1
Running head: INTEGRATIVE LITERATURE REVIEW
Integrative Literature Review: A Systematic Review of Bachelor of Science in Nursing (BSN) as
the Entry Level Requirement for Registered Nurses
XXXXXX
Liberty University
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INTEGRATIVE LITERATURE REVIEW
Abstract
There are currently four pathways to becoming a registered nurse (RN). In 2010, the
Robert Wood Johnson Foundation sponsored a study through the Institute of Medicine (IOM)
that recommended by the year 2020, 80% of the nursing workforce should be BSN prepared
(IOM, 2010). Some nursing professionals believe that there is value in a BSN as the preferred
degree for entry level RNs. Although there is a large consensus among the literature, more
research is needed to make changes in education routes to practicing as an RN. The purpose of
this systematic literature review can be defined in the following PICO statement; Are RNs who
have a BSN degree better prepared for entry level nursing jobs over those with diploma or
associate level education? The goal is to add to the current literature recommendations of a
minimum of a BSN as the entry level for RNs. The Jerry Falwell Online Library System was
used for study selection. After specified inclusion and exclusion criteria, a total of twenty articles
were identified. After use of the modified PRISMA checklist (2009) for critical appraisal, fifteen
studies were selected for inclusion. Among the fifteen included studies, the following themes
will be discussed: safety, dual programs, barriers to BSN education, BSN preparation, and
further research needed. It was concluded that although more research is needed, the evidence
supports the idea that the BSN degree be the minimum requirement for entry level nursing
positions.
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INTEGRATIVE LITERATURE REVIEW
Integrative Literature Review: A Systematic Review of Bachelor of Science in Nursing (BSN) as
the Entry Level Requirement for Registered Nurses (RNs)
Rationale/Summary
Safety is a key foundational concept in nursing. It is heavily focused on in nursing
education. Nursing education to prepare for the National Council Licensure Examination- RN
(NCLEX-RN) can be a diploma program, associate degree, BSN, or even more recently a
master’s degree (MSN) (Krugman & Goode, 2018). This is four pathways to the same entrance
examination. In 2010, the Robert Wood Johnson Foundation sponsored a study by the Institute of
Medicine (IOM) that recommended that by the year 2020, 80% of the nursing workforce should
be BSN prepared (IOM, 2010). The state of New York took this into consideration when
developing the BSN in 10 law. This law states that all nurses must obtain a BSN within ten years
of initial licensure or their license would be suspended (Ball, 2018). Although not all states have
instituted this type of rule, it is important to discuss why the IOM made this recommendation.
Some nursing professionals believe that there is value in a BSN as the preferred degree
for entry level RNs. Clarke (2016) supports this by stating that a BSN degree includes liberal arts
and humanities education that gives nurses a stronger base for professional practice. Zittel et al.
(2016), agrees. They cite that literature demonstrates with a ten percent increase in BSN-
prepared nurses there is five percent decrease in patient deaths and failure to rescue events.
Boyce et al. (2001) takes this a step farther by recommending that the master’s degree should be
the minimum entry level for RNs. They cite quality improvement and establishment of the
profession as reasons for their recommendation. Although there is a large consensus among the
literature, more research is needed to make changes in education routes to practicing as an RN.
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INTEGRATIVE LITERATURE REVIEW
The rationale for this systemic review of the context of what is already known is differing
opinions amongst the profession. There needs to be further research demonstrating the need for
BSN prepared nurses. This literature needs to not only support the BSN route, but also assist in
eliminating the diploma and associate degree routes to standardize entry level nursing (Krugman
& Goode, 2018). The role of the nurse educator is important in this discussion. They are needed
to conduct this research, disseminate the information, and act as change agents. Whether in the
academic or hospital setting, nurse educators should review the literature and develop ways to
increase the BSN workforce in compliance with the IOM recommendation.
Objective/Research Question
The purpose of the literature review, or more specifically systematic review, can be
defined in the following PICO statement; Are RNs who have a BSN degree better prepared for
entry level nursing jobs over those with diploma or associate level education? The goal is to add
to the current literature recommendations of a minimum of a BSN as the entry level for RNs. By
adding to the literature, changes can be made to eliminate the diploma and associate degree
programs or convert them into BSN programs. This change is supported by the background
information described above. The ultimate goal is to then discuss these findings in terms of
safety and improved patient outcomes.
