The 2017 Environmental Scan

Abstract

The past year was momentous for science and technology. In May, the White House Office of Science and Technology Policy announced meetings and an interagency workgroup to probe opportunities for the use of artificial intelligence (Felten, 2016, May 3Felten E. Preparing for the future of artificial intelligence. 2016, May 3https://www.whitehouse.gov/blog/2016/05/03/preparing-future-artificial-intelligenceGoogle Scholar). In October, the President hosted a landmark meeting, The White House Frontiers Conference (Holdren and Smith, 2016Holdren J. Smith M. President Obama to host White House Frontiers Conference in Pittsburgh, PA. 2016, Augusthttps://www.whitehouse.gov/blog/2016/08/30/president-obama-host-white-house-frontiers-conference-pittsburgh-paGoogle Scholar). Scientists, economists, and workforce planners were among the participants asked to envision the country in 50 years and to project how robotics, artificial intelligence, and other technological breakthroughs will influence health care, space travel, communities and cities, climate change, and poverty. Also part of the White House initiative were two landmark reports: Preparing for the Future of Artificial Intelligence, from the Executive Office of the President, National Science and Technology Council Committee on Technology, 2016Executive Office of the President, National Science and Technology Council Committee on Technology Preparing for the future of artificial intelligence. 2016, Octoberhttps://www.whitehouse.gov/sites/default/files/whitehouse_files/microsites/ostp/NSTC/preparing_for_the_future_of_ai.pdfGoogle Scholar and a companion document, The National Artificial Intelligence Research and Development Strategic Plan (National Science and Technology Council, Networking and Information Technology Research and Development Subcommittee, 2016National Science and Technology Council, Networking and Information Technology Research and Development Subcommittee The national artificial intelligence research and development strategic plan. 2016, Octoberhttps://www.nitrd.gov/PUBS/national_ai_rd_strategic_plan.pdfGoogle Scholar). This White House agenda is a critical indicator of the rapidly developing innovations that will impact the nursing profession. Not only does nursing need to prepare for these changes, but nurses must be “the architects of change,” which was the theme of the National Council of State Boards of Nursing’s (NCSBN’s) 2016 Annual Meeting. In 2015, the United Nations published Transforming Our World: The 2030 Agenda for Sustainable Development, its 2030 agenda for sustainable development. To help regulators prepare for the future, NCSBN held a conference in October 2016, Regulation 2030, during which regulators and nursing leaders from around the world imagined the world in 2030 by addressing 25 emerging trends. The discussions resulted in concept maps that can be operationalized to accelerate progress and positive outcomes in nursing policy and regulation or can be used to manage risks and deter negative consequences. Immediately after Regulation 2030, NCSBN held the International Nurse Regulators Consortium, during which regulatory leaders from seven countries explored the evolution of concepts that inform public protection models. The keynote speaker, Dr. Daniel Susskind, highlighted essential themes from the book he recently coauthored, The Future of the Professions: How Technology will Transform the Work of Human Experts (2015), and led a discussion on how the work of professionals will change as machines become increasingly capable of doing that work, as medical monitoring devices are increasingly worn or imbedded in people and used in homes, and as people rely more on information from collective and Web-accessible platforms (Susskind and Susskind, 2015Susskind R. Susskind D. The future of the professions: How technology will transform the work of human experts. Oxford University Press, USA, Cary, NC2015Google Scholar). Benjamin Franklin said, “By failing to prepare for the future, we prepare to fail.” The first step in preparing for the future is to be fully aware of the present and to comprehend its implications for the future. The 2017 NCSBN Environmental Scan discusses the current state of nursing, explores the milieu in which regulators are immersed, and investigates the rapidly evolving innovations in health care, technology, politics, and society. It also describes where regulators need to focus their attention to stay ahead of change and to ensure a future that is safer than today. A health care workforce does not consist of a well-defined set of roles, but changes over time in response to many factors. It is influenced by the form of government of the society, definitions of health, social values, costs, the society’s expectations for the health care system, and the political power of various players. Ada Jacob Cox, PhD, RN, FAAN (1997) Making