staff. The facility I worked for viewed LPNs and RNs as interchangable, and they simply are not.

  • sothernnurse
    April 3, 2012 3:19 am

    Since when have we decided that the most basic needs should not even be met? Not bathing our patients…not changing linens…but making sure that our credentials are shining in the patients faces? I agree with many of the posts. we have become so top heavy with advanced practice nurses that the average RN is looked down upon and the LPN doesn’t have a chance. Really????

    Fed Up.

  • Peter DiGiuseppe
    April 2, 2012 1:09 pm

    Please let’s stop with all the fake altruism about how having nurses run back to school is for the benefit of patients. There is no additional hands-on patient care training in RN-BSN and MSN programs. In the programs I mentioned, students mainly write papers. As baby boomers aged, enrollments at colleges decreased. Schools see this BSN push as way to increase revenue and professors see it as a way to stay employed. The schools benefit; not the patients nor the indebted students. Peter D.

    April 2, 2012 2:53 am

    Think about this…We are the youngest profession and yet our status as a profession is often question. We fight everyday to prove ourselves. No other profession has so many academic entries as nursing. All other profession at least enter with a BS if not a Master’s degree. The lack of education only hurts our profession. As dynamic as nursing is we have too many nurses not equipped to give the BEST standards of care. How do I know this? I teach many nurses with punitive marks on their licenses.

  • Telling nurses that they need to run back to school and take on thousands of dollars of debt to earn BSNs and MSNs at a time when there are cut-backs in government financial aid and nursing jobs are scarce shows just how out of touch with reality academic elitists are. It proves my theory that the more time one spends in the fantasy world of academia, the more out of touch with reality they become. Peter DiGiuseppe, B.A., RN.

  • Spirithealer
    March 21, 2012 9:32 pm

    I apologise for the gap in continuity in my post below. In the future, I will not attempt to respond via iPhone no matter how strong my reaction is to the subject being discussed. The thrust of what I was trying to say is that although I have jumped through every hoop presented to me in order to obtain the necessary education to work as a nurse educator and nurse practitioner, the bar has been raised. Now, at 65, do I take on another $60k in debt in order to teach? Good grief!

  • Spirithealer
    March 21, 2012 9:15 pm

    After obtaining my ADN at the age of 52 in 2000, completing my childhood dream that was interrupted by life and 2 children that began in 1965, I worked as a RN in almost every area available. Most of my time was in gerontology. In 1995, I got my BSN At that time, in FL, a MSN was required. Now at 65, I have completed my MSN/ED, hoping to teach online to supplement SS income. Universities now require a doctorate. With $48K in student loans, now another 60k for the PhD? I am so discouraged!

  • How senseless and short-sighted is it when the type of program a nurse graduated from becomes more important than being experienced, skilled and competent. Many hospitals are now telling nurses who are their 40s and 50s with 25+ years of experience and specialty certifications that demonstrate excellent that they must go back and get a BSN. Many of these nurses will have a student loan debt that will not be paid off by the time they are ready to retire. Many have said they would leave the profes

  • There are excellent practicing nurses who do not have the academic credentials, as well as unfortunate indivdual situations. However, we must be forward thinking as Dean Lyder to maintain our relevance in the world of expanding knowledge and, hopefully, accepting responsibility of our roles. I wish these nurses would not be so defensive and look to the future needs of the population as well as the profession. Karen Reichensperger, Ph.D., R.N.

  • I have an AD degree from a Big 10 school that I received in 1983. I also have a Child Development and Family Studies BS with a focus on child health. Should I be forced into obtaining another degree to keep my nursing practice intact? I think with 28 years of nursing at the bedside and 2 degrees from a nationally accredited school should count for something….sadly it seems the only accepted degree is a BSN and higher! Talk about elitist!!!!

  • I truly appreciate the comments posted reagarding my thoughts. Seeking higher education should not be viewed as elitist, but one that should be aspired too if we are to continue elavating our profession. I have met in my 25 years of nursing amazing healers who were CNAs, LPNs, ADNs, Diploma and BSNs. By suggesting higher education takes nothing away from my colleagues where ever they may be educationally. We have a responsibility to breakdown any barriers for nurses to achieve higher education.

  • Having an advance degree does not make a better nurse. It depends on the person. I know of several associate degree nurses who have knowledge far beyond their BNS nurses co-workers.

  • This idea is crazy! I am a 3yr hospital RN diploma nurse that has been in practice for almost 23yrs now. Ms Lyder may be just a nurse (in academia) but I am more than that. I am a mother, a wife, a family member and a friend. I do alot of reading and attending seminars on my own. I have learned more out of school than in school. People like Ms Lyder would take that away from many of us! My key challenge list would look much different from this one. Viewpoints like this one would be the first.

  • I am a clinical instructor who is being forcibly retired (along with all others who are not pursuing a doctorate and several who had a PhD, but not from nursing, regardless of age and time until full retirement. The college seems to be expecting that the DNP graduates will be willing to provide clinical instruction for undergrads as well as some of the newer PhD graduates. This has ot been an expectation of this level of faculty in the past and is being met with resistance. Budget concerns.

  • The article contradicts itself in that one paragraphs wants us all to have advanced degrees that are supposed to trump years of experience, while another paragraph wants to remove scope of practice barriers. I’ve known many wonderful LPN’s with years of experience that have it hands down over newer RN’s with whatever degree. I’m a 30 yr. 3 yr. diploma nurse who has more experience under my pin than any new grad with a BSN. paragraph 3 now wants me to learn a new language in MY country. Pffft.