Research Criteria/Methods
This systematic review includes qualitative and quantitative studies that gave insight on
the specific PICO question, Are RNs who have a BSN degree better prepared for entry level
nursing jobs over those with diploma or associate level education? All databases included in the
Jerry Falwell Library online search were used. The key phrase with the primary variables, or data
items, used was “BSN as entry level nursing degree”. A review of reference lists were also
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INTEGRATIVE LITERATURE REVIEW
utilized. Inclusion criteria were as follows: scholarly and peer reviewed journal articles published
in the past five years in the nursing genre with full text available online. This yielded 273
articles. Studies that were conducted outside of the United States and studies that focused on RN
to BSN programs were excluded. The studies were scanned for eligibility by the author. Sixteen
articles were deemed appropriate after reviewing the titles and abstracts to the PICO question.
An additional four articles were selected based on review of references.
Each study was assessed for risk of bias. This was done through review of funding
sources and explicit conflicts of interest defined. Other factors that were considered included
missing data, participant selection, participant compensation, and reported expected outcomes.
Identified biases will be used during data synthesis. They will affect the reliability of the study in
adding the overall goal of the systematic review. The same methods were used to prevent
cumulative evidence bias in the development of the systematic review as a whole. Identified bias
will be defined in Appendix A.
Results/Matrix
In Appendix A, the results are presented in a matrix. This matrix includes study selection,
study criteria, risk of bias within studies, results of individual studies, and risk of bias across
studies per the modified PRISMA checklist (2009). The sections if the matrix include APA
reference for article, research method, study design, population and sample size, study
process/interventions, theoretical framework, summary of findings, details of bias, level of
evidence, included or excluded, and rationale. See Appendix A for specific details on each of the
above components.
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INTEGRATIVE LITERATURE REVIEW
Analysis and Selection
The identified studies were evaluated by the author for quality and level of evidence. The
analysis was guided through the PRISMA checklist (2009) in matrix form. The levels of
evidence were also appraised through the tool by Melnyk and Fineout-Overholt (2005). Fifteen
studies were selected for inclusion. See Appendix A for rationale on the inclusion or exclusion of
each study. Of the fifteen studies, three were Level VI, ten were Level IIb, and two were Level
Ib. This demonstrates a majority of the articles being of high reliability.
Summary of Evidence
First it is important to note that almost all of the studies reference the IOM
recommendation in The future of nursing: Leading change, advancing health (IOM, 2010). As
stated above, this recommendation was for 80 percent of the nursing workforce to have a BSN
by 2020. The recommendation is the driving force between research like this systematic review.
Markowitz and Bastable (2017) cite an estimation of 64 percent of the nursing workforce being
BSN prepared by the end of 2020. Spetz (2018) suggests that only 63 percent of the nursing
workforce will be BSN prepared by the year 2025. These differing estimations is just one
example of the mismatched evidence on this topic.
Safety
Among the evidence, safety was a major theme that was present throughout the articles
examined. Ambari and Vogelsmeier (2018) stated that in their research only one out of eight
participants stated their BSN education yielded safer nursing practice. Most of their participants
cited career advancement as a reason for seeking BSN education, not to promote safe nursing
practices. Blegen et al. (2013) defined safety in terms of hospital acquired pressure ulcers
(HAPUs), post-operative complications, length of stay (LOS), failure to rescue events, and
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INTEGRATIVE LITERATURE REVIEW
Congestive Heart Failure (CHF) mortality rates. Blegen et al. (2013) found in their study that
these Agency for Healthcare Research and Quality (AHRQ) outcomes decrease with an increase
in BSN prepared nurses. They conclude that hospital characteristics and staffing may also be
significant factors in this scenario.
Kutney-Lee, Sloane, and Aiken (2013) also note staffing as a key factor to safety. One of
the key safety factors they discuss are post-surgical complications. Like Blegen et al. (2013),
Kutney-Lee et al. (2013) shows an inverse relationship between post-surgical complications and
BSN prepared nurses. O’Brien, Knowlton, and Whichello (2018) further explore this concept by
presenting data that shows an increase in BSN prepared nurses decreasing mortality, failure to
rescue events, and readmission rates. With safety being the key focus of healthcare, these
implications are important to consider.
