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Chapter 1 Entry Into Practice: The Debate Rages On

Entry-to-Practice Debate

1940s

Esther Lucille Brown’s Nursing for the Future

1965

ANA Position Paper

Orderly transition from hospital-based diploma programs to education in colleges/universities

ANA Position Paper #1

Premises

Education in institution of higher education

BSN as minimum for professional nurse; associate’s degree as minimum for technical practice

Short, intensive preservice programs in vocational educational institutions for assistants in health care occupations

ANA Position Paper #2

Two levels of preparation

Technical

Junior or community college 2-year programs

Associate’s degree (ADN); beginning, technical practitioner to provide care in acute-care settings, under supervision of professional nurse

ANA Position Paper #3

Two levels of preparation

Professional

College or university 4-year program

Bachelor’s degree (BSN)

ANA Position Paper #4

Reaffirmed in 1978 by ANA House of Delegates with BSN as entry to practice by 1985

Resolution in 2008

BSN within 10 years of licensure for diploma- and associate-degree-educated nurses.

Individual states for mandating and implementing

Issue still not settled

Proliferation of ADN Education #1

1960s

Primarily diploma schools of nursing education

Baccalaureate enrollment increasing

Associate’s degree programs just beginning

Proliferation of ADN Education #2

2000s

Diploma programs virtually gone

ADN as primary model for initial nursing education

BSN education on the rise with 15 consecutive years of enrollment growth

55% of current RN workforce holding a baccalaureate or graduate degree

Question #1

Is the following statement true or false?

During the 1960s, most nursing education was provided at the baccalaureate level.

Answer to Question #1

False

Diploma nursing programs were the most common type of nursing educational program in the 1960s.

Licensure and Entry Into Practice

NCLEX passing rates—no significant differences

Similar competencies across educational spectrum

Minimum technical competencies versus performance measurement over time or test of all knowledge, skills

Similar criteria for state board approval

Demographic differences of BSN, ADN grads

Employers’ lack of role differentiation, incentives

Shorter time for ADN; cost- or time-prohibitive for BSN

Educational Levels and Patient Outcomes #1

Arguments against raising entry level

Educational degree unrelated to providing high-quality care

BSN too theoretically oriented; deficiency in basic skills mastery

Educational Levels and Patient Outcomes #2

Research findings associated with BSN

Higher educational levels  better patient outcomes

Better care environments, best nurse staffing levels, and most highly educated nurse  lowest surgical mortality rates

Clarke (2017) raises some doubts about concluding that these outcomes are related to BSN nurses providing a higher quality of care vs. practicing in the hospital environment, where more BSN nurses are employed

Employers’ Views and Preferences #1

Usually no distinction in scope of practice or incentives for BSN education

Possible increasing awareness of differences between BSN and ADN grads

Preference for clinical placements by some employers based on higher degree programs

Nursing manager and administrator positions now requiring or preferring at least BSN

Employers’ Views and Preferences #2

A 2014 survey by the American Association of Colleges of Nursing found that 45.1% of hospitals across the country require new hires to have a bachelor’s degree

Magnet hospital programs require nurse managers and leaders to have a bachelor’s degree and also require a higher percentage of nurses at BSN level

Veterans Administration requires BSN as minimum for new hires as well as all non-entry-level nurses

Shifting Health Care Delivery Sites and Required Competencies #1

Hospitals  community and integrated health care settings; need for more highly educated, autonomous nurses

Affordable Care Act: RNs must be skilled in population health, case management, and quality metrics emphasized in baccalaureate nursing curriculum

Tri-Council for Nursing: education advancement to enhance quality and safety across health care settings

Shifting Health Care Delivery Sites and Required Competencies #2

IOM 2010 report

Increase from 50% to 80% of BSN nurses in workforce over the next 10 years

Double population of nurses with doctorate degrees

Shifting Health Care Delivery Sites and Required Competencies #3

Educating Nurses: A Call for Radical Transformation

BSN as entry level

Master’s degree within 10 years of initial licensure

NACNEP: 2/3 of RNs with BSN or higher by 2010

Council on Physician and Nurse Supply (2007): shift in federal funding for more BSN-level programs

Entry Level and Professional Status

Most other professions require graduate degree for entry

Growing educational gap between nursing and other health professions

View by some: BSN for entry is elitist

Failure of educational parity contributing to view of nurses as “second-class citizens” in health care arena

Nursing as the only health care profession not requiring at least a bachelor’s or higher degree for entry into practice

Question #2

Is the following statement true or false?

