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ADVANCE Perspective: Nurses

BSN as Entry-Level Requirement

Published June 16, 2014 10:54 AM by Linda Jones
To those of you who earned an ADN several decades ago and believe you can nurse circles around today's new grads (and I don't doubt that's true), let me say, before you write a letter,  that I understand you are a good and valuable nurses. I don't question your skills, especially at the bedside, and I don't think you should have to go back to school to earn a degree if you have years of experience. That said, I believe the entry level education for nursing should be at least a bachelor's. Healthcare is not what it was 20 years ago and nurses need to change along with it.

To me, it's simple: research supports there are better outcomes when nurses have a BSN. Among the many resources to support this is "Charting Nursing's Future" from the Robert Wood Johnson Foundation. As an industry that supports evidence-based practice, nursing should follow the evidence in regard to education levels.

One of the benefits of the ADN is that is makes entry into nursing affordable. Paying for a two-year degree makes the field accessible to many more people who are qualified academically. Currently, as noted in this issue's cover story, community colleges and four-year universities are partnering in what is now RN-to-BSN programs. A similar model could be developed, but the requirement to take the licensing exam would be a bachelor's degree.

Advanced Practice

One of the things nursing is doing right is differentiating nurses who practice at advanced levels. Advanced practice nurses (NP, CNS, CRNA, CNM) are recognized by healthcare systems, physicians and increasingly by the public, as having knowledge and skills beyond the staff RN. The acknowledgement is well earned and necessary, especially for nurse practitioners and clinical nurse specialists, who are taking on more leadership roles within health systems (and independent practice in the case of the NP) in conjunction with their clinical expertise.

Nurses have to be part of the health system leadership team. In a recent online article, "Non-Nurse Nursing Directors?" we heard loud and clear that many believe only a nurse can lead nurses. But there are additional skills needed for most leadership positions and education is the way to acquire that knowledge and it begins with a bachelor's degree, which could lead to an MSN or doctoral degree.

Johns Hopkins School of Nursing recognizes the need for higher education for nurse leaders and has taken a unique approach. Just announced is the "Master's Entry Into Nursing" program designed for students with a bachelor's degree not in nursing. Students will graduate with a master's degree and be eligible to take NCLEX.

"The future of healthcare demands that nurses have a solid foundation in evidence-based practice, strong leadership skills, and a commitment to lifelong learning," noted Johns Hopkins School of Nursing Dean Patricia M. Davidson, PhD, MEd, RN, FAAN.

Time for Change

Other healthcare disciplines have successfully changed their entry level requirements. Physical therapy is a good example. It moved from certificate to a bachelor's degree in the ‘50s, to master's in the ‘80s. And now, the vision of the national association (APTA) is "By 2020, physical therapy will be provided by physical therapists who are doctors of physical therapy." The changes did not result in a devastating shortage, but instead elevated the field academically, professionally and clinically. It's time for nursing to catch up with other healthcare professions and require a bachelor's degree as entry to the field.

posted by Linda Jones

12 comments

I am a retired Med/Surg nurse with 40 yrs. experience. I do not think all nurses need a BS. All new nurses do need more hands on patient care before they get any degree. Education to get a piece of paper does not necessarily make you better at anything, especially the art of nursing. I think the constant push to get more and more education is counter productive sometimes. It says that if you want to be a good and successful nurse, you must educate yourself out of actual nursing care.

Lorraine Brandon December 4, 2014 12:19 PM

BSN as entry level requirement is desirable,but should not be a mandatory requirement for nurses. If this is the case all prospective nursing students should be aware that it is futile to pursue the ASN program,instead they should proceed to the BSN.%0d%0a%0d%0aAnd for those nurses who have ASN degrees, many years of nursing experience,as well as advanced non-nursing degrees,it is my opinion that they should be grand fathered into the BSN program to bring them on par with their BSN colleagues.,BSN as entry level requirement is desirable,but should not be a mandatory requirement for nurses. If this is the case all prospective nursing students should be aware that it is futile to pursue the ASN program,instead they should proceed to the BSN.%0d%0a%0d%0aAnd for those nurses who have ASN degrees, many years of nursing experience,as well as advanced non-nursing degrees,it is my opinion that they should be grand fathered into the BSN program to bring them on par with their BSN colleagues.,BSN as entry level requirement is desirable,but should not be a mandatory requirement for nurses. If this is the case all prospective nursing students should be aware that it is futile to pursue the ASN program,instead they should proceed to the BSN.%0d%0a%0d%0aAnd for those nurses who have ASN degrees, many years of nursing experience,as well as advanced non-nursing degrees,it is my opinion that they should be grand fathered into the BSN program to bring them on par with their BSN colleagues.

