The National Education Progression in Nursing (NEPIN) recently released a comprehensive report of academic progression from the ADN to the BSN between 2016 and 2020.

In the 2019 NSP II Program Evaluation, findings included the following outcomes of ATB:

1. Improved time to completion of Associate to Bachelors in Nursing (ATB) by 50 percent, with an estimated cost saving of approximately $13,000 per new nurse graduate.

2. Increased from 55% to 60% the proportion of BSN-prepared nurses to meet hospital needs.

Alternative academic progression models have been among the top-funded ($28.8 million) competitive institutional grant projects. In the Associate to Bachelor's (ATB) model, a student nurse enrolled at a community college can concurrently enroll in a university, allowing completion of both an Associate and BSN degree within three years. This minimizes educational costs and time to degree completion. Integrating nursing curricula for community college and university programs without redundancy is a major challenge. Since 2015, 12 nursing programs have received approximately $14 million for a variety of competitive institutional grants to implement the ATB partnership dual enrollment, or alternate concurrent enrollment to the BSN with good results.

Recent updates to the Center to Champion Nursing in America, which coordinates the Future of Nursing: Campaign for Action, initiatives of AARP Foundation and the Robert Wood Johnson Foundation indicate Maryland has now reached 67.1% BSN. We are outpacing all of our geographic neighbors with our focused ATB programs. We are #4 in the nation behind North Dakota, Washington, DC and Vermont.

Across Maryland, universities and community colleges are working together through funded projects to promote the BSN with Associate to Bachelor's (ATB) agreements for seamless academic progression. A concerted effort was necessary to ensure access to BSN education through targeted strategies, streamlined financial aid processes, and a unified message with hospital leaders that newly licensed nurses should make every effort to complete the BSN within 3-5 years of employment at a Maryland hospital. In 2017, MHEC with the Maryland Council of Deans and Directors of Nursing Programs (MCDDNP), revised and updated the Maryland Nursing Articulation Education Agreement (1985) for seamless academic progression for Licensed Practical Nursing to Associate Degree Nursing to BSN.

NSP II staff worked with the Maryland Longitudinal Data System (MLDS) at MHEC to measure ATB completions and determine time and cost savings to the individual nursing student. Early data are encouraging. Approximately one in five pre-licensure nurses graduate from a community college with an Associate Degree in Nursing and completes the BSN within one year. Using the ATB model has shown a 50 percent improvement in the time to completion of the Associate to Bachelor degree and an approximate cost saving in tuition of $13,000 per student. The seamless transition is expected to result in cost savings to newly licensed registered nurses and the hospital where they work; fewer courses will be needed to complete the BSN, thereby reducing the amount of tuition reimbursement. Cost savings are much higher for ATB students enrolled in a private university partnering with a community college, compared with attending the private university's traditional BSN program. This cost saving is transferred to hospitals in reduced tuition expenses for newly hired nurses. Along with cost savings, the ATB model is providing much needed access to BSN programs for those qualified applicants who were not accepted to traditional BSN programs for lack of space. Statewide dissemination of best practices in the ATB Model is continuing through ongoing ATB Coordinator meetings. Maryland has made significant progress toward increasing the proportion of nurses with a BSN working in hospitals and healthcare organizations to 80 percent. The Campaign for Action Maps, funded through the AARP and Robert Wood Johnson Foundations, used American Community Survey data to display national trends in BSN-prepared nurses. During the NSP II Program Evaluation in 2019, Maryland's average was about 60 percent and is among 12 states with over 60 percent BSN prepared nurses, outpacing the national average (55.9 percent) and neighboring states Virginia, West Virginia, and Pennsylvania (Courville & Green, 2019).

Along with this promising trend, hospitals are reiterating this message with their hiring practices. In a survey of Maryland hospital nursing leaders (MCSRC, 9/10/19), most Maryland hospitals (54 percent) require the newly hired nurse to be enrolled in a BSN program prior to or within 6-12 months of starting work and complete it within three years. Another 21 percent are developing similar policies, and 25 percent do not have a policy on BSN completion. Research on healthcare quality also indicate that BSN-prepared nurses improve patient outcomes. A recent study involving five states (including New Jersey and Pennsylvania) found that for each 10 percent increase in a hospital's proportion of BSN prepared nurses, there was a 24 percent increase in the odds of surviving a cardiac arrest to discharge with good cerebral performance (Harrison, et al., 2019). The findings indicated that a higher level of surveillance, quicker recognition of a deteriorating condition, and intervention with life-saving measures were important indicators to minimizing potential neurologic damage (Harrison, et al., 2019).

