University Times

Jacqueline Dunbar-Jacob, dean of the School of Nursing, delivered an inaugural lecture on nursing education May 28 in recognition of her appointment as distinguished service professor of nursing. (See Aug. 29, 2013, University Times.)

The designation recognizes her “distinctive contributions and outstanding service to the University in support of its teaching, research and service mission as well as her national stature in her field,” said Arthur Levine, senior vice chancellor, Health Sciences, and dean of the School of Medicine, in presenting her a commemorative medallion.

Levine said: “It’s difficult to overstate Dr. Dunbar-Jacob’s positive impact on the School of Nursing,” which ranks No. 6 among its peers in National Institutes of Health funding, and rose to No. 5 in the U.S. News and World Report’s most recent annual ranking of the nation’s Best Graduate Schools. (See March 19 University Times.)

Dunbar-Jacob came to the University in 1984, having been recruited to Pittsburgh as director of nursing at Western Psychiatric Institute and Clinic.

“She quickly showed she was a natural leader and mentor with a clear talent for administration,” said Levine. After three years she became director of Pitt’s Center for Nursing Research, and in 1999 was named chair of the school’s Department of Health and Community Systems.

Dunbar-Jacob, who holds appointments in psychology, epidemiology and occupational therapy, became dean of the nursing school in 2001.

The call for nurses to have at least a bachelor’s-level education “is a recommendation that has been long and persistent and has been based on a variety of studies looking on the impact of nursing in the health care system,” said Dunbar-Jacob in her inaugural lecture, “Academization of Nursing.”

“The Institute of Medicine (IOM) is recommending that 80 percent of nurses have a baccalaureate degree by 2020, and that we prepare more students at the graduate level in nursing,” she said, noting that the World Health Organization in 2009 established standards for professional nursing and recommended raising the standard of education to the university level.

Many countries are striving to achieve those standards and 46 countries around the world now require a bachelor’s degree as an entry to nursing practice, she said.

History of nursing education

Education for nurses initially was through apprenticeship, with students learning at the side of someone engaged in the practice of nursing. Florence Nightingale established the first hospital-based nursing training program in 1860 in England.

“She believed that nurses needed to be well-grounded in the sciences that underlie disease and its management,” Dunbar-Jacob said.

New York’s Bellevue Hospital established the first hospital-based nursing education program in the United States in 1873.

Baccalaureate education for nurses in the U.S. began in 1909 at the University of Minnesota, but formal calls for nurses to have university training date back to 1901, when Ethel Fenwick of the International Council of Nurses first recommended it.

Fenwick’s call has been echoed over the years by professional organizations in health care, nursing and nursing education.

In 2005 the American Association of Colleges of Nursing and the American Organization of Nurse Executives issued a joint statement supporting baccalaureate education as entry to practice “in the interest of patient safety and enhanced care,” Dunbar-Jacob said. And in 2010, the Carnegie Foundation for the Advancement of Teaching completed a study of nursing, recommending baccalaureate education as a minimum requirement for nurses, with all nurses receiving a master’s degree within 10 years of graduating, she noted. The IOM’s recommendation followed in 2011.

The need for higher education

Why do nurses need a bachelor’s degree? And why do advanced-practice nurses need doctoral education? What is the nature of nursing research and why do nurses do research?

“As we’re educating nurses, we’re educating nurses for a variety of settings,” the dean said, noting that while 56 percent of Pennsylvania’s nurses are employed in hospitals, the remaining 44 percent are working in the military, in patients’ homes, in schools, community health, maternity clinics and birthing centers or in pediatrics, among others.

“Our education of nurses needs to prepare them to enter each and every one of those kinds of settings,” said Dunbar-Jacob.

Impact on patient care

Research over the past two decades indicates that increased RN staffing in hospitals is associated with lower patient in-hospital deaths and fewer adverse outcomes such as pneumonia, respiratory failure or cardiac arrest.

“It’s the professional nurse, the RN, rather than the delivery of nursing care by non-nurses that makes the difference,” the dean said. “Non-RN hours are actually associated with increases in errors and with other adverse outcomes among patients.”