Isis,Isis,Isis Phoeniix,Phoeniix,Phoeniix, Nursing,Nursing,Nursing - Staff Nurse,Staff Nurse,Staff Nurse, n/a,n/a,n/a June 25, 2014 9:56 PM
NYC,NYC,NYC

I have read eveyone's comments above. Let me tell you a little about my background and the city I work in. I am a graduate of a diploma program( that is closed now). The city I work in originally had 3 diploma schools of nursing which all eventually closed in the mid 80's. They also have a ADN program at the local community college that has been here for at least 40 years if not more.They currently have 2 BSN programs; one is hospital based and the other independent. I have been a nurse for 33 years(30 plus in hospital bedside nursing). The city I live in has a hospital that is magnet certified-thus if you want to work their you will need to agree to get your bachelor's within certain timeline(prove you are enrolled in a program) or you will not be hired. They also will not let their current employee's transfer within the system unless they are enrolled in a program. When I was newly graduated I worked with a newly graduated BSN nurse who had very little clinical background. She eventually was a great nurse but it took her along time due to her lack of clinical background. She also did not stay at the bedside for long(about 3-4 years). She is now an APN. Looking back at her and several other BSN nurses they did not stay at the bedside long and went on to nonbedside/management nursing. I don't believe the nurses from a BSN program have any idea of what it is like to be a bedside nurse. They do not stay in their positions long because they discover they do not  actually like taking care of patients at the bedside( I believe due to lack of clinical experience) and thus go onto management (where they have most of their education). I wholeheartedly agree that bedside nursing should not require a BSN. My city does not pay any difference between a ADN or BSN nurse. It is very hard for nurses(experienced and new to get a job at any of the local hospitals).I have heard many stories of new graduates leaving the area because they don't even get replies from job applications. Yes there are many RN to BSN programs but, why would I want to pay a minimum of $25,000 to obtain this degree at my age. It would take me several years to pay back the loan. I totally agree with several of the above comments from Carolyn,Cesaer and Steve. I am beginning to think that the push for BSN nurses is because the state colleges see how much money they can make off the nursing programs. Also today, ironically I saw a billboard for the local community college stating a nurse's salary is about $58,000!!!?? I sure would like to know how that sum was derived, because that is not the starting salary and is very misleading.

Kayla, School Nurse - RN June 24, 2014 2:10 AM
Rockford IL

It's time to make it happen. Unfortunately you can see even from the comments you have received that there is much debate about this topic. It is difficult for nursing to move forward as a profession when we are not cohesive as a group.

Cathy June 19, 2014 9:28 AM

The thought that a nurse is more qualified to handle responsibility to provide bedside care isn''t based on education but commitment.  I know it is hard to face the truth about our differences in educational requirements, but, What you do at the bedside is a task of care not nursing.  I worked with nurses who are very good at what they do and I understand how they may perceive education, so this will be hard to explain without offending those less qualified through formal training.  Preparation is the best way  to reduce risk and improve outcomes.  The actions of a skilled educated provider will enhance the care experience without guessing but using scientific science.    Nursing is a science that requires more that  bedside care.  I know aides who can do beside care better that most nurses, bu they lack the science to create outcomes that are repeatable and logical.  To nurse is more than beside care it is the whole of a profession.  That is what separated Nightinggale from those who simply followed doctor's orders.  See she was an educated women with the ability to see beyond the beside.  She measured cause and affect.  She applied science to the kind acts.  She understood the evaluation of outcomes.  She was more that a task completion expert.  She was a nursing professional.  See beyond your limits.  This isn't about your skill it is about the application of all of nursing.  Managing care, Providing Safe and infection free environments, Promoting Health and Maintaining health, Psychosocial integrity, Basic care and comfort, reduction of risk, Pharmacological and parenteral therapies, and physical adaptation.  I have seen the bedside nurse who is rushed for time.  She doesn't actually give the client what they need

