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ADVANCE Perspective: Nurses

Critical Thinking

Published August 15, 2008 10:05 AM by Lyn McCafferty

Want to spark a lively debate among your peers? Ask them one question and step back while the sparks fly.

The question: Do you need a bachelor's degree to be a good nurse?

The responses will vary widely depending on who you talk to. Some will even quote quantifiable research by nurses like Linda H. Aiken, PhD, RN, FRCN, FAAN, who demonstrated hospitals that employ a higher proportion of nurses with at least a bachelor's degree have lower rates of death for surgical patients.

Since Aiken's findings were printed in JAMA in 2003, a number of proposals have emerged to elevate the nursing profession.

The American Organization of Nurse Executives supported a proposal calling for a bachelor's degree to be the entry level for all new nurses.

Others - such as the New Jersey State Nurses Association and the American Association of Colleges of Nursing - support a compromise plan. Initially conceived by Barbara Zittel, PhD, RN, executive secretary of the New York State Board of Nursing, the plan would keep open the multiple paths to become an RN (diploma, associate and bachelor's), but require new nurses to earn their BSNs within 10 years of passing their boards. Current nurses would be exempt from the BSN requirement.

Another Option

There are pros and cons to both proposals but the goals of both are similar: elevate the nursing profession, increase critical thinking among nurses and improve patient outcomes.

Here's another option to throw into the mix: Evidence-based practice (EBP) in 10 years. Every new nurse could pick one of two tracks, either earn a BSN in 10 years or complete a significant EBP project in the same time period.

For nurses choosing EBP, they'd need to do research on a topic or area they work in, compare literature and options available, develop a thesis/hypothesis and conduct experiments. This would require the nurse to work with her facility leaders and fellow nurses on her unit to test it, report it and suggest changes to facility operations as necessary. EBP projects could be clinical in nature or environmental.

Of course, we'd need some sort of oversight for the plan to work. I suggest the licensing board of each state be tasked with reviewing the reports, serving as project advisors, asking for changes, etc. Perhaps a group of nurses with varying academic degrees could serve as a sounding board during the process and as an approval board when the project was complete.

Then, each year, the state would compile a synopsis of its best EBP findings and post them on the Web for nurses across the country to view and learn from.

Benefits

This plan isn't perfect and it's certainly not for everyone. Some nurses may opt for the more straight-forward approach of getting their BSN in 10 years. And that's fine.

What this plan does is give people options. It encourages and rewards nurses for critical thinking, teamwork and searching out new options for better patient care. It may be a more attractive - from a family or financial standpoint - than an additional 2 years of school.

This plan also preserves the multiple entry points to nursing that is even more important now as America continues to gray and the nursing shortage worsens. This plan would help create a national database of EBP and encourage nurses everywhere to look beyond the status quo.

Have another idea? We'd like to hear it. Send your comments to me by hitting the button below.

posted by Lyn McCafferty
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14 comments

I am a retired OR nurse. Eight as scrub and circulating nurse, 3 as the E-ENT  ORnurse.(those days  we only had one room to devote to them.) Thirteen years  as nurse manager of a 7 room OR. It was a small hospital and has since been closed.  In your article about Peri Operative Nursing in your Oct 27th issue, I noticed that Lutheran Medical Center of  Brooklyn had nurses lighting candles. As my grandchildren would say  DUH!!! . Not one of them was  a Peri Operative Nurse !!!!! I knew many nurses from Lutheran and they were active in the AORN community.  Next time use OR Nurses. We need the publicity !!!!

marie gallo, OR - nurse manager OR, bayely=seton hospital October 27, 2008 5:42 PM
staten island NY

Iam a retired OR nurse. Eight as scrub and circulating nurse, 3 as the E-ENT  ORnurse.(those days  we only had one room to devote to them.) Thirteen yeas  as nurse manager of a 7 room OR. It was a small hospital and has since been closed.  In your article about Peri Operative Nursing in your Oct 27th issue, I noticed that Lutheran Medical Center of  Brooklyn had nurses lighting candles. As my grandchildren would say  DUH!!! . Not one of them was  a Peri Operative Nurse !!!!! I knew many nurses from Lutheran and they were active in the AORN community.  Next time use OR Nurses. We need the publicity !!!!