accurate nursing workforce predictions beyond a few years requires knowing as much about emerging technology as knowing about data and trends. The process of making such predictions is complex and nuanced: one must look as far ahead as possible and determine if the economy and a multitude of other unpredictable factors will influence the data. In 2017, an additional question arises: will the profession be flexible enough to accommodate changes in personnel and staffing as well as the technology and innovation that are destined to influence the health care workforce of the future? NCSBN’s National Nursing Database tracks the number of U.S. licensed nurses from 55 boards of nursing (BONs) daily. The database does not include numbers from the Oklahoma, Hawaii, and Louisiana-PN BONs. As of September 2016, the database revealed 3,880,565 registered nurses (RNs) and 913,453 licensed practical nurses and licensed vocational nurses (LPN/VNs) in the United States (National Council of State Boards of Nursing, 2016aNational Council of State Boards of Nursing National Nursing Database: A profile of nursing licensure in the US. 2016https://www.ncsbn.org/national-nursing-database.htmGoogle Scholar). The most recent Occupational Employment Statistics data indicate that 2,687,310 RNs and 695,610 LPN/VNs were employed in the United States as of May 2015 (U.S. Bureau of Labor Statistics, 2016U.S. Bureau of Labor Statistics Occupational employment statistics. 2016http://www.bls.gov/oes/oes_emp.htmGoogle Scholar). These statistics show that 2015 had the largest number of employed nurses in more than a decade. However, as Figure 1 illustrates, the RN workforce has increased, and the LPN/VN workforce has decreased since 2012. The distribution of employed RNs varies substantially by state, as shown in Figure 2. California, Nevada, Utah, Oklahoma, and Georgia have the fewest RNs employed per capita: 600 to 700 nurses per every 100,000 people (U.S. Bureau of Labor Statistics, 2016U.S. Bureau of Labor Statistics Occupational employment statistics. 2016http://www.bls.gov/oes/oes_emp.htmGoogle Scholar; U.S. Census Bureau, 2016U.S. Census Bureau Annual estimates of the resident population for the United States, regions, states, and Puerto Rico: July 1, 2015. 2016http://www.census.gov/popest/data/index.htmlGoogle Scholar). Alaska, Hawaii, Colorado, Maine, Nevada, Oregon, Rhode Island, and Utah have the fewest LPN/VNs employed per capita: 0 to 100 LPN/VNs per every 100,000 people. Over the past year, the supply and demand of nurses has been a topic of much discussion. The maps in Figure 2 demonstrate a state-level snapshot of the supply of employed nurses. However, for those studying and monitoring the nursing workforce, regional differences within states are often the main concern. For instance, California has one of the lowest employed nurse-to-population ratios; however, within the state, city centers such as San Francisco may have high nurse-to-population ratios, whereas rural areas may have low nurse-to-population ratios. In-state regional nurse employment numbers are available for download from the U.S. Bureau of Labor Statistics, 2016U.S. Bureau of Labor Statistics Occupational employment statistics. 2016http://www.bls.gov/oes/oes_emp.htmGoogle Scholar. Nurse employment settings have slowly shifted over the past few years, possibly driven by health care costs. The most expensive places to deliver care are inpatient facilities and emergency departments (National Center for Health Statistics, 2016, October 7National Center for Health Statistics CDC health expenditures. 2016, October 7http://www.cdc.gov/nchs/fastats/health-expenditures.htmGoogle Scholar). Care traditionally delivered in those settings will increasingly be provided at home or in the community. Moving care to the community or the home is likely to produce large savings and a shift in workforce distribution. Urgent care clinics employing advanced practice registered nurses (APRNs) are projected to grow to 12,000 by 2019 and deliver simple services at a 72% savings over emergency departments (Rechtoris, 2016, March 9Rechtoris M. 7 statistics on urgent care centers, EDs & retail clinics. 2016, March 9http://www.beckersasc.com/asc-quality-infection-control/5-statistics-on-urgent-care-centers-emergency-departments.htmlGoogle Scholar). The home care market is projected to expand to $157 billion by 2022 (Elsevier, 2016Elsevier Revenue cycle management in home health care. 2016, Julyhttp://icd-10online.com/wp-content/uploads/2016/08/EL-Home-Health-White-Paper-web.pdfGoogle Scholar). The growth of these nonhospital settings will affect the nursing workforce, especially APRNs. In the United States, more than 250,000 APRNs practice in four roles: certified nurse practitioner , certified registered nurse anesthetist (CRNA), certified nurse midwife (CNM), and clinical nurse specialist (CNS). In 2014, the number of certified nurse practitioners was 222,000 (American Association of Nurse Practitioners, 2016American Association of Nurse Practitioners American Association of Nurse Practitioners fact sheet.2016https://www.aanp.org/all-about-nps/np-fact-sheetGoogle Scholar). CRNAs currently number more than 45,000 (Phillips, 2017Phillips S. The 29th annual APRN legislative update.The Nurse Practitioner. 