Lee Williams, Nursing - Charge RN, forest Creek June 18, 2014 1:38 PM
Indianapolis IN

The concept of BSN as entry level has been around since I graduated with a BSN in 1977. It is about time our profession come to a consensus in reference to this issue. %0d%0aHealthcare is more complex, patients have more chronic illness and critical thinking is warranted. I do not believe BSN nurses are opposed to working at the bedside .%0d%0aI agree with Ms. Fuller in reference to Advanced Practice Nursing and the Consensus Model. I was told over 10 years ago that SBON were trying to limit focus due to the amount of work it took to review individual programs and certificate applications. The CM is a way for states to do just that. Ultimately, it is restrictive trade and shuts out many nurses who are qualified to provide safe care.

Mary Elaine Southard, Intefrative Care - Director June 18, 2014 1:17 PM
Scranton PA

There will always be examples of nurses who are excellent at patient care, critical thinking, leadership – and everything else nurses do – no matter what their education. There are ADNs who can run a hospital and there are BSNs and MSNs who can’t start an IV. However, when you look at larger numbers (multi-center research) the patient outcomes are better when there are more BSNs in the mix.

Granted, any study that looks at patient outcomes is complex. There are many variables that impact outcomes beyond nursing education. That said, several studies aim to focus on the effect of nursing education levels on patient outcomes. Here are just a few:

Aiken L, et al. The effects of nurse staffing and nurse education on patient deaths in hospitals with different nurse work environment. Med Care. Dec 2011; 49(12): 1047–1053.

doi:  10.1097/MLR.0b013e3182330b6e

Blegen, M, et al. Baccalaureate education in nursing and patient outcomes. J Nurs Adm. 2013 Feb;43(2):89-94. doi: 10.1097/NNA.0b013e31827f2028.

Weinberg D, et al. Analyzing the relationship between nursing education and patient outcomes. Journal of Nursing Regulation. July 2012: 3(2): 4-10.

Regarding first-time pass rates of NCLEX, although BSNs performed better, the difference is not significant. So far this year first-time pass rates are: diploma 87.88%, associate’s 82.09% and bachelor’s 87.96% with similar results in 2013: 83.42%, 81.43% and 85.18%.

You can’t replace clinical experience with more education; both are needed to make excellent healthcare professionals. Research says that if you want better patient outcomes, the BSN is the way to go. And if nurses want better salaries and to have a voice in hospitals and in the healthcare industry, they need to keep up with other healthcare providers, which are already at a master’s degree of higher.

Linda Jones June 18, 2014 9:00 AM

NO. I do not believe you should have a BSN for nursing. I know from personal experience and collection of information myself that whoever does a study usually finds what they are looking for.

Like you say a ADN nurse performs as well as a BSN nurse. If you are looking for more money and all nurses are BSN then the playing field is lowered and there is no chance of negotiating for higher pay. I have never or met few BSN nurses who wanted to do bedside nursing. I have heard over and over again I am only doing this until I can find something in management, or some kind of desk job. I wonder if that is what you want why didn't you go to school for business.

Let us take a lesson from our teachers. They are all required to have minimum Of a BS degree. In North Carolina anyway starting salary is around 23 to 25 k/ year. Do you really want this to happen to nursing? Do you want nurses going to work in department stores because they can make more money there?

We have more BSN nurses now than ever before and I have seen a significant decrease in benefits since I first went into nursing 35 years ago.

More responsibility and less pay and benefits is what we are getting for all our hard work and better education. But they told us it would get better. Not from what I have experienced.

If we all have a BSN then they will want a Masters degree to work in management. If we all get Masters then they will want a PHD to be in management. It won't make that much of a difference to me I will be retiring soon (I hope). Didn't ever make enough to retire early. And Pensions have virtually disappeared. So have to keep working to keep living.