marie , OR - nurse manager OR, bayely=seton hospital October 27, 2008 5:40 PM
staten island NY

iIam a retired or nurse. Eight as scrub and circulating nurse, 3 as the e= ent  ORnurse.(those days  we only had one room to devote to them.) Thirteen yeas  as nurse manager of a 7 room OR. It was a small hospital and has since been closed.  In your article about Peri oOerative Nursing in your Oct 27th issue, I Inoticed that Lutheran Medical Center of  Brooklyn had nurses lighting candles. As my grandchildren would say  DUH!!! . Not one of them was  a Peri Operative Nurse !!!!! I knew many nurses from Luteran and they were active in the AORN community.  Next time use OR Nurses. We need the publicity !!!!

marie , OR - nurse manager OR, bayely=seton hospital October 27, 2008 5:37 PM
staten island NY

iIam a retired or nurse. Eight as scrub and circulating nurse, 3 as the e= ent  ORnurse.(those days  we only had one room to devote to them.) Thirteen yeas  as nurse manager of a 7 room OR. It was a small hospital and has since been closed.  In your article about Peri oOerative Nursing in your Oct 27th issue, I Inoticed that Lutheran Medical Center of  Brooklyn had nurses lighting candles. As my grandchildren would say  DUH!!! . Not one of them was  a Peri Operative Nurse !!!!! I knew many nurses from Luteran and they were active in the AORN community.  Next time use OR Nurses. We need the publicity !!!!

marie , OR - nurse manager OR, bayely=seton hospital October 27, 2008 5:37 PM
staten island NY

Imagine my surprise when I learned that after 31 years of nursing practice, I was not capable of critical thinking as I graduated from a 3 year, hospital based diploma program.  

I have worked in several different areas of nursing, have a certification, have been in management, and have served as a preceptor and mentor.  I have had students in a BSN program tell me that I have taught them more than they have learned in school.  I am just plain tired of the attitude that I am somehow substandard.

A classmate and I worked together and our manager asked me why this classmate and I learned the job so quickly compared to others (who happened to have bachelor degrees)and were so good at it.  My answer to her was that we were taught how to think, that if we didn't have the answer to the question, we better know the question to ask to get the answer.  "I don't know" was not an acceptable response at our school.

I now work in surgery, and have seen patients come into the OR that have not had basic nursing care addressed.  I would have been asked to leave nursing school for less.  A degree does not necessarily make a better nurse or vice versa.

I did return to school and obtained a bachelor's degree in another field, and must say that there was no general education course that I took that would have made me a better nurse.  In fact, I would say my nursing experience made me a better student.

Standardizing the education of nurses would eliminate this controversy.  Why not combine the positive qualities of all programs and come up with a solution such as the physical therapy and pharmacy programs have done?  How about a 5 year program that can devote additional time to clinical skills?  An additional summer semester for clincal experience?  

Laura, RN September 22, 2008 7:44 AM
New York NY

Having read what everyone has had to say, I will say that this debate over who is a "better nurse" or a "professional nurse" has been going on since I was in nursing school! I started as an aide 31 yrs ago and watched the different types of nurses: ADN, BSN, and MSN; and to be perfectly honest with all of you, found fault with all. There is no one perfect nurse, we all like to think we are and that we are better than others because of our degrees, we aren't.  I think what makes a difference is the amount of clinical that you get while in nursing school.  I started as an ADN and had 2 1/2 days of clinical every week for 3 yrs.  The nurses coming from ADN programs are getting 2 days of clinical while BSN programs are getting 1 day of clinical.  Typically both programs have pre and post conference, then the student goes on the floor to care for their patients. If your pre and post conference take 1-2 hrs, your hands on time is decreased significantly. I have worked with ADN and BSN nurses, have had made it known that I would prefer to work with 2 fantastic LPN's over 90% of these RN's from BSN programs because they have NO CLUE what nursing is all about!  From the nurses that I have seen and worked with that come from BSN programs they are educated more to management than actual patient care. These nurses have actually had the gall to say "I don't have to do that, that's what LPN's and Aides are for."  My God take your head out of your butt and help the patient, isn't that what we are all here for??????  These same BSN nurses have no concept how to do many basic nursing procedures.  When I asked them about it their response is "we were told how to do it but never got to practice and do it."   What are these BSN programs actually teaching the students?  Obviously it's not appropriate patient care.  I see the frustration on staff and management when these nurses take forever to catch on and perform competently as a nurse, worse some never do catch on and become competent.  As a nurse in the profession just shy of 32 yrs (Oct makes 32), and as a nursing instructor I push my students to get as much out of clinical as they can and I challenge them constantly while we are on the floor.  I don't do pre conference, I am a firm believer that they need as much time on the floor caring for patients and doing procedures, so that when they do graduate they are better prepared to care for the patients.