2017; 42: 18-46Crossref PubMed Scopus (15) Google Scholar). In 2015, the American Midwifery Certification Board reported 11,210 CNMs. The number of CNSs is more difficult to estimate because they were not recognized in some states until recently and still are not recognized in a few states (Newman, 2016, April 21Newman R. Obamacare is in better shape than you think. 2016, April 21http://finance.yahoo.com/news/obamacare-united-health-repeal-not-happening-150042506.htmlGoogle Scholar). The overwhelming majority of APRNs prescribe (95.2%) and, on average, have been in practice more than 12 years. Ninety-six percent of APRNs have graduate degrees, and 83% hold advanced certification in primary care (American Association of Nurse Practitioners, 2016American Association of Nurse Practitioners American Association of Nurse Practitioners fact sheet.2016https://www.aanp.org/all-about-nps/np-fact-sheetGoogle Scholar). APRNs, who are growing in number, are well positioned to step further into the primary care arena (Academy of Medical-Surgical Nurses et al., 2016Academy of Medical-Surgical Nurses American Association of Colleges of Nursing American Association of Critical-Care Nurses Critical Care American Association of Neuroscience Nurses American Association of Nurse Anesthetists American Association of Nurse Practitioners Public Health Nursing Section American Public Health Association RE: CMS-5517-P – Medicare program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) incentive under the physician fee schedule, and criteria for physician-focused payment models (81 Fed.Reg. 28162 May 9, 2016).2016, June 27http://www.aacn.nche.edu/government-affairs/aprn-advocacy/CMS-QPP-Proposed-Rule-APRN-Comment.pdfGoogle Scholar). When allowed to practice to the full extent of their education and training, they care for the vulnerable in designated health professional shortage areas, both urban and rural (Xue et al., 2016Xue Y. Ye Z. Brewer C. Spetz J. Impact of state nurse practitioner scope-of-practice regulation on health care delivery: Systematic review.Nursing outlook. 2016; 64: 71-85Abstract Full Text Full Text PDF PubMed Scopus (97) Google Scholar). In a large national sample of ambulatory patients, Barnes and others found that APRNs have a 13% greater likelihood of working in primary care in states that allow full-practice authority and that they are 23% more likely to be caring for Medicaid patients if the state allows full reimbursement for their care (2016). As shown in Table 1, the trend for new graduates finding employment has improved since 2012. In 2012, only 51% of new graduates had a job less than 1 month after graduation. In 2016, 75% did. After 6 months, 97% had jobs, compared with 86% in 2012.Table 1New Graduate RNs Employed After Graduation2012 (n = 4,110)2013 (n = 6,121)2014 (n = 8,902)2015 (n = 3,861)2016 (n = 3,901)Employed (%)Employed (%)Employed (%)Employed (%)Employed (%)> 1 month (graduated in summer)5156627175>4 months (graduated in spring)7176788588>6 months (graduated in previous year)8687889397Data for 2012–2015 from previous scans. Data for 2016 from National Student Nurses’ Association, 2016National Student Nurses’ Association 2016 NSNA survey of new graduate nurse employment. Manuscript in preparation.2016Google Scholar. RN = registered nurse. Open table in a new tab Data for 2012–2015 from previous scans. Data for 2016 from National Student Nurses’ Association, 2016National Student Nurses’ Association 2016 NSNA survey of new graduate nurse employment. Manuscript in preparation.2016Google Scholar. RN = registered nurse. In 2016, the American Association of Colleges of Nursing (American Association of Colleges of Nursing, 2016American Association of Colleges of Nursing Employment of new nurse graduates and employer preferences for baccalaureate-prepared nurses.2016, Novemberhttp://www.aacn.nche.edu/leading_initiatives_news/news/2016/employment16Google Scholar) conducted a brief online survey of 743 deans of nursing, asking about employment rates for new nurses immediately after graduation and 4 to 6 months after graduation. The survey, which had a response rate of 77.5%, found that the average job-offer rate at graduation for entry-level nurses with a Bachelor of Science in nursing (BSN) degree was 70%; for entry-level nurses with a Master of Science in nursing, or MSN, degree, the rate was 74%. The survey also revealed that 92% of entry-level BSN nurses had job offers 4 to 6 months after graduation. These results mirrored those of the National Student Nurses’ Association, 2016National Student Nurses’ Association 2016 NSNA survey of new graduate nurse employment. Manuscript in preparation.2016Google Scholar. The employment rates varied across regions: the South had the highest rate (77%), and the West had the lowest (66%). A comparison of these findings with those of a survey conducted by the National Association of Colleges and Employers, 2015National Association of Colleges and Employers The class of 2015 executive survey report. 