  • Again it seems that those in favor of requiring nurses to return to school for BSNs and advanced degrees are affiliated with academia. Have to keep that revenue flowing. Telling a nurse with 25+ yrs experience and specialty certifications that demonstrate excellence and expertise that they must now go into debt for a degree that will not impact patient care is ludicrous. Many of these nurses are 40+ yrs of age and will not have the student loan debt paid by retirement. This is one big scam.

  • I agree fully with Ms. Lyder. I am a BSN from the 70’s. Yes the argument was going on then to make a BSN entry level for nursing; it needs to happen. Our patients are becoming more and more complex every year; we need new learning. Since I graduated mid 1970’s I have pursued a Masters and two certifications. I did this in in my thirst for more education My only regret is that I was born to early and will miss seeing all the wonderful things that are going to happen to our nursing profession

  • In the ’70s the Canadian Nurses Association put out a ‘position paper’ to inform stakeholders the Canadian nurses would be Bachelor prepared by the year 2000. The ANA was discussing the same proposal, but but it didn’t happen. here. NOW U.S. nurses are obtaining crucial nursing knowledge with on-line coursesand entering the work force lacking basic skills. Nurse education has diminished rather than gone forward for the majority of nurses.Too many on-line courses.

  • I too have heard these same arguments since the early 80’s. Getting financial aid to get a BSN is the only way it would be worth going back to school for the majority of RN’s without a BSN. Somebody wants us to have BSN’s without giving us the financial incentive to do so.

  • JK has it right – as long as nurses are part of the room charge what we do won’t be valued. The room charge is easier allowing the variety of activities that are carried out for our patients every shift to be ignored (and therefore uncompensated).

  • Agree with the other posts. This is the same language almost word for word that I have been reading and hearing since 1988. As long as nursing has no authority at the table these problems will never change. They will just be passed on to a new generation of nurses. We have to have degrees to be nurses but just strong backs with no back bone in the workplace.

  • While the necessity to pursue a higher degree is pushed by the majority of those who hold higher degrees is a wonderful idea many of those who work at the bedside have no financial means or see a reason to pursue a higher degree. There are no differences in salaries for those degrees that cost thousands of dollars to pursue just as there is no difference in the NCLEX that they take to obtain that degree.
    While I obtaing my BSN there is only personal satisfaction that will be obtained no other

  • It is appalling to me that as a profession we cannot realize and appreciate that there is a need for each level of care giver. As an educator I am honored to provide training for an entry level that can use their education as a “stepping stone” to progress and add to their knowledge. Not everyone can be an Advanced Practice Nurse!

  • First of all, I’ve been hearing this entry level battle since I graduated from my ADN program in 1985! My question??? Why are we still offering AD Nursing Programs? If we want the change WE have to make it. Seems like we as a profession are not willing to “bite the bullett” and “Just Do It”.
    But FIRST!
    We must change nursing curricula to meet the needs of the profession! I orient new nurses and find no difference in orientation needs of ADN vs BSN in acute care.

  • Nursing has been talking about most of these issues since 1965 – with little to no action taken. If nursing is serious this time then lets start: first, close ALL remaining diploma schools – it is professionally embarrassing that they remain open; second, as of 2015, ALL ADN junior college programs must affiliate with a BSN program to remain open – any ADN thereafter will be a Technical RN, until they meet the BSN standard; third, pay nursing faculty a comparable wage to other professors.

  • Two areas I feel need more dialogue and emphasis. First,the wellness of nurses holistically as they face the challenges of an increasingly hi-tech environment. How do they reclaim their healing presence at the bedside rather than just being present for tasks. Second, the validation of men’s contribution in nursing is critical to the profession’s future growth.Caring is gender neutral as is healing presence. S.O. author- The Ecology of Wellness-a personal and professional resource for nurses.

  • When I graduated with my ADN in 1978 I understood that this was only the first step. I went on to work full-time and pursue the BSN and MSN. It saddens me that we are still no closer to resolving the entry level into practice issue now than we were then. I agree wholeheartedly with the comments of the other posters. Enough talking already -do something.

  • I work worldwide in nursing and there are not enough PhD prepared faculty anywhere, including the US; problem is incentives for further study are few, and having recently retired from a prestigious US university along with 6 other of my PhD faculty, no attempt has been made to continue to engage us..what a waste.

  • In regard to the nursing faculty shortage: I am a PMHCNS board certified through the ANCC. I was told I could not teach at UCLA or in the community college system in Los Angeles because I do not have INPATIENT nursing experience in the PAST 5 years. This supposedly has something to do with the BRN regulations. I had 17 years of inpatient experience in addition to my 20 years of outpatient experience as a CNS in Geriatric Psychaitry. No wonder there is a faculty shortage.

  • I have been an RN for 45 years.
    I retired as a Dean of Health Education which included nursing and several other health programs. If I had $1 for each hour I have spent in meetings dis-cuss-ing these issues locally, state and nationally I would be wealthy! Now I am just frustrated to have spent all those hours and nursing is STILL talking. When will we ACT???

  • I am a diploma school grad who was around when the position paper came out in the mid 60s. What’s amazing to me is we are STILL discussing this. Instead of getting a BSN IN 10, how about on level of entry only by 2022. A wise woman I met years ago convinced me when she sai “it’s many parent’s dream to have their child graduate from college. Why is it not the dream of the nursing profession. Wise woman, Marilyn Prouty.

  • Mandating BSN within 10 years of entering practice is unrealistic These elitist ideas do not consider the human factor.The best approach to empowering nurses is for hospitals to start billing for nursing services so we can show we are revenue producers. Then we can sit at the table with equal power in decisions.

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