I now work with 3 new nurses from a BSN program and they have the same attitude as the nurses when I started yrs ago, "I'm better than you and don't have to get my hands dirty caring for patients, that's what others are for." They have actually had the nerve to say this outloud.

Until I see BSN nurses better prepared to care for the patients that we have in the hospital, I will take an ADN prepared nurse everytime.  BSN = book smart, not clinical smart.  ADN = clinical smart, not always book smart.

Denise, Critical Care - MSN, RN, MHSC September 16, 2008 8:49 AM
Salem NJ

When having a BSN  means better marketability for nursing, then I'm sure you'll see an increase in those nurses either opting for BSN from the beginning or gaining one soon after licensure.  From my experience, the harder working nurses have traditionally been those with ADNs. The BSN nurses are groomed for management and tend to not have the hands-on skills as well developed. Having said that, the best thing I ever did was get my BSN. I had been a nurse almost 20 years when I faced a burn-out crisis in my career. Going back to school ( I did an online degree program) renewed by interest in nursing and made me realize that the BSN programs take a totally different spin on nursing than ADN programs. It most certainly helped my day to day practice in intangible but important ways. I felt BETTER about myself because I felt BETTER about nursing.

My advice: Take the fluff in BSN programs (the theory, leadership, etc. courses) and put them online. Send the nurses to the bedside after two years of hardcore clinical training. Let them continue their education online. Hospitals can offer incentives to complete the BSN..ten years is ridiculous. These courses can be done relatively quickly. And then, when the BSN is obtained, give the nurses a significant salary increase.

Sarah , RN, BSN, MS September 13, 2008 11:36 AM
San Francisco CA

While the author's proposal is innovative and creative, I agree with previous commentary that it does not address the core problem: disparity in our profession's baseline preparation.  

The existing evidence of better patient outcomes at the hands of BSN-prepared nurses, coupled with the need for our profession to unify its actions and elevate itself to the same plane as others - Pharmacy, Physical Therapy and Teachers - gives credence to the BSN in 10 proposal that we in New York State have been promoting.

Evidence based practice projects have a fitting place in the work of bedside nurses, they are not a substitute for the academic preparation and critical thinking skills that will ultimately improve the safety of our patients.

Thank you for the opportunity to comment.

Ann Harrington, Nursing - Director , Highland Hospital September 7, 2008 10:02 AM
Rochester NY

  As a supporter of the proposal to require nurses to obtain a baccalaureate degree within ten years of licensure, I am glad to read further discussion and ideas about how best to advance the nursing profession, and thus I read Lyn McCafferty’s Editorial (“Critical Thinking,” August 18, 2008 ) with great interest.  But the Editorial raised some concerns.

  My biggest concern with the Editorial is the question on which it is premised— “Do you need a bachelor’s degree to be a good nurse?” That question isn’t the one posed by supporters of the “BSN in 10” proposal. This issue is not about whether any individual nurse is a “good nurse” or not. It is about advancing the educational level of the profession as a whole. The proposal, in fact, is one that moves the discussion on educational level away from the old, frankly pointless debates about whether or not this or that BSN-prepared nurse is “better” than an ADN-prepared nurses, or vice versa.

   The Editorial proposes that an alternative approach would be to require that nurses complete an “Evidence-Based Practice” (EBP) project within ten years. But why would this be a preferable—let alone workable—approach?

