Apprenticeship and Nursing

There is a way to design an RN-BSN program that makes registered nurses’ current work a foundation to build upon rather than an obstacle to overcome. It is called apprenticeship, a time-tested teaching and learning model that makes the workplace a location of learning, full of valuable instructors and opportunities to connect theory and practice. In fact, putting work at the center of theoretical and applied learning is the hallmark of apprenticeship.

Nursing is not an occupation that springs to mind when one thinks of apprenticeship. But modern apprenticeship programs share much in common with pre-licensure nursing degree programs. Similar to the associate and bachelor of nursing programs which require significant on-site learning through clinical experiences and practicums, apprenticeship combines structured on-the-job learning with related classroom instruction. To be sure, the emphasis in an apprenticeship program is more tilted toward the on-the-job learning component, and apprentices are full-time, paid employees, but the combination of academic and hands-on learning is common to both approaches.

Nursing is not an occupation that springs to mind when one thinks of apprenticeship. But modern apprenticeship programs share much in common with pre-licensure nursing degree programs.

Apprenticeship also shares much in common with a new trend in nursing education: residency programs for recent nurse graduates. Residencies are a form of paid, on-the-job learning, combined with a related curriculum, that help new entrants to the profession connect their academic preparation to the real-world demands of nursing. Residencies have become more common over the last decade as the number of nurses entering the field from four-year degree programs has increased. They are designed to address complaints from employers about the lack of practical skills, knowledge, and experience among entry BSN graduates. They also aim to stem the high attrition rates among new BSN graduates entering acute care settings who can feel overwhelmed. The need for more programs to help new BSN graduates connect their academic learning to the actual practice of delivering care is widely recognized in the field. In fact, the same IOM report that calls for 80 percent of nurses to hold a BSN also includes a recommendation calling for the expansion of residency programs for new nurse graduates.

From the practice-focused hospital-based diploma programs of the last century to the academically-focused BSN programs in high demand today, the nursing profession has been struggling to find the right balance between on-the-job and classroom-based learning. The trend has been toward ever greater reliance on academic and classroom learning delivered by universities. The re-introduction of on-the-job training for new BSN graduates in the form of residencies brings the field full circle and points to the critical need for a combination of practical and academic learning to build a highly-skilled nursing workforce. Apprenticeships and residencies are essentially the same. In fact, they are so similar that Yale New Haven Hospital in Connecticut recently registered its longstanding first-year residency program as an apprenticeship, offering integrated seminar-based and work-based learning opportunities to new nurses launching their careers.

Today’s nurse residency programs are primarily designed for nurses who have already completed their bachelor’s degree. But there is a way to bring the same model to nurses without a bachelor’s degree. Many modern Registered Apprenticeship programs demonstrate how to combine a paid, on-the-job learning model with a degree program. For example, Harper College just outside Chicago has established a variety of degree apprenticeship programs in financial services, logistics, and information technology. The Community College of Philadelphia delivers an Associate of Arts in Early Education through a Registered Apprenticeship program. The New Jersey Institute of Technology recently launched an apprenticeship program that can lead to either an associate or bachelor’s degree.

A well-designed nursing apprenticeship could take many of the best elements of associate degree, bachelor’s degree, and nurse residency programs and combine them to create an affordable, high-quality RN-BSN program that allows working nurses to master new knowledge in an applied setting with the support of their peers and mentors. It could operate much like a residency—but in reverse. Rather than being designed to help new graduates apply academic knowledge to real world settings, the programs can help veteran nurses master new academic knowledge through the work they are already performing. Integrating academic and practical learning could take the form of expanding technical skills through on-the-job mentoring or opportunities outside of the clinical setting, such as defining, practicing, and reflecting on principles of ethical nursing with the guidance of a mentor.¹

A well-designed nursing apprenticeship could take many of the best elements of associate degree, bachelor’s degree, and nurse residency programs and combine them to create an affordable, high-quality RN-BSN program.

Apprenticeship offers several potential advantages over existing BSN models – both traditional BSN and RN-BSN. As in a residency, nurse apprentices are employees paid to learn on the job. They have access to on-site mentors, designated time to attend classes, and opportunities to connect classroom learning with hands-on learning. But unlike a residency program, the on-the-job learning occurs simultaneously with the academic experience, not afterwards. And while the apprenticeship-like diploma programs of nursing’s early days were of varying quality and sometimes exploitative, Registered Apprenticeship programs today are required to meet clearly-defined industry standards and include a host of worker protections. When considered alongside the growing reliance on residency programs, it is clear that apprenticeship might be a valuable tool for expanding access to the bachelor’s degree. That is what the leadership at Fairview Health Services has decided to find out.

By 2016, Laura Beeth knew that Fairview’s existing strategies for increasing the share of bachelor-degreed nurses were hitting their limits. The tuition assistance was just not enough for some nurses. She also knew that asking nurses to find the time and money to return to school put too heavy a burden on their shoulders. “Life happens. It’s really hard for people to go [back] to school,” she said. Well aware of the challenges of juggling family, school, work, and the rest of life, Beeth and her team knew they needed another pathway to the BSN that would keep burden on nurses to a minimum.