2015, Septemberwww.naceweb.org/uploadedfiles/.../2015-student-survey-executive-summary.pdfGoogle Scholar (n = 39,950) of new college graduates across disciplines indicates that nursing is doing well. The National Association of Colleges and Employers found that only 50.6% of their respondents had job offers at graduation, a percentage that was the highest since the recession. As shown in Table 2, BSN graduates continue to be employed as RNs at a greater percentage (92.73%) than graduates of associate degree (i.e., ADN) programs (89.59%) or accelerated BSN programs (86.08%) (National Student Nurses’ Association, 2016National Student Nurses’ Association 2016 NSNA survey of new graduate nurse employment. Manuscript in preparation.2016Google Scholar). Similarly, in the 2016 annual survey of new graduate employment (American Association of Colleges of Nursing, 2016American Association of Colleges of Nursing Employment of new nurse graduates and employer preferences for baccalaureate-prepared nurses.2016, Novemberhttp://www.aacn.nche.edu/leading_initiatives_news/news/2016/employment16Google Scholar), deans of baccalaureate programs (n = 576) reported that 54% of hospitals and other health care settings require new hires to have a BSN degree—a 6.6% increase from 2015. Further, the deans reported that 97.9% of employers express a strong preference for hiring BSN program graduates. Likely, the recommendation in the Institute of Medicine’s (IOM’s) report, Future of Nursing (2011), to increase the percentage of BSN-educated nurses, as well as research findings indicating that increased ratios of BSN-educated nurses positively affect patient safety, has influenced employers to prefer BSN-educated nurses to ADN-educated nurses. The reason accelerated BSN graduates are being hired at lower percentages is not as clear. Brandt et al., 2015Brandt C.L. Boellaard M.R. Zorn C.R. The faculty voice: Teaching in accelerated second baccalaureate degree nursing programs.Journal of Nursing Education. 2015; 54: 241-247Crossref PubMed Scopus (7) Google Scholar suggest that employers may have an inaccurate perception that accelerated BSN programs are abbreviated and that the content is trimmed. As the nursing shortage plays out, these hiring differences may dissolve.Table 2New Graduate RN Employment by Program20122013201420152016Type of ProgramEmployed RNs (%)Number of employed RNsEmployed RNs (%)Number of employed RNsEmployed RNs (%)Number of employed RNsEmployed RNs (%)Number of employed RNsEmployed RNs (%)Number of employed RNsAssociate Degree61966721,316721,013821,07089.591,208BSN prelicensure721,686811,686821,698871,57192.731,953Accelerated BSN5821869386812048342286. 08553Note. BSN = Bachelor of Science in nursing; RN = registered nurse. Open table in a new tab Note. BSN = Bachelor of Science in nursing; RN = registered nurse. National Student Nurses’ Association, 2016National Student Nurses’ Association 2016 NSNA survey of new graduate nurse employment. Manuscript in preparation.2016Google Scholar) also looked at a 2-year trend of employment percentages by type of institution (Table 3). These data illustrate that graduates of private not-for-profit institutions have the highest employment percentages, followed by public institutions and then private for-profit institutions. All three types of institutions increased their employment percentages from 2015 to 2016.Table 3Employment Rates of Graduates of For-Profit Versus Not-for-Profit and Pubic InstitutionsEmployed as RNPublicPrivate (Non-for-Profit)Private (For-Profit)2015 n = 3,548Yes84.6% (1,930)86.1% (709)82.24% (366)No15.4% (351)13.9% (114)17.0% (78)2016 n = 3,901Yes89.56% (2,265)90.77% (757)87.92% (473)No10.44% (264)9.23% (77)12.08% (65) Open table in a new tab Discussion continues regarding the supply and demand of nurses. Does a surplus exist? Or a shortage? The answers depend on whether the interpretation is based on a macro or micro view of the nursing workforce. A national view, a state-level view, or an in-state regional view may result in different conclusions. Nuances of the nursing workforce can only be understood by interpreting both the macro and micro views. For instance, if a surplus exists at the state level but a shortage exists at an in-state regional level, the data suggest recruiting more practicing nurses and simultaneously adding more nurses to the educational pipeline in the affected region. Another common nursing workforce question is: Will enough nurses will be available