  As described, this EBP project would require nurses to engage in research, generating and testing a hypothesis, evaluating and analyzing results of “experiments”—in short, it would require them to acquire and utilize knowledge and skills that would generally be taught in an academic program. But they would they be learning and implementing these new skills outside of an academic program, with no apparent standards for who would be teaching them or what would be taught. And they would be performing all of this work without gaining credit toward an academic degree. Unlike the “BSN in 10” proposal, the “EBP” alternative would do little if anything to improve the educational and career mobility of ADN- and diploma-prepared nurses.

  Moreover, under this approach as described, completion of this EBP project—and thus nurses’ continued licensure—would be tied to their employing facility or agency. Intended or not, this is a variant on an old theme—institutional licensure—that the nursing profession rejected long ago. What if the nurse finds significant problems with current institutional practices? Many employers would welcome the opportunity to discover and improve problematic practices. Unfortunately, some would not.  If nurses are to be encouraged (or required) to investigate practice issues or problems, they should be able to do so free of concerns that their findings might have an adverse impact on their employment (and possibly, under this plan, their continued licensure).

  The prospect of enlisting state boards of nursing to evaluate and request revisions of these EBP projects is difficult to imagine as well. It would divert considerable time from the Boards’ regulatory function—and their basic mission of protecting the public—by having Board members correct papers instead.

  The “BSN in 10” proposal reflects a spirit of compromise and presents an important opportunity for the profession to meet the goal of advancing its educational level without closing off any current routes to entering nursing practice.  Of course, ongoing dialogue about  this proposal can be productive. But why rush to find “alternatives” that have not been clearly thought through and that don’t address the same goals?

David Keepnews, School of Nursing, - Associate Professor, Adelphi University September 3, 2008 12:17 AM
Garden City NY

  After reading your editorial I have two main comments, the first is on the skills and competencies needed by the nurses of today to participate in an EBP culture, the second comment is a review of Dr. Linda Akins’s work:

EBP and Research

  I found your choice of words in the attached sentence muddy:  "For nurses choosing EBP, they'd need to do research on a topic or area they work in, compare literature and options available, develop a thesis/hypothesis and conduct experiments."

  EBP (as defined by Sackett, Richardson, Rosenberg & Haynes-2000) is the conscientious use of current best evidence in making a decision. EBP is a problem-solving approach to clinical practice.  

  Research is a systematic inquiry that uses disciplined methods to answer questions or solve problems.  Research develops and expands our nursing base of knowledge.

  A nursing practice based on EBP does not mean that each nurse has to conduct research to answer their burning clinical question. The clinician can search for the most current best evidence which can be databases which house healthcare literature (Cochrane Database of Systematic Reviews CINAHL, MEDLINE, and National Guidelines Clearinghouse), RCT-Randomized Controlled Trials, quantative and qualitative research studies, expert and professional organizational guidelines.

  Research and EBP both required skills, competencies and educational preparation that I believed must be mentored and guided by advance practice nurses and doctoral prepared nurses. An associated degree nurse can not just jump right in. To state that:  “Every new nurse could pick one of two tracks, either earn a BSN in 10 years or complete a significant EBP project in the same time period”  demonstrates a lack of appreciation for the complexity of the current EBP movement in this time of expanding scientific research and information. Your comment does not take into account the skills needed to critically evaluate the evidence or the knowledge needed to perform a scientific research study.

Dr. Aiken’s landmark research

  I have included an overview of Dr. Linda Aiken’s landmark work-please note the key findings.

  The American Association of Colleges of Nursing (AACN) applauded the landmark new study which finds that surgical patients have a "substantial survival advantage" if treated in hospitals with higher proportions of nurses educated at the baccalaureate or higher degree level. In the study, Dr. Linda Aiken and her colleagues at the University of Pennsylvania's Center for Health Outcomes and Policy Research found that patients experienced significantly lower mortality and failure to rescue rates in hospitals where more highly educated nurses are providing direct patient care.

  "Dr. Aiken's research clearly shows that baccalaureate nursing education has a direct impact on patient outcomes and saving lives," said Dr. Kathleen Ann Long, president of AACN. "Nurses with baccalaureate and higher degrees are particularly well-suited to meeting the demands of today's complex health system, reducing patient risk, and lowering mortality rates."