The American Nurses Credentialing Center's Magnet Recognition Program is acknowledged as the premier international recognition of organizations that were able to attract and retain nurses, keeping nurse vacancy and turnover rates low, and improving patient outcomes. Magnet® designation validates the highest-level nursing standards within the hospital (Graystone, 2018). Preliminary research has shown improved patient experiences in Magnet® designated hospitals compared to non- Magnet. The Magnet® designation is also associated with hospitals that can attract and retain high-quality nurses who are more satisfied and committed to their work environments (McCaughey, et al., 2018).

In 2019, eight (8) hospitals in Maryland have successfully achieved Magnet® and one has achieved Pathway to Excellence® designation with funding from the NSP I. Of those hospitals, four newly achieved Magnet® or Pathway to 13 Excellence® designation and three were re-designated. Seventeen hospitals are pursuing either Magnet® or Pathway to Excellence® designation. The Pathway to Excellence® designation was achieved by UM Upper Chesapeake Health Medical Center.

The ANCC Magnet® designated hospitals are: • Anne Arundel Medical Center, • MedStar Franklin Square Medical Center, • Mercy Medical Center, • Meritus Medical Center, • Suburban Hospital, • The Johns Hopkins Hospital, • University of Maryland (UM) Medical Center, and • UM Shore Regional Health. An examination of the U.S. Agency for Healthcare Assessment of Healthcare Providers and Systems (HCAHPS) scores found overall hospital ratings were significantly higher in Maryland hospitals with Magnet or Pathway designation. In addition, the Maryland Hospital Acquired Conditions Potentially Preventable Complications (PPC) differences were statistically significant.

Launching your ATB Programs

Establishing Partnerships

The first step is to secure at least one university partner to launch your ATB Program. In fact, it may be best to start with just one partner, work to get the program running smoothly, and then consider adding additional university partners who offer excellent BSN opportunities to your ADN students.

The most successful ATB programs have 4 or less university partners for operational ease. NSP II recognizes that “one size does not fit all", but in general it is preferable to partner with the instate Maryland universities. As a state, we host the ATB Coordinator's meetings and provide funding support through grants to advance the NSP II goal of 80% BSN by 2025.

Which university/universities have our ADN graduates traditionally attended to earn their BSNs?
These schools are your logical partners. Contact them to propose a meeting to explore a partnership. Be sure to point out that many of your ADN students come to their RN to BSN programs and ask, what if we could connect our students to you earlier at a time when they may be more open to learning about the content you have to teach? Move forward with the school(s) eager to partner. Get assistance from your leadership team in drawing up a Memorandum of Understanding (MOU) specifically outlining how the partnership will work. Advocate for university services and possible tuition/fee discounts for your students. Secure all necessary signatures from both institutions. Assemble faculty from both institutions to map out the dual enrollment ATB curriculum plan. Include pre-requisite courses needed for both the ADN and BSN programs, the dual enrollment nursing course sequence, timing of NCLEX exam and time/courses remaining to complete the BSN post ADN graduation.

Recruiting ATB Students

Once your partner(s) and curriculum plan(s) have been secured, it is time to market your program and recruit students. Consider the following. Which students do you consider the best candidates? Consider those already taking pre-nursing course or considering a nursing or health career. Think about high school and adult career changers who have strong math and science skills or STEM preparation. Take advantage of the college communications team. They can make invaluable contributions, helping you to explore outreach with materials geared to the potential ATB student. Examples would be ATB FAQ's, ATB nursing information session flyers, ATB nursing brochure, ATB high school recruitment cards, ATB building banners, and ATB information sheets. Be sure to work with the college's website developer to ensure the ATB Option is highly visible on the nursing program page.

Organize your outreach through advisors, high school recruiters, college faculty teaching pre-requisite courses, admissions offices, departments sending college catalogs/email blasts, college communications sending press releases and alumni mailings.

Admitting ATB Students

As you are creating your curriculum plan, discuss with your university partner(s): ATB admission criteria, the process for submitting/reviewing applications and making final admissions decisions.

Prospective ATB students may need additional prerequisite courses and higher GPAs tan those applying to the ADN program alone. If a standardized exam is used for admission, then a test by deadline and minimum score should be set. Admission to ATB is contingent on admission to the ADN program. Most ATB programs recommend students have a GPA of 3.0 or higher and a TEAS score of Proficient or higher with a minimum of 69% on the reading component. Decide on your application procedures and deadlines. The ATB Option requires two applications- one to the community college and one to the partner university. The deadline for a spring program start is August 31st and for a fall start, January 31st. Students must submit official transcripts to both schools.

Determine when admission decisions to the ADN program will be complete and report acceptances to the partner university(s). The university can then pull eligible ATB applications. Promptly schedule a joint ATB admission meeting for community college and university representatives. Prepare a spreadsheet containing key information for each ATB applicant (GPAs, TEAS scores, pre-requisite courses in progress, prior college degrees and notes concerning academic patterns, repeated sciences) to share at the meeting, Student files with transcripts are also available for review.