to make up for the looming baby boom retirements? Auerbach et al., 2015Auerbach D.I. Buerhaus P.I. Staiger D.O. Will the RN workforce weather the retirement of the baby boomers?.Medical Care. 2015; 53: 850-856Crossref PubMed Google Scholar conducted a study that forecasted the size and age distribution of the nursing workforce through 2030. The researchers projected that annual retirements from nursing will accelerate from 20,000 per year a decade ago to 80,000 per year in the next decade. However, projections also revealed that the entry of new RNs into the workforce could counteract this acceleration. Of course, the projections are contingent on the entry into nursing remaining at its current high rate. In addition, the researchers compared their results with demand estimates by the U.S. Department of Health and Human Services (HHS) Health Resources and Services Agency and noted that their estimate of the future RN supply fell slightly below the agency’s estimates. The retirement rate of older nurses and the entry rate of newer nurses are just two variables that fluctuate. Additional factors that may impact future workforce demands include global economic downturns or upturns, changes in health care laws, and new methods and modes of health care delivery, including better preventive health care that keeps patients out of the hospital. Advances in technology may have the greatest impact on the nursing workforce, making the current use of workforce data and modeling obsolete. In Japan, where the elderly outnumbers the labor force, robotic nurses are projected to save the country $21 billion per year in health care costs. Engineers have already created robotic nurses that look and speak like human beings. These machines are performing nursing skills, including helping patients transfer, taking vital signs, and administering medications. They also perform telehealth, serving as an intermediate between physician and patient (Masui, 2016, January 27Masui A. Development of care robots growing in aging Japan.The Japan Times. 2016, January 27http://www.japan-times.co.jp/news/2016/01/27/national/social-issues/development-care-robots-growing-aging-japan/#.V-A1ePkrJaQGoogle Scholar; Leiber, 2016Leiber N. Europe bets on robots to help care for seniors.http://www.bloomberg.com/news/articles/2016-03-17/europe-bets-on-robots-to-help-care-for-seniorsDate: 2016Google Scholar). In the United States, Duke Pratt School of Engineering and the School of Nursing has invented a telerobotic intelligent nursing assistant, or TRINA, a mechanical robot nurse that takes vital signs and delivers medications to patients. The scientists at Duke have greater plans for TRINA and others like it. They envision robotics playing a role in the care of patients with highly infectious diseases such as Ebola (Bridges, 2016, November 16Bridges V. Duke officials test, refine robot-nurse.2016, November 16http://www.newsobserver.com/ news/local/community/durham-news/article114543668.htmlGoogle Scholar). What do changes in technology mean for the nursing workforce? Presently, the impact on nursing is uncertain; however, the types of nursing skills required in the future may be drastically different than those of today. Perhaps, the future will require fewer nurses but have increased demands for highly technically skilled nurses and direct-care nurses for aging patients (Macy, 2016Josiah Macy, Jr. Foundation Registered nurses: Partners in transforming primary care. Presented at the Macy Foundation conference on preparing nurses for enhanced roles in primary care, Atlanta, GA2016, JuneGoogle Scholar). As machines become more sophisticated and take over some responsibilities of humans, questions emerge about the role of regulators in keeping patients safe. Today, robots cannot reason through ethical dilemmas, make decisions weighing options, or consider a person’s feelings or a family situation. However, delegation may be cast in a new light, with nurses delegating tasks once performed by them or assistive personnel to robots. Questions also emerge about who will oversee the robotic workforce and be accountable when things go wrong. These are a few challenging issues of the near future. As new workforce modeling techniques are developed and new ways of estimating workforce needs emerge, NCSBN works with BONs to build a national workforce database of the future. The long-term vision is to have workforce data and statistics on the entire U.S. nursing workforce. The database already provides aggregate data that reflects local, regional, state, and national workforce characteristics. However, only 17 BONs currently provide data to NCSBN’s nursing workforce database: Arizona, Arkansas, Connecticut, Georgia, Iowa, Kentucky, Maine, Minnesota, Mississippi, Nevada, New Hampshire, North Carolina, Ohio, South Dakota, Texas, Washington, and Wyoming. Data are collected at the time of licensure renewal. Questions are based on the