  The study, titled "Educational Levels of Hospital Nurses and Surgical Patient Mortality," was published in the Journal of the American Medical Association. Key findings include:

  * In hospitals, a 10 percent increase in the proportion of nurses holding Bachelor of Science in nursing degrees (BSN) decreased the risk of patient death and failure to rescue by 5 percent.

  * Patient mortality and failure to rescue would be 19 percent lower in hospitals where 60 percent of nurses had BSNs or higher degrees than in hospitals where only 20 percent of nurses were educated at that level.

  * If the proportion of BSN nurses in all hospitals was 60 percent rather than 20 percent, 17.8 fewer deaths per 1,000 surgical patients would be expected.

  * At least 1,700 preventable deaths could have been realized in Pennsylvania hospitals alone if BSN prepared nurses had comprised 60 percent of the nursing staff and the nurse to patient ratios had been set at 1 to 4.

  * Nurses' years of experience had no impact mortality or failure to rescue rates.

  * The study was based on an analysis of the outcomes of 232,342 surgical patients in 168 Pennsylvania hospitals over a 20-month period. The percentage of baccalaureate and higher degree nurses in those hospitals ranged from 0 to 77 percent.

  * Only 11 percent of the hospitals studied had 50 percent or more of their registered nurses prepared at the baccalaureate or higher degree level.

WASHINGTON, D.C., September 23, 2003 - The American Association of Colleges of Nursing

Patricia Maria Lavin, MS, RN

Magnet Project Coordinator / EBP Coordinator

Good Samaritan Medical Center, a Magnet Organization

West Islip, NY  

Patricia Lavin August 28, 2008 11:45 AM
West Islip NY

I received a number of e-mails in response to my column and wanted to share them with all. Please continue the posts. Thanks.

- Lyn

--------------------------------------------------------------

  I need to write and let you know how disappointed I was in reading your editorial regarding the BSN in 10 and your suggestion that doing an EBP or research project in lieu of the BSN would be a viable alternative.

  NYONE, SED, NYSNA and many others have spent an enormous amount of time attempting to gain support for our bill. We are proud of our efforts and the amount of support from legislators and professional nurses that we have been able to receive so far.

 It is imperative that we stand united on this issue so that the attention and spotlight on the bill does not get diluted. I am afraid that you have put the cart in front of the horse. In reality, I think,  the more BSN’s we have, the more EBP we will see.

 I urge you to publicly support the work we are intensely committed to completing.

Pat Hogan, MA, RN, NEA-BC

Sr. VP/CNO

Good Samaritan Hospital Medical Center, a Magnet designated hospital

West Islip, NY

Co-Chair, Public Policy Committee, NYONE

--------------------------------------------------------------

I could not agree more with Pat's sentiments. The more educated the nurse, the better off we will be in our efforts in advancing EBP.

Harriet R. Feldman, PhD, RN, FAAN

Dean and Professor, Lienhard School of Nursing

Interim Dean, School of Education, Pace University

----------------------------------------------------------

Thanks, Harriet. The more people who write to the author, the more she will understand the number of people who think differently than she does.

Barbara Zittel, PhD, RN

Executive Secretary,

NY State Boards for Nursing and Respiratory Therapy Education Building

Albany, NY 12234

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I agree. We need one voice. Additionally, a non-BSN nurse is NOT prepared to do an EBP project. Let's finally build the right foundation.

Katie Capitulo, DNSc, RN, FAAN

Chief Nursing Officer

North Shore University Hospital

-------------------------------------------------------------------

  I, too, agree with you Pat - not only because I work with you  -  but because I came from a hospital that didn’t even hire nurse’s that did not have a BSN.  

  The theoretical backgrounds and the research components we learn prepare us to be the most qualified professionals we can be.  Every now and again I will make a reference to a theorist and some staff members look at me like I have 3 heads - they are usually the ones that don’t want to change things and make them better.

  The BSN nurses have exposure to so much more, and they want to know that what they are practicing is proven stuff-or they want to prove it themselves.  That “extra” education is like the oxygen in their lungs-it gives them life and it energizes them.  

