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Destination RN: Which Road to Take?

The nursing profession has been seeking consensus on entry-level education for registered nurses for decades.

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What do optometrists, physicians, osteopaths, audiologists, physical therapists, pharmacists, speech pathologists and chiropractors have in common?

They all have achieved consensus about a minimal educational standard for entry into practice.1

The educational pathway of the registered nurse has been branched for many years, offering hospital-based diploma programs, associate degree programs, and baccalaureate programs. This has contributed to "educational inconsistency and confusion for prospective students, healthcare consumers, employers, and the profession itself."2

Because there are multiple pathways to the RN degree there has been an overall weakening of the collective empowerment of nurses, while the debate about the best route to take has long been seen as fueling a civil war among the ranks of the differently trained nurses.

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Educational Background

Nursing is a vibrant and critical element of the healthcare experience, with more than 2.5 million registered nurses making up the backbone of the U.S. healthcare delivery system.

Woolley (2004) hypothesizes that nursing has always been able to respond to the needs of society by training and releasing scores of nurses to address the nation's healthcare needs at various points of crisis throughout history, most notably during World War I and II.3

The trade-off was that in order to mobilize nurses into the community quickly, the educational process needed to be shorter and more direct than a traditional university education. It was seen as a success when curriculum was developed to produce nurses in less than 3 years.3

In 1965, the American Nurses Association (ANA), sensing the need to capture nursing's stature and educational standards, formally endorsed that all nurses should be minimally trained at a baccalaureate degree level, and that the educational process should move from the hospital to the university setting.4

The desire to be accepted as an autonomous and powerful profession in its own right had been established as far back as the 1890s by a small group of nursing leaders who recognized that true empowerment and respect would come from nursing's success at finding one single unified voice.5

The ANA attempted to re-energize this idea in 1978, and again in 2008 with the "BSN in 10" legislation, currently under review in several states (Starr & Edwards, 2010).6

Arguing the Case

Forty-five years later, the nursing profession is still looking for consensus and solutions.

The two prevalent arguments for a baccalaureate entry-level education fall under the umbrellas of patient outcomes and professional status.

Although all three educational pathways will prepare potential candidates to take and pass the NCLEX-RN exam, evidence suggests that patient safety and outcomes are enhanced under the direction of a baccalaureate trained nurse.

Aiken, et al (2003) found that in hospitals staffed with a higher percentage of nurses with a bachelor's degree, mortality and complications related to surgery were significantly reduced.

In addition, they found that mean years of experience did not factor into the mortality or complication rates, despite anecdotal, passionate, but ultimately spurious arguments from associate or diploma trained nurses which attempted to equate exposure with education.7

The second argument - professional standing and status - is a more difficult position to reinforce quantitatively.

The data is not as objective and concrete with regard to patient outcomes, but this is where nursing can begin to make gains if nursing leaders are able and willing to incorporate lessons from other disciplines that faced similar journeys.

The pharmacy profession, in 1977, realized that the then-current two-degree system "might be detrimental to the profession" and "would promote fragmentation in the profession."1

In 1997, after years of academic debate, the American Council on Pharmaceutical Education mandated that the PharmD should be the sole avenue of accreditation beginning in 2000.1

The American Physical Therapy Association took a similar path, recognizing that the Doctorate of Physical Therapy degree would be the only appropriate education preparation able to respond to the growing complexity of knowledge necessary to provide care to patients.1

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The Future Depends On It

For major educational streamlining and reform to take place, the nursing profession will have to form consensus and align its major professional advocacy groups. This has already begun to gain traction.

The Tri-Council for Nursing, which includes the American Association of Colleges of Nursing, the American Nurses Association, the American Organization of Nurse Executives, and the National League for Nursing, issued a consensus statement on May 14, 2010. It "encourages all nurses, regardless of entry-point into the profession, to continue their education in programs that grant baccalaureate, master's, and doctoral degrees."8

Taylor (2008) states