Early studies on the impact of education levels on patient outcomes found that “each 10 percent increase of nurses with a baccalaureate degree in the hospital setting decreased the risk of dying or of failure to rescue by 5 percent,” Dunbar-Jacob said, adding that the nurse’s experience level was not a factor.

“We have evidence now from multiple countries across four continents that converge on the finding that the education level of the nurse is an important determinant of whether or not a patient is likely to die in the hospital, or whether or not patients are likely to be rescued when they’re declining, as well as whether or not numerous other adverse consequences might occur.”

Research from 2014 and 2015 shows an even more profound effect than the initial studies, she said: “Each 10 percent increase in the proportion of nursing in a hospital that has the baccalaureate degree is associated with a nearly 11 percent decline in mortality.”

Dunbar-Jacob quoted nursing education researcher Linda Aiken’s reasoning: “More education, and particularly university education, enhances critical thinking.

Professional nurses are called upon to quickly synthesize a large amount of clinical information about acutely ill patients, process this information in the context of scientific evidence, reach evidence-based conclusions, communicate salient information and their conclusions to physicians, and act in the absence of a physician at the bedside, which is most of the time.”

Pennsylvania’s nurses, by the numbers

“We have much room to grow and to change in the state of Pennsylvania,” the dean said.

Here, more than 205,000 nurses renewed their license in 2012-13. About 85 percent of them actually are in practice within the state, with 56 percent of them working in hospitals, said Dunbar-Jacob.

Thirty-nine percent had a baccalaureate degree, 9 percent had a master’s degree and fewer than 1 percent held PhDs or doctoral degrees in nursing practice, she said.

Pitt’s undergraduate nursing program

The University’s nursing school is working to achieve the nursing education standards set by WHO and nursing professional organizations, she said.

In undergraduate admissions, “we are looking for students with math and science backgrounds, students with strong academic credentials,” Dunbar-Jacob said, noting increasing readiness among applicants with higher SAT scores since 2000 and greater numbers of incoming students who graduated in the top 10 percent of their high school class.

This fall’s incoming class boasts SAT combined math and reading scores averaging 1327, with 72 percent graduating in their high school’s top 10 percent.

“We believe that we are bringing students into nursing who will meet those criteria that we’re seeing set by our professional organizations and by the World Health Organization,” she said.

Nursing students at Pitt get a strong education in the physical sciences (26 credits) and in the humanities (nine credits), in addition to 1,620 hours in supervised clinical practice. Nearly a quarter opt for a mentored research experience, with interest among students exceeding the number of available mentors, she said.

BSN graduates may go on to work as staff nurses in hospitals, schools, ambulatory care, home health, community health, the military or in veterans hospitals.

Opportunities abound for nurses who go beyond the baccalaureate degree, Dunbar-Jacob said, with positions in leadership and administration, advanced practice, business and entrepreneurship, education or consulting.

Graduate nursing education

“We’ve seen incredible growth in both clinical specialist and nurse-practitioner programs” since Rutgers established the first graduate nursing program in 1955, and the University of Colorado followed a decade later with the first nurse-practitioner program, she said.

Most recently master’s-level clinical nurse leader programs have arisen as a “generalist” option for nurses who want to advance their education and still provide direct care to patients.

Pitt offers five master’s programs: nursing informatics; nursing administration; clinical nurse leader; neonatal nurse-practitioner, and nurse-anesthetist. Each takes nearly two years beyond the bachelor’s degree.

“The current components of master’s education include advancing the background in sciences and humanities, but adding into that organizational and systems leadership and a heavy emphasis on quality improvement and safety at the institutional level,” Dunbar-Jacob said, adding that nursing students at all levels increasingly are being required to develop competence in informatics and health care technologies. “Many of the individuals working in hospital and health systems settings in the area of informatics are nurses,” she said.

Advanced-practice nursing

Graduate education is transitioning to the doctoral level, she said, pointing to a 2015 target date set by the American Association of Colleges of Nursing for the transition of all advanced-practice programs to a clinical doctorate. “The discipline is not there yet, but Pitt is,” she said.

