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I Love New York — If the Empire State Leads, Will Others Follow?

The views expressed are those of the author and do not necessarily reflect the views of ASPA as an organization.

By Burden S. Lundgren
November 19, 2018

Let me make two things clear. First, I am in favor of life-long education. In fact, I am its exemplar. I completed my undergraduate degree 10 years after becoming a nurse, my masters at midlife and people were inquiring about my (presumed) retirement while I was writing my doctoral dissertation. Second, I do not believe all education has to be “useful.” I spent most of my time as an undergraduate studying philosophy and European history. It was the most intellectually enriching experience of my life. I wouldn’t trade a minute of it.

But some education is meant to be useful and should be. In the case of health care professions, the use is and ought to be improved patient outcomes. To meet this goal, over the past decades, continuing education (CE) requirements for health care professionals have mushroomed.

To look at my own profession, 13 states have no requirements for CE. The remaining 37 have a dizzying array of both qualitative and quantitative CE specifications well exemplified by those states in which I have held licenses. New York requires nothing beyond three-contact hours infection control course every four years while Virginia requires:

  • 30 contact hours as a student or teacher every two years;
  • 15 contact hours and 640 hours of active practice or teaching an academic or specialty certification course;
  • Completion of an article (author or co-author);
  • Completion of three credit hours relevant to nursing practice; or,
  • Current specialty certification.

Looking at the Virginia requirements more closely (and Virginia is not alone in the diversity of its requirements), what is the equivalency of each of these requirements to the others? Is teaching a course really the same as taking it? Is reading an article (one way to complete contact hours) the same as writing one? What science could possibly support these diverse requirements both across states and within states? None. There is no evidence that CE requirements, no matter what they are, result in improved patient outcomes.

And they may do harm. Continuing education is not free, and costs added to a system are passed on to the end-users of that system, in this case, patients. Higher health care costs create barriers to access, and barriers to access result in poorer health outcomes – exactly what CE is intended to prevent.

A thriving industry has been created to meet CE requirements. There are, of course, the formal courses – often traveling shows offered in a variety of cities (which puts them out of reach for nurses in rural settings) and prices and time requirements that put them out of reach for nurses in any setting since, in almost all cases, nurses do not receive time off or reimbursement from their employers. But sitting on my desk right now is a catalog of offerings from a private company that will sell me contact hours for reading what amounts to articles about the diagnosis of Alzheimer’s Disease (five contact hours) or a longer presentation on diabetes in children (25 contact hours). Suppose I work in obstetrics. No problem. Contact hours can be in any specialty no matter how irrelevant to my practice. After I do my reading (an assumption), I can complete a self-assessment (multiple choice, open book with the correct answers supplied on another page), and a course evaluation and mail it in to the company. It’s a bargain — both courses for less than $30.

It is not surprising that nurses can’t agree on CE. We can’t agree on entry level preparation either. Registered nurses can sit for their licensing exams after completing a two-year, a three-year or a four-year program. Throughout most of our history, hospital-based three-year programs were the norm. Now, almost half of American nurses are graduated from community colleges with the rest finishing baccalaureate programs. There’s not much science behind that either.

Is there any science concerning nursing education and patient outcomes? Despite the fact that the profession has pushed for baccalaureate entry-level education for a century, studies looking at education and outcomes are fairly recent. But they do point in one direction. Patients do better, often considerably better, when their nurses are graduates of four-year colleges. North Dakota implemented a baccalaureate requirement in 1987, but with only 15,000 nurses, the new specification made the state a small, isolated island in a sea of lower standards. The requirement died in 2003. Now New York is requiring all newly licensed nurses to have or to complete a baccalaureate degree within 10 years of graduation. New York has over 300,000 nurses, eight percent of all the nurses in the United States. Will it be enough of a critical mass to ignite national requirements?

Besides the obvious, there is a real pay-off here. Better patient outcomes mean fewer complications and shorter hospital stays, both major sources of cost savings. Here is a case where front-end investment will pay dividends in the long term. It’s my home state, and, right now, I’m loving New York.


Author: Burden S. Lundgren, MPH, PhD, RN practiced as a registered nurse, specializing in acute and critical care. After leaving clinical practice, she worked as an analyst at the Centers for Medicare and Medicaid Services and later taught at Old Dominion University in Norfolk, Virginia. She has served as a consultant to a number of nonprofit groups. Presently, she divides her time between Virginia and Pennsylvania. She can be reached at [email protected]

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