Consider whether the applicant meets minimum admission criteria and the overall strength of the academic record. Select the strongest applicants for the seats available. When an ATB applicant has a pattern of withdrawing, failing or repeating courses, the two schools may feel it is in the best interest of the student to begin the ADN program only. They are encouraged to apply for second year ATB entry once they have demonstrated success in their first year ADN courses.

When the ADN program notifies students of their acceptance to its program, a statement is included that if they applied to an ATB university, they can expect to hear the university's decision in about 2 weeks. The community college and university partners coordinate the dates when admission decisions will go out and when students must commit to enroll in the ADN/ATB programs. If the student is required to pay a seat fee when committing to the program, the fee is applied to the first semester tuition.

Manage an ATB Program

Once you have admitted ATB students into your program, now what? There are a number of ongoing tasks that will need to be accomplished in order to successfully manage your ATB Program. Below are some of those tasks considered most critical to the successful management of an ATB Program.

ATB Calendar

Faculty assigned to leading their institution's ATB program will likely have other teaching, advising, and committee responsibilities. It is highly recommended that the ATB Coordinator create a separate semester or year-long calendar to map out all necessary ATB related activities.

This calendar would include such things as:
•Key ATB deadlines for students (i.e., TEAS test, application to community college Nursing ATB option and to the partner ATB university)
•ATB recruiting events (i.e., quarterly ATB 1.0 Information Sessions, fall/spring ATB 2.0 and 3.0 Recruitment, fall/spring high school and college fairs)
•Deadlines for updating/printing ATB marketing materials
•ATB admissions meetings with each university partner
•ATB admission decision notifications and seat acceptance deadlines
•ATB new student orientation sessions.

Report ATB Participation

Participation in a dual enrollment program requires that you report to a number of constituents which of your incoming class of ADN students are also ATB. The ATB Coordinator creates a master spreadsheet by university of each new ATB cohort (i.e., Fall 2017 ATB 1.0 Cohort) that includes the student name, ID number, campus/ program attending (i.e., Day, Evening, Online Hybrid), ATB university, phone, school email and other email. The spreadsheet is shared with those personnel needing this information for their planning purposes:

•Nursing Program Directors and their administrative assistants who maintain student lists
•First semester nursing faculty who need to know which students may be exempt from their course because they will take an equivalent course at the university (i.e., Health Assessment)
•The registrar and financial aid officer who collaborate to code ATB students to protect courses while students wait for financial aid awards through the university; the registrar also generates registration and grade reports
•The ATB data manager who assists in the tracking of all ATB students.

Advise ATB Students

The ATB Coordinator will need to serve as an advocate for all ATB students as they navigate both their ADN and BSN coursework. Prior to course registration periods, ATB students may need gentle reminders about next courses needed at both institutions to stay on track with their ATB program of study. This is particularly true for summer and winter session required courses. The community college and partner university require that any student who fails or withdraws failing from any nursing course must meet with both school advisors. After an assessment of factors leading to the course withdrawal/failure, both advisors collaborate on a decision regarding the student's eligibility to continue in ATB, step out of ATB altogether, or step out and apply for ATB 2.0 (second year start) once the first year of community college nursing courses have been successfully completed. The student's goal of becoming a registered nurse is primary.

Collaborate with ATB Partners

The community college ATB Coordinator will need to regularly communicate with his/her counterpart at the university. Emails are effective in exchanging information about upcoming shared ATB events, meetings, ATB student withdrawals and course scheduling, for example. Phone calls may be necessary to discuss student or curriculum issues that are more complex in nature. Periodic face-to-face meetings involving the community college ATB Coordinator and all partner university ATB Coordinators are vital to discuss program successes/issues and discuss/propose program improvements. The ATB Coordinator organizes a face to face meeting for all partner university ATB Coordinators twice yearly. Other personnel from both the community college and/or the universities may be invited to these meetings when input is needed to address ATB issues. The statewide ATB Coordinator's meetings are invaluable.

Collaboration is also needed between the community college and university registrar's and financial aid offices. The community college must provide official course registration information prior to the start of each semester to the student's ATB university. They must also provide final grades at the completion of each semester to the partner university. This information is needed for the administration of financial aid. Students are required to sign a FERPA form upon entry to ATB, granting their permission for the sharing of information between the community college and their partner university.

Track ATB Progress/Outcomes

It is highly recommended the ATB Coordinator seek assistance from his/her institutional research department to track the progress and outcomes for all ATB students. The ATB Coordinator works with a data manager to maintain and update a master ATB spreadsheet. Demographic data is captured in the spreadsheet.