Dual Programs
A unique adaptation to BSN education is the development of dual enrollment programs.
Bopp and Einhellig (2017) and Markowitz and Bastable (2017) both discuss these types of
programs. Both explain how BSN courses are taken concurrently during associate level
education courses. Another similarity is the overall concept of completing associate level
courses, taking the NCLEX, and then completing the BSN coursework while working as an RN.
The only difference between the two programs is number of courses before taking the NCLEX
and the content in the BSN courses. Bopp and Einhellig (2017) cite cost savings, efficiency, and
time as supportive factors to these programs. Markowitz and Bastable (2017) adds that dual
enrollment programs combine the strengths of both programs, helps to share scare faculty
resources, and is seen as a viable option for most learners.
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INTEGRATIVE LITERATURE REVIEW
Barriers to BSN Education
Although the BSN education is supported by the evidence, there are many barriers for
educators to consider. The largest barrier is money. Schuler et al. (2017) discusses the
implications of BSN education on tuition reimbursement and employee assistance programs.
Many organizations do not cover all expenses. More recently, the COVID-19 pandemic is
causing these programs to be cut from organizations in an effort to save money. The average
nurse, with a family, is not able to afford pursuing a BSN degree without substantial monetary
assistance. Kutney-Lee et al. (2013) offers better utilization of public funding of BSN education
programs as a possible solution to the financial barriers.
Duffy et al. (2014) further defines barriers to include work and family sacrifices, support,
and value. Schuler et al. (2017) also notes value recognition as a barrier. They state that many
nurses do not see the perceived benefit to their practice as a bedside RN. Many nurses that do not
wish to move into more advanced roles away from the bedside do not see the value in the BSN
education. Finally, scheduling and staffing is seen as another major barrier to completing the
BSN education tract (Schuler et al., 2017).
BSN Preparation
The evidence shows that there is value in the BSN education over the diploma and
associate level educational programs. First, Håkansson Eklund et al. (2019) concludes that BSN
education increases the RNs ability to practice empathy. Empathy is a key skill in nursing.
Without the development of this skill, nurses find it difficult to develop meaningful relationships,
practice therapeutic communication, and master the “art” of nursing. Kavanagh and Szweda
(2017) explains how BSN programs yield high level of critical thinking, which enhances clinical
reasoning. In an ever-changing, high acuity healthcare system, this skill is vital. Nurses are often
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INTEGRATIVE LITERATURE REVIEW
at the epicenter of complex patients and complex healthcare systems. In order to navigate both of
those to produce safe, high-quality outcomes, highly development critical reasoning skills are
required.
Along with the increased empathy and critical thinking, a BSN education may enhance
certain professional values (Bopp & Einhellig, 2017). Nursing theory and professional practice
principles are more highly explored in BSN education. These courses help to develop values
such as lifelong learning, continuing education, and career advancement. They also help to
develop the competencies of altruism, autonomy, integrity, justice, and ethical considerations.
Finally, Tyndall and Scott (2017) note enhanced scholarly writing ability in BSN prepared
nurses. Bedside nurses are often presented with unit and hospital wide problems that require
formal and informal research. Part of that research process is translation of findings. In order to
appropriately translate the findings, nurses should have some knowledge in scholarly writing.
This skill is also important to those nurses that want to pursue education after their BSN, focus
on nursing research, or advanced their role through clinical ladder programs.
Limitations
This research has several limitations. First, only one online library system was used, The
Jerry Falwell Online Library System. After scanning the titles, previews, and abstracts, only
sixteen were found to be applicable to the research. The remaining four articles were found from
the references of the sixteen articles. This is a very small number of articles to form concrete
evidence. The use of additional databases may have yielded more articles for the study to add
further value to the recommendations. Also, the author of the study is a BSN prepared nurse.
This may pose some bias in the recommendation of BSN prepared RNs being better prepared for
10
INTEGRATIVE LITERATURE REVIEW
entry level nursing jobs over those with diploma or associate level education. In order to better
develop this research, more time is needed.