An employer will most likely pay a nurse with a BSN a larger salary than a nurse with an ADN.

Answer to Question #2

False

Employers commonly provide no incentives for BSN education in terms of pay, recognition, or career mobility.

Two-Year ADN Program?

Argument: 2-year ADN program a myth

Minimum of 12 to 24 months of prerequisites + 2 full years of nursing education

60 semester units or 90 quarter units of coursework (or more)

BSN programs: approximately 120 semester units

Increased ADN time: need to prepare ADNs for more diverse environments, positions needing management skills

ADN content versus BSN content

Shortages and Entry-Level Requirements

Short-term threat of raising entry level: exacerbation of existing nursing shortage

Long-term effects

Elevation of nursing’s public image with increased recruitment

Increase in recruitment-profession with greater academic prestige

Increased retention rates—possible stabilization of workforce due to increased job satisfaction

Persistence of chronic nursing shortage negates argument as excuse for postponing action to raise educational standards

Professional Organizations, Unions, and Advisory Bodies Speak Out #1

NOADN: Reaffirmation of role, value of associate’s degree nursing education, practice

NLN: Multiple entry points for nursing; focus on lifelong learning, progression

Nurse Alliance of the Service Employees International Union (SEIU): Rejection of BSN as necessary for entry into or maintenance of practice

More resources to support nursing education at all levels

Professional Organizations, Unions, and Advisory Bodies Speak Out #2

Specialty professional organizations (AACN, NANN, ANNA, AORN, AONE): Position statements supporting BSN as entry level

National Advisory Council on Nurse Education and Practice: 2/3 of working RNs with BSN or higher by 2010

Federal and state regulation into practice still not a reality

Grandfathering Entry Levels

If entry level raised, debate over how, when grandfathering applied

Some advocate for all RNs to be grandfathered

Others argue for no grandfathering

Still others suggest it be conditional (retain title for a certain time but be required to return to school to meet new entry level)

Linking ADN and BSN Programs #1

Barriers for returning to school

Cost, time, fear, lack of recognition for past education/success

Equal treatment of BSN, ADN, diploma RNs

Negative ADN or diploma school experience

Institute of Medicine (IOM) report 2010

Expectation to coordinate care with other health care professionals with higher degrees

ADN or diploma-educated nurse being set up to fail

Linking ADN and BSN Programs #2

Incentives for returning to school

Being at the right time in life; working with options; achieving personal goal

BSN as credible professional identity

Encouragement from contemporaries; user-friendly RN-BSN programs

Linking ADN and BSN Programs #3

RN-to-BSN programs; RN-to-master’s degree programs

Statewide articulation agreements to facilitate credit transfers

Issues

Integration, standardization, or cooperation between public systems of education

Transition programs

Alternative education pathways

Funding/cost

Question #3

Which of the following would most likely be the major barrier to obtaining advanced nursing education?

A. Fear of going back to school

B. Limited time available

C. Cost of the program

D. Little recognition for past experience

Answer to Question #3

Although fear, limited time, and lack of recognition for past educational and life accomplishments can be a concern for those considering continuing their education, cost is often the chief obstacle to obtaining advanced education.

International Issue

Establishment/adoption of baccalaureate degree as entry level by other countries

Canada, Australia, South Africa

Wales, Scotland, N. Ireland

Italy, Norway, Spain, Ireland, Denmark

Sweden, Portugal, Brazil, Iceland, Korea, Greece, and Philippines

Continued conflict even in those who have adopted or are moving toward BSN entry level

End of Presentation