National Forum for Nursing Workforce Centers Minimal Dataset, and data are stored in Nursys®, NCSBN’s nurse licensure and disciplinary database. BONs currently participating in the project transmit the data to Nursys and can later access their aggregate data and run real-time workforce reports for their state. To keep pace with the changing environment of health care, educators must continually monitor the pulse of nursing in the United States. Students must be prepared to enter a challenging workforce that holds high expectations for performance and advanced delivery of care. How should nurses be prepared for the future? The IOM’s 2010 Future of Nursing recommended an 80% BSN workforce by the year 2020 (Institute of Medicine (IOM) Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, 2011Institute of Medicine (IOM) Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing The future of nursing: Leading change, advancing health. National Academies Press, Washington, DC2011Google Scholar). This goal inspired the formation of nursing coalitions around the country that developed strategies to meet it, and in subsequent years, the number of BSN graduates has risen in the United States. In 2016, Altman, Butler, and Shern assessed the progress of the Future of Nursing recommendations and concluded that, between 2010 and 2014, the number of employed nurses with a BSN degree increased from 49% to 51%. Further, they found that the number of baccalaureate programs has increased faster than associate-degree or diploma programs. Buerhaus et al., 2016Buerhaus P. Auerbach D. Staiger D. Recent changes in the number of nurses graduating from undergraduate and graduate programs.Nursing Economic$. 2016; 34: 46-48PubMed Google Scholar published comparable data. They analyzed the most recent findings from the Integrated Postsecondary Education Data System and observed that in 2002, 893 ADN programs and 667 BSN programs existed. In 2014, the number of ADN programs increased to 1,245 (28%), and the number of BSN programs increased to 1,078 (38%). Current data, however, suggest that the overall number of RN programs may be beginning to taper. The number of RN programs increased from 1,571 in 2003 to 2,410 in 2015, but, in 2016, the number decreased to 2,402 (See Figure 3). These data do not include the RN-to-BSN programs (National Council of State Boards of Nursing, 2016aNational Council of State Boards of Nursing National Nursing Database: A profile of nursing licensure in the US. 2016https://www.ncsbn.org/national-nursing-database.htmGoogle Scholar). Funded by the Robert Wood Johnson Foundation to develop a more highly educated nursing workforce, the Academic Progression in Nursing (APIN) program was created by the Tri-Council for Nursing—an alliance of the AACN, the American Nurses Association, the American Organization of Nurse Executives, and the National League for Nursing. Grants provided by the program have been instrumental in advancing strategies and models that promote the advancement of nursing education and employment. More than $9 million has been invested in the APIN program, and nine states—California, Hawaii, Massachusetts, Montana, New Mexico, New York, North Carolina, Texas, and Washington—have received grants. Some APIN states have reported an increased BSN workforce compared with the national average, although outcomes vary widely from state to state. APIN identified the following five models to allow a more seamless advancement of education (Altman et al., 2016Altman S.H. Butler A.S. Shern L. Assessing progress on the Institute of Medicine report on the future of nursing. The National Academies Press, Washington, DC2016Crossref Scopus (126) Google Scholar): •Baccalaureate completion programs in community colleges: Currently, 22 states allow community colleges to confer baccalaureate degrees, although only seven states allow community colleges to administer nursing degrees; of those seven, only Florida and Washington have a structured path.•State or regionally shared competency models or outcomes-based curriculum: The prelicensure nursing curriculum is not standardized, but the model is intended to achieve standardized outcomes.•Accelerated RN-to-MSN programs: These programs offer ADN-educated nurses a streamlined way to obtain an advanced degree. Some programs allow students to “step out” with a BSN degree.•Shared statewide or regional curriculum: Universities and community colleges form partnerships and collaborate on a shared curriculum or curricular components, allowing students to seamlessly transition from an associate degree to a baccalaureate program, without repeating coursework.•Shared baccalaureate curriculum: Community colleges and universities work together to establish a baccalaureate curriculum; students can take courses at community colleges and universities, but they can take the National Council Licensure Examination only after completing the baccalaur