Although there is a substantial amount of evidence on the topic, more research is needed.
O’Brien et al. (2018) outlines that more tangible evidence is needed to support the relationship
between BSN rates and quality outcomes such as readmission rates, LOS, healthcare cost, and
patient satisfaction. O’Brien et al. (2018) adds that this data will give nursing leadership the
support to make changes in the nursing education tracts. If more research shows similar findings
to that of Blegen et al. (2013), Kutney-Lee et al. (2013), and O’Brien et al. (2018), the
recommendation of BSN as the minimum level education for entry to nursing will be adequately
supported. The buy in of the nursing workforce is also key to this recommendation. Thielmann et
al. (2019) adds that nurses’ perception of the value of the BSN degree of diploma and associate
level needs to be further explored.
Conclusions
In the nursing workforce, there are four pathways to becoming an RN; diploma,
associate, BSN, and masters. Regardless of your education tract, all students take the NCLEX-
RN at the completion of their program to practice as an RN. The IOM made the recommendation
in 2010 that by the year 2020, 80 percent of the nursing workforce should be BSN prepared. In
order to better understand the reality of this recommendation, this systematic review was
conducted. The purpose of this systematic literature review can be defined in the following PICO
statement; Are RNs who have a BSN degree better prepared for entry level nursing jobs over
those with diploma or associate level education? The goal was to add to the current literature
recommendations of a minimum of a BSN as the entry level education for RNs.
11
INTEGRATIVE LITERATURE REVIEW
The Jerry Falwell Online Library System was used for study selection. After specified
inclusion and exclusion criteria were applied, a total of sixteen articles were identified. An
additional four articles were identified through reviewing the references of the sixteen articles.
After use of the modified PRISMA checklist (2009) for critical appraisal, fifteen studies were
selected for inclusion. Among those studies, the following themes were discussed: safety, dual
programs, barriers to BSN education, BSN preparation, and further research opportunities. It was
concluded that although more research is needed, the evidence supports the recommendation that
the BSN degree be the minimum requirement for entry level nursing positions.
The role of the nurse educator is important in this recommendation. They are needed to
conduct this research, disseminate the information, and act as change agents. Whether in the
academic or hospital setting, nurse educators should review the literature and develop ways to
increase the BSN workforce in compliance with the IOM recommendation. Nursing leadership
should be well-versed in the research supporting the BSN degree as the minimum requirement
for nursing practice. They should work closely with state health officials to change the
requirements to take the NCELX-RN to support this recommendation.
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INTEGRATIVE LITERATURE REVIEW
References
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Ball, L. K. (2018). The winds of change are upon us. Nephrology Nursing Journal : Journal of
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E. (2001). End the debate. entry level into practice should be the master's degree. The
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Running head: INTEGRATIVE LITERATURE REVIEW
Appendix A
Hakansson
Eklund,
J.,Holmstrém,
|.
K.,
Ollén
Lindavist,
A,
Sundler,
A
2.,
Hochwllder,
J,
Marmstal
Hammar,
L.,.
Hiégskolan
|
Boras,
2019).
Empathy
levels.
among
nursing
students:
A
comparative
[cross-sectional
study.
Nursing
Open,
6{3},
983-989.
SPSS
version
24
used
fordata
analysis.
ANOVAs
were
used
with the
significance
level
of
p|
(Gonferroni)
was
also
used.
Due
to
the
small
amount
of
male
participants,
gender
was|
Jexcludedas
a
factor.
Age
was
alse
exicudded
due
to
weak,
quantitate,
comparatwe
Nursing
students
in
{their
2nd and
6th
semesters
in
BSN
program
and
MSN
students
and 34
MSN
[students
were
selected
through
Jconvience
sampling.
No
compensation
was
Participants
rated
thes
Jown
empathy
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the
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Scale of
Physician
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te
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from
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disagree}
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agree}.
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education,
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isa
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AND
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Krugman,
M.,
&
Goode,
C.J.
(2018).
BSN
preparation
for RNs:
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into
BSN
programs,
promotion
of
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now.
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The
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mortality
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rates
of
postsurgery
mortality.
Health
Affairs
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