In 2015, Beeth attended an event on German models of apprenticeship that caught her attention. Speakers described clear, well-structured pathways to new skills and higher credentials, all led by employers. Apprentices worked with highly-skilled mentors to learn by doing, in addition to taking rigorous coursework applicable to their day-to-day work. Theory and applied learning came together in apprenticeship to launch participants into and through career pathways, without any cost to the apprentice.

Beeth thought of all the Fairview nurses she knew were struggling to earn a bachelor’s degree and thought: “We can do this!”

Creating a Registered Apprenticeship made perfect sense as a clear and financially viable path for more Fairview nurses to earn the BSN. “We already have all the academic pieces in place,” Beeth later explained. “We have history and infrastructure with people who know how to do this, our workforce development team.” Beeth and her team connected with the Minnesota Department of Labor and Industry and Department of Employment and Economic Development (DEED) to discuss creating a groundbreaking RN-BSN Registered Apprenticeship.

Fairview began the process of creating a Registered Apprenticeship at an opportune time. Besides the groundswell of support for apprenticeship among business and community leaders, the Obama Administration had just launched the American Apprenticeship Initiative (AAI), a $175 million investment administered by the U.S. Department of Labor to help spread apprenticeship into new sectors. The state of Minnesota was one of 46 recipients of AAI funds, receiving $5 million to create the Minnesota Apprenticeship Initiative (MAI), designed to bring apprenticeships into key industries and to support 800 apprentices participating in new programs.² A nursing apprenticeship fit perfectly into MAI’s vision for expansion, and Fairview received $800,000 from the MAI to support new RN-BSN apprentices.

To qualify for MAI funds, Fairview had to register the program with the state’s apprenticeship agency, DLI, and meet all the requirements specified in federal regulations.³ The registration process involved working with a team at DLI to prepare the apprenticeship standards, a document describing programs’ on-the-job training component and related technical instruction—in this case, apprentices’ BSN classes. Once an apprentice earns a BSN, they will have completed the apprenticeship, moved into Fairview’s pay scale for BSN nurses, and earned a certificate of completion for the apprenticeship program from the state of Minnesota.

In January 2017, after a year of collaboration, DLI approved the apprenticeship standards. Getting the program off the ground was a fairly easy feat for Fairview, since it aimed to make maximum use of existing education partnerships and employee assessment practices. Fairview also limited eligibility for the apprenticeship to nurses who were already enrolled in RN-BSN programs, smoothing the apprentice recruitment process. By early 2018, Fairview had 122 nurse apprentices enrolled, making it one of the largest single-employer apprenticeship programs in the country.

The classroom instruction component of Fairview’s apprenticeship is delivered by accredited colleges and universities and consists of the courses necessary to complete an RN-BSN program. Since all of Fairview’s apprentices were already enrolled in bachelor’s programs at wide variety of colleges and universities, from local schools like St. Catherine’s University and Metropolitan State University to large online programs like the University of Texas–Arlington and Western Governors University, each of these schools became de facto education partners of the apprenticeship program. The institutions may or may not know that some of their students who work at Fairview are also registered apprentices or that they are providing the related technical instruction of a Registered Apprenticeship program.

The on-the-job learning components of Fairview’s program, including the list of skills apprentices should acquire, were developed through collaboration between nursing leadership and higher education partners. Usually, the process of moving apprentices through the list of skills includes connecting them with experienced mentors, providing hands-on opportunities to acquire new competencies at work. But at Fairview, all nurses are already regularly assessed on technical skills needed for quality patient care. So, rather than creating a separate assessment structure for apprentices, Fairview counts regular performance reviews as an assessment of competencies required to progress through the apprenticeship. The fact that the roles of nurses, supervisors, and colleges changed very little within the context of the apprenticeship kept the implementation process simple.

Fairview succeeded in quickly setting up a Registered Apprenticeship, leveraging the program to offer additional financial resources to nurses in RN-BSN programs. The relative ease of the program launch shows just how compatible apprenticeship is with existing approaches to nurse education. But by making so few changes to existing programs for supporting nurses in RN-BSN programs, Fairview left significant value on the table. In particular, the health care system missed opportunities to connect the academic coursework nurses are taking with the structured, on-the-job learning required of an apprenticeship program. It might seem like nurses who have been working in the field for years would not benefit from formal on-the-job training. But research on adult learning indicates that when experienced students have opportunities to connect new knowledge to what they already know and are doing, they learn faster and retain more.⁴ On-the-job training could consist of a variety of professional and leadership development experiences, such as working alongside hospital nursing administration or learning from mentors in a research setting.

The growth of nursing residencies points to the field’s appreciation of the need to better connect theory and practice, even for experienced nurses. For example, the Clinical Ethics Residency for Nurses at Massachusetts General Hospital is a 10-month program that combines classroom instruction on the theory and history of ethics in health care with an on-the-job practicum aimed at helping nurses apply new knowledge.⁵ Although the first cohort of nurses in the program had, on average, 20 years of experience, they benefited from the opportunity to connect their new knowledge to their everyday work through a structured curriculum. The emphasis of the program on connecting the classroom learning to the actual practice of caregiving also sends a powerful signal about the hospital’s goals and expectations of the nurses it enrolls in the program, in strong contrast to the broad-based tuition reimbursement programs that most hospitals use to support BSN attainment. Investing in apprenticeship provides employers opportunities to wrest more value out of degree attainment strategies for the nurses they employ.