What do Canada, Sweden, Portugal, Brazil, Iceland, Korea, Greece and the Philippines have in common? They are just some of the countries that require a four-year undergraduate degree to practice as an RN a move some believe is necessary to create a more-informed, higher-skilled nursing work force. Similar initiatives have been awaiting approval in the New York, New Jersey and Rhode Island legislatures for the past two years. Although they have yet to pass, states across the country are taking notice. With reports of as many as 18 states preparing some type of initiative requiring newly graduated RNs to obtain a BSN in order to maintain their licensure, the idea is gaining momentum.
As associate director, state government affairs for the Silver Spring, Md.-based American Nurses Association, Janet Haebler, RN, MSN, is no stranger to the debate over minimum licensure requirements. In 1964, ANAs House of Delegates designed a position statement calling for all nurses to advance their education in order to improve competencies. However, Haebler says, the ANA does not endorse state legislation. We endorse the concept, she says.Linda Aiken, RN
The state-level bills S4051/A2079B in New York, S620 (nee S2529)/A3768 in New Jersey and HB7416 in Rhode Island are essentially dead and will need to be reintroduced. In Rhode Island, the bill has been recalled in order to make some important additions, according to Donna Policastro, RNP, executive director of the Rhode Island State Nurses Association.
The bill was heard on the House side but not the Senate side, so before reintroducing it, we decided we wanted to do a little more work, Policastro says. We didnt really clarify hardship, so this time around we will embed a clause in the bill. In addition, we want to include a clause that covers articulation agreements with AD and diploma programs.
North Dakota had a similar law pass in 1987. That law, requiring all newly hired nurses to possess a baccalaureate degree, was repealed in 2003 because of opposition from various factions that fought to have it removed, citing a nursing shortage.
The former law has a positive legacy, however, notes Becky Graner, RN, MS, a consultant for the North Dakota Nurses Association. We do retain a high number of BSN graduates as the BSN programs that were established during the brief time BSN was the entry level remain full and have a waiting list, she says.
Why the Sudden Surge?Janet Haebler, RN
In January 2010, the Carnegie Foundation for the Advancement of Teaching released a study directed by University of California at San Francisco School of Nursing professor emeritus Patricia Benner, RN, PhD, FRCN, FAAN, that calls for the baccalaureate degree as the minimum requirement for RN licensure. The Institute of Medicines report, The Future of Nursing: Leading Change, Advancing Health, released in October, recommends that the bulk of the nations RNs be baccalaureate-prepared within the next 10 years.
The IOM report calling for 80% of RNs to have a minimum of a BSN by 2020 has brought forth a national debate and movement, says Pamela Brown, RN, PhD, president, Blessing-Rieman College of Nursing, in Quincy, Ill. Brown is preparing a conference for the Illinois Organization of Nurse Leaders on the BSN-in-10 movement in May and is leading a summit in association with the Illinois Association of Colleges of Nursing, the Illinois Nurses Association, and the Illinois Organization of Nurse Leaders to bring all views to the table. The 2011 summit is focused on how Illinois will meet the IOM goal, she says.
Brown says the increased complexity of healthcare is playing a role. Research shows that there are better patient outcomes when patients are cared for by nurses with a BSN.
The landmark 2003 study to which Brown refers was done by University of Pennsylvania professor Linda Aiken, RN, PhD. The study noted that the death rates of surgical patients at Pennsylvania hospitals where less than 10% of the RNs held bachelors degrees were nearly twice that of hospitals where more than 70% did. Aiken and her colleagues concluded that recruiting nurses from bachelors degree programs rather than two-year associate degree programs could lead to substantial improvements in care.
No Legislation RequiredSandie Soldwisch, RN
Aiken says she isnt sure that states are moving quickly toward requiring BSNs. What is changing is employer preference for nurses with BSN and higher education, she says. We know from our recent study of all hospitals in Pennsylvania, New Jersey, California and Florida that there are an increasing number of hospitals in which BSN nurses constitute 60% or more of bedside nurses; some hospitals have over 90% BSN nurses.
This is certainly true at the North Shore-LIJ Health System in Manhasset, N.Y., the nations second-largest non-secular healthcare system (based on number of beds). Although BSN-in-10 legislation in New York has come to a stalemate, last summer, the 14-hospital health system announced its plan to require all newly hired RNs to either be baccalaureate-prepared or enroll in an accredited program within 24 months of hire in order to earn the degree within five years.
Maureen T. White, RN, MBA, NEA-BC, the health systems senior vice president and chief nurse executive, has said that the increasing complexity of healthcare and the studies showing decreased mortality, improved quality outcomes and reduced adverse events at facilities with more highly educated RN staffs spurred the decision.
Some predict that other hospitals across the country will follow suit, regardless of whether BSN-in-10 legislation passes, just to remain competitive.
Diploma and ADN ProgramsJudi Crume, RN
Despite the trend, Haebler said she believes diploma programs are relatively safe. Hospital-based programs are in a unique situation because they receive graduate medical education dollars for funding, she says.
The associate degree is still the most common method of entry into nursing practice, but if laws requiring the baccalaureate degree pass, schools offering ADN programs will have to adjust accordingly, experts say. The impetus for more collaborative and stronger articulation agreements between lower division and upper division nursing programs will be required, says Sandie Soldwisch, APN, PhD, ANP-BC, dean of nursing at Resurrection University in Oak Park, Ill. Greater creativity in program design for the returning RN student is also required so that the return to school yields new knowledge and advancements in healthcare delivery.
Haebler agrees and says she doesnt understand the fear of initiatives such as BSN in 10. It shouldnt mean anything because its not taking away from any programs, she says. Diploma and associate degree programs are still affordable options for entry. Schools of nursing need to talk to one another regarding articulate agreements to work together.
Judi Crume, RN, PhD, administrator, MaricopaNursing, a consortium of eight Maricopa County (Ariz.) community colleges that offer ADN programs, and president of the National Organization for Associate Degree Nursing, says that in the Phoenix area the crunch is already being felt. Were sitting on a qualified applicant pool of almost 3,000, and the consortium has an average ongoing enrollment of 2,100 students, she says. According to Crume, the ADN students in her area already are being affected by the preference of facilities to hire BSN-prepared nurses. And to make matters worse, these facilities are not even taking ADN students for clinicals. Crume is understandably concerned. If the healthcare organizations are not hiring AD nurses and are giving preference to BSN nurses, that leaves us with a lot of candidates who are not finding jobs, she says.
Crume says she doesnt know of legislation in the works in Arizona. However, Crume said she believes that, in addition to the IOM and Carnegie reports, a reason behind the BSN push is Magnet status. Its being driven by the services agencies, the healthcare organizations, she says. In this area, the thrust has been to increase the ratio for Magnet status.
Not to be left behind, Crume says that the consortium is gearing up to meet the challenges ahead. Not only are they in the process of developing a concurrent AD/BSN program with area universities, but they are also thinking ahead to the likelihood of going from AD to MSN and skipping the BSN degree altogether. The American Association of Community Colleges supports that, and so do I, she says.
Tracey Boyd is a regional reporter.