I am just saying for future nurses and the future of nursing. Wake up and quit believing that things will get better because you have a better education. It's not gonna happen

Carolyn, Cardiology - RN June 17, 2014 8:59 PM
Raleigh NC

Having a BSN doesn't make you a safer RN. You should cite the research that you mentioned showing "better outcomes" from BSN prepared nurses. I went through rotations at reputable hospitals along in southern California with BSN students, and I must say, I am unimpressed. They were unable to handle their patient load at a Magnet recognized hospital, and even the nurses preferred the students coming from our Community College. I completed my ADN program with honors, and it was the hardest degree I have ever obtained. I passed my NCLEX on the first attempt, while some BSN students I know had to take it twice. If you want to reform the system, strive to make the NCLEX so that ADNs and BSNs dont take the NCLEX at the same difficulty. Make the BSN degree harder to obtain, because where I live ADN degrees are not easy to get, in fact, ADN is much harder to get than your BSN here. The proof is in the drop out rates. They have increased,and even in my class alone we lost about 23 people by the end of our program. Our program has the same accreditation as a BSN program, well at least one of the accreditation because the other one required a program to be BSN. ADNs are just if not more prepared to jump into the field in my opinion.  

Caesar, ER - RN, NA June 17, 2014 7:39 PM
Placentia CA

The idea that a GN with a BSN is a better prepared nurse than a GN with an ADN is a myth that seems to be perpetuated solely by those who want a BSN only model.

As a newer ADN RN, I can say that my education and knowledge is as good, if not better than a BSN RN with the equivalent amount of floor experience. The first letter, posted by Ann Fuller indicates that BSN nurses seem to have better understanding of complex disease processes. I would like to see that defended with any kind of clinical proof.

I graduated with 250 more clinical hours than my BSN counterparts. Where I was immediately comfortable in a clinical setting, the BSN GN's I worked with were not. They spent more time in a classroom on theory nursing than actual nursing. And it showed in their inability to adequately manage time and give quality care on the floor. In school I did 12 hour clinicals every week. At the end of my program, I was taking a full patient load during clinicals while still doing classroom time. If you were not capable of doing so, you wouldn't graduate. The BSN students I have at my hospital are on the floor for 5 to 6 hours, one day a week. They will graduate with no real idea of what it really means to be a nurse.

Look at ADN-BSN programs. Are they making us take classes on disease theory, or courses to improve knowledge regarding critical thinking? Of course not. Those programs focus on what the ADN programs did not. Nursing management and community health. Classes that have no impact on the ability to provide effective and safe patient care in an acute setting.

I sat the same board that BSN grads did. And my school, like many of the other ADN programs, had a higher first time pass rate compared to the larger 4 year universities. I am enrolled in an ADN to BSN program. I don't want to be, but I can see the writing on the wall. There is a move to shut out ADN nurses. The classes I am taking do not do anything for my clinical skills, critical thinking skills, or knowledge of disease and systemic health issues. It's pure theory, and this push for BSN only nurses is just petty politics.

Steve Dunne, RN, ADN June 17, 2014 6:06 PM

Posted with permission on behalf of Ann Fuller MSN-Ed, RN, CRT, AHN-BC, HSM-I

Dear Ms Jones,

          In response to the June editorial in Advance for Nurses, I agree with the suggestion that a bachelor’s of nursing becomes the entry level for bedside nurses. Disease processes are far too complicated to understand without more in depth education than what one can obtain as an associate degree nurse (ADN). However, I am vehemently opposed to the idea that prescriptive authority is the criteria for advanced nursing practice. Advanced Education should be what makes one an advanced practice nurse; not everyone wants to have pharmaceutical prescriptive authority. That preference makes them no less instrumental in caring for the population. To diminish a person’s worth because they do not prescribe is short sighted and discriminatory, it defeats the meaning and purpose of the Institute of Medicine (IOM) directive that we partner with each other to provide higher quality care. It also defeats the Affordability Care Act’s (ACA) focus on health promotion.