Each new entering cohort is tracked for:
•completed courses with grades
•withdrawal from courses
•withdrawal from the ADN program
•withdrawal from the ATB program
•failure out of ADN/ATB programs
•month/year of A.S. degree
•date of NCLEX-RN pass
•month/year of B.S. degree

Revise ATB Program

Ongoing evaluation of the ATB Program is of course necessary to making program improvements. Analysis of input from ATB students, ATB Coordinators, Nursing Program administrators, faculty, other college/university personnel and tracking data is required to make informed decisions. The ATB programs across the state have made a number of revisions since the first pilot group began with CCBC and Towson University in fall 2012, with three additional partners universities joining the ATB option in fall 2015.

Some examples include:
•repeated student inquiry prompted the development of ATB 2.0, a second year entry to ATB
•revisions to some BSN course sequences to rebalance the clinical course load
•revisions to some BSN course sequences to avoid unnecessary repetition of course content
•revisions to number of BSN credits a student must take per semester post ADN graduation and RN employment
•revision of ATB progression policy: one clinical course failure formerly required dropping of ATB, now a meeting with ATB coordinators is required to discuss factors related to failure and advisability of continuing in ATB
•increased number of hybrid or online BSN courses offered to reduce course scheduling conflicts
•repeated student inquiry prompted us to develop a joint Financial Aid Guidelines for ATB Students

As revisions are considered for ATB Programs, they are always considered with this key question in mind:
Will this proposed change help us achieve our overarching goal? – to connect eligible ADN students early to a clear pathway to successfully earn their BSN degree and thereby help create a more highly educated nursing workforce.

Experienced Maryland ATB partner universities are working with 15 community colleges.

We want to thank Professor Karen Wons, MS, RN, CNE, ATB Director at the Community College of Baltimore County for sharing her expertise, providing guidance and sharing the following list of sample forms. These forms may be revised and customized to any community college program that would like to utilize the groundwork completed over the last decade with the first ATB programs at CCBC and Towson University. NSP II advocates a “shared resources" approach so we can all advance more quickly to the overall goal, 80% BSN by 2025.

•Overview of Community College and University Partnership
•ATB MOU
•Frostburg State University ATB Dual Enrollment Curriculum Plan
•Notre Dame of Maryland University ATB Dual Enrollment Curriculum Plan
•Stevenson University ATB Dual Enrollment Curriculum Plan
•Towson University ATB Dual Enrollment Curriculum Plan
•Academic Progression Reading List
•ATB FAQs Sheet
•ATB Information Session Flyer
•ATB Nursing Brochure
•ATB High School Card
•ATB Building Banner
•ATB Information Sheet
•ATB Policy Manual
•ATB FERPA Release Form
•ATB Financial Aid Guidelines

References

Community College of Baltimore County, Associate to Bachelor's Option

Courville, M. & Green, J. (2019). Campaign for Action Maps Show Nurses' Progress in Earning BSN Degree, AARP and Robert Wood Johnson Foundation.

Graystone, R. (2018). How Magnet designation helps hospitals tackle the nursing shortage. Journal of Nursing Administration, 48(9), 415-416.

Gubrud, P., Spencer, A. G., & Wagner, L. (2017). From start-up to sustainability: A decade of collaboration to shape the future of nursing. Nursing Education Perspectives, 38(5), 225-232.

Harrison, J.M., Aiken, L.H., Sloane, D. M., Brooks, Carthon, J. M., Merchange, R.M., Berg, R.A. & Hugh, M. D. (2019). In hospitals with more nurses who have baccalaureate degrees, better outcomes for patients after cardiac arrest. Health Affairs, 38(7), 1087- 1094.

Maryland Council of Deans and Directors of Nursing Programs. (2017). Maryland Nursing Education Articulation: Policies and Procedures Manual. Maryland Higher Education Commission.

Maryland Health Services Cost Review Commission, NSP II Program Evaluation FY 2015-2019 and Funding Recommendations, December 11, 2019.

McCaughey, D., McGhan, G., Rathert, C., Williams, J., Hearld, K. (2018). Magnetic work environments: Patient experience outcomes in Magnet versus non-Magnet hospitals. Health Care Management Review: April 2, 2018 - Volume Publish Ahead of Print - Issue – p doi: 10.1097/HMR.0000000000000198

Robert Wood Johnson Foundation. (2016). RWJF Academic Progression in Nursing (APIN). Academic Progression in Nursing

Schuler, M. E., Johnson, M. P., Stallings, K. D. & Li, Y. (2017). Chief nursing officer survey: BSN and higher degree initiatives in North Carolina. Nursing Education Perspectives, 38(5), e8-12. ATB Contact Information​