Advanced-practice nurses have additional clinical education and expertise in care management for a specific population, as opposed to a specific condition. They fall into four specialty areas: nurse-practitioner; clinical nurse specialist; nurse-anesthetist, and nurse-midwife.

The value of their care is backed by research. “Comparisons between nurse-practitioners and physicians caring for similar kinds of patients show similar outcomes in patient satisfaction, health status, functional status, the number of emergency room visits, the number of hospitalizations, blood glucose levels, blood pressure levels and mortality,” she said. Similar positive outcomes have been found in studies of patients under the care of nurse-anesthetists and in long-term care and midwifery settings.

Research showing similar or better health outcomes for patients of advanced-practice nurses compared to physicians has led to rising interest among health care systems.

The work of advanced-practice nurses is governed by state standards, which tend to diverge on levels of physician engagement and the ability to prescribe medications, she said. Nurse-practitioners are recognized as primary-care providers in 45 states, can engage in autonomous practice in 33 states and are independent prescribers in 22 states.

Pennsylvania’s requirement that advanced-practice nurses have a collaborating relationship with a physician currently is under discussion, she said, noting that there is interest in expanding opportunities for nurse-practitioners.

Doctoral education for nurses

As advanced-practice nurses have gained more of a role in health care systems and are taking on more complex responsibilities, professional associations have recommended the development of a clinical doctorate specifically for advanced-practice nurses and nurse administrators.

“There really has been a rapid escalation” since the first doctor of nursing practice program was established in 2004, the dean said, noting that there currently are 243 DNP programs in the United States.

Education for DNP nurses requires a bachelor’s degree and is designed to prepare an expert advanced-practice provider, the dean said. These individuals receive at least 1,000 additional supervised clinical hours in their specialty area in addition to education in quality improvement, methodologies in leadership, translation of research into practice, policy, prevention and other areas important to practice in today’s health care system.

The additional education typically takes a minimum of three years and includes coursework, supervised clinical practice and a capstone project, typically focused on a quality-improvement initiative within an institutional setting.

Pitt offers nurse-practitioner, clinical nurse specialist and nursing administration programs; a midwifery program is poised to open in 2016, Dunbar-Jacob said.

Graduates of Pitt’s advanced-practice programs have a 100 percent first-time certification pass rate, she said. “We feel we’re doing a good job with our advanced-practice nurses in our educational programs,” she said.

U.S. News ranked Pitt’s graduate nursing programs No. 5 overall among more than 500 such programs in the United States, she said, adding that individual programs are ranked highly as well.

Pitt nursing’s anesthesia program ranked No. 1 and others were in the top six in the nation, she noted.

Research doctorates

In addition to clinical programs, PhD nursing programs prepare nurses for research careers.

“The focus for nursing is not the discovery of cures for disease, so our research takes something of a different focus than a researcher you might see in medicine,” the dean said. “Our nursing practice requires that we do research to support what we do, why we do it, to whom we do it and when we do it  — and when we need to change what we’re doing.”

Pitt nursing faculty are engaged in research in areas including genomics, cancer survivorship, symptom management, sleep, prevention, gerontology, self-management and adherence to treatment regimens, Dunbar-Jacob noted.

The effect on graduates

“There are many, many places that nurses can leave our graduate programs in nursing and assume influential positions in the development of health care today,” she said, noting that the school is expanding internationally with a focus on education — in sending students to other countries; assisting nations in developing and educating their own workforce, and developing international faculty through faculty scholar programs here.

“When we put individuals through these kinds of educational programs and expose them to the kind of research that supports practice, we expect that they will assume strong leadership positions when they leave us,” the dean said.

Currently, Pitt nursing alumni hold 11 dean of nursing positions at institutions in the United States; are at the helm of professional organizations, hospitals and health systems, and hold positions in government and industry. The first nurse to become U.S. Army surgeon general is a Pitt nursing graduate, Dunbar-Jacob said.

“We believe that Pitt is doing well and is placing graduates in positions to influence health care and health care delivery,” said Dunbar-Jacob, thanking the nursing school’s faculty and staff for lifting the school to its current high stature.

—Kimberly K. Barlow