Michele Solomita, MSN, RN

Clinical Nurse Specialist, Maternal Child Nursing

Good Samaritan Hospital Medical Center

West Islip, NY

------------------------------------------------------------

  Please allow me to respond to your editorial of August 18th.

  First and foremost, your question intimates that those nurses graduating from an AD program are “not good”. I vigorously disagree. While I can appreciate that you may not have meant that, others will seize on the thought and incorrectly attribute it to those supporting the advancement of nursing education.

  Secondly, I find it interesting that when discussing EBP you seem to dismiss the evidence and suggest another alternative.

  I am unaware of any evidence to support your proposal. On the contrary, you've acknowledged that evidence already exists with regard to educational preparation.

  The difficult question is how to achieve it in light of the nursing shortage. Since the BSN in 10 is a vision for the future and has no impact on those in school or already in practice, it will not exacerbate the nursing shortage. I believe the BSN in 10 is a well thought out plan to improve the image of the nursing profession and meet the increasingly complex needs of patients.  

  For your readers who prefer to read more, I would suggest visiting the website below www.rneducationadvanceny.org.

Thomas Nolan, MS, RN, NEA-BC

Lyn McCafferty, August 28, 2008 11:36 AM

Having started my nursing career with my ADN I went right to work on a neuro/trauma floor. Within 2 years I was working in the neuro/trauma stepdown unit when I decided to go back to school for my BSN, strickly a personal goal. While completeing courses for my BSN at an expensive private school, I kept asking myself, "how is this going to help me at the bedside?" The papers I had to write and the classes I took did nothing to make me a better nurse in any way!

I am all for continuining education, however, I don't think requiring a BSN is the best way to keep nurses up to date. Think about it, once you get a BSN you're done, you never have to open a book again. Not to mention the BSN curriculum is geared more toward nurses who want to move away from the bedside...exactly where we need nurses.

I personally believe board certifications carry much more weight than a BSN degree. I have certifications in Neuroscience Nursing and Critical Care Nursing and I can tell you that I never studied so hard, learned so much, or took so much back to the bedside while preparing for these incredibly intense exams. Anyone can get a BSN degree, it was a piece of cake compared to my ADN program and my certifications. To maintain a certification you need to keep up with CEU's or retake the exam; it's constant learning and usually it's geared toward your specialty.

By saying a nurse has to complete their BSN within 10 years is implying that for the first 10 years, they are not "equally" capable of taking care of patients as a nurse with a BSN. What does that say to their patients? What are you going to do when patients and family members start saying, "I only want a nurse with a bachelor's degree?" We would have a tough time filling that request in our ICU as we have more ADN nurses than BSN nurses.  

Bottom line is, if an ADN nurse can take and pass the same boards as a nurse with a BSN, that should say it all.      

Gayle, Neuro/Trauma ICU - RN, BSN, Hartford Hospital August 26, 2008 8:16 PM
Hartford CT

I believe the question from the editor is a problem and is generating the wrong debate.

The NY/NJ proposal was not introduced because there was a debate as to the ability of the AD graduate to practice today BUT rather to increase the knowledge base of the professional nurse for the future. The nurse is the fulcrum of the coordination of care for patients in healthcare agancies and often in the home.

How often do we hear comments that nursng input is not accepted and that nurses are not equally accepted as decision makers. Nurses need to be seen as peers.

In addition the changing nature of healthcare means that more and more care will be delivered in the community where the need for independent critical thinking is required and the practitioner has a different relationship with the client/significant others. This experience is gained in the collegiate programs.

To suggest that one evidenced based project concentarting on a single practice can equate to the the knowledge gained in the transition from AD to BS is hardly accurate.

Claire Murray, , Executive Director NYONE August 24, 2008 10:04 AM
Rensselaer NY

The present system of licensure for nurses is not perfect. It misleads us to think that ADN and BSN nurses are prepared in the same way. But there is a difference in the degree of thinking and preparation of ADN and BSN nurses. ADN education slows down the elevation of the nursing profession. They should hold different licenses and perform different tasks. I suggest giving ADNs a different kind of licensure such as ‘registered technical nurse’.

Claudia , Med/Surg - RN August 20, 2008 9:23 PM
New York NY

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