           Nurse Practitioners follow a medical model and CNSs follow a nursing model yet few know the difference between the two classifications. To add to the confusion, a new designation was created a few years ago called the clinical nurse leader (CNL), which has encroached on the CNS career path. This in effect is pushing the CNS out of existence. However, CNL do not have advanced practice status, because they do not prescribe. Additionally, the advanced practice holistic nurse (APHN-BC) is not recognized as an APN in any documentation that I can find, yet they have the same qualifications and the same prescriptive authority as a classical APN, except they have additional specialized education.

           The consensus model segregates APNs from other graduate level nurses because APNs are the only ones that prescribe. Graduate level nursing educators and those who hold other masters and doctorate level education in other nursing specializations such as informatics and holistic nursing...none of them are considered advanced practice. The consensus model and laws that follow the directions of that document divides the nursing profession and sets one above the other based on prescriptive authority rather than on advanced education.

           The consensus model also makes any other advanced education meaningless. Therefore, it shortchanges the American population that is interested in health promotion. It is incongruent with the ACA and the IOM recommendations, which call on nurses to partner with health care providers to afford the highest quality of patient care. Instead, the professional body of nursing that wrote this model is dividing the profession. Even though, the issue has far-reaching negative consequences the most pressing issues at this time is legislatures are making laws based on the consensus model which supports the removal of healthcare practitioners from the work force unless they prescribe. It hinders anyone with advanced education without prescriptive authority from serving the American public. In effect it returns those without prescriptive authority to practicing at a bachelor’s degree level.

           Much more is involved than what either of us has addressed, but I recognize time and space is limited. I do not want my points lost. The implications of what we begin to address in the editorial and this response has far reaching consequences for the nursing workforce, the educational system, the American population, and the American economy. Once you touch one domino without examining all aspects of the issue, it will eliminate the precarious balance. Granted, we need changes but at whose expense? All aspects of the issue must be considered not just one faction, because the issue has many intertwined threads.  

Linda Jones June 17, 2014 8:31 AM

Posted with permission on behalf of Lynda R. O'Neal RN, ASN

Dear Ms. Jones, You stated that you really do not wish to hear from indignant ASNs, but you shall. at least from this one.  I somehow believe that my 46 years of experience as staff and associate manager in CCU and ER will stand alongside most nurses these days, and I will not apologize as such.  Yes, we are still fighting you, and no, we do not care what you think of us - that's been over for many decades.  The diploma nurses insisted that we were not worthy, so we learned early in the game to simply stand on our record, To this day, it seems that ASNs still make higher board scores than our BSN sisters and brothers, and we seem to have a significantly easier transition into the workforce.  Somehow we seem to glean as much or more clinical experience in half the time.  (No one has ever satisfactorily explained that to me.)

The BSNs do eventually catch up clinically, if they are given adequate support from their actual coworkers during the early years of practice, but don;t you think that they should really be significantly ahead of the ASNs right out of the gate? I do, and I think that this should be solved prior to terminating the programs that appear to be actually preparing nurses on favor of ones that really don't.   It seems somewhat silly to end something that appears to be effective in favor of something that isn't working so well,  Just sayin'.

The next problem is that of the newly-minted MSN, who is now frequently found in a purely administrative or educational position.  She/he may have gone straight through, without pausing to work after the BSN, which means that they are now charged  with  administrating/teaching  others who are charged with performing tasks that the new MSN does not possess the skill sets to perform themselves.  (Awkward.)  And yes, you really should have some idea how to do that which you are directing others to do.  It looks better, and it makes you vastly more credible in any setting.

Therefore I am 100% behind you if you can manage to get BSN nurses at least as roadworthy as ASN, and insist on at least two years worth of clinical practice between the BSN and the MSN levels.  Nursing will have a significant number of us leaving in the next few years, and we are terribly  uneasy about what we leave behind us. New nurses have always seemed to be underprepared and overwhelmed upon arrival into a clinical setting - that we are used to.  Somehow, the readiness of nurses to function appears to be varying inversely to the increasing needs of the population, and it scares me to death that these kids will be precepted by clinical educators who have never held a clinical job and led by an administrative staff who will set lofty goals and parameters without ever having met such an agenda themselves.  I don't know- maybe I'm more fortunate than I knew to be retired.

Linda Jones June 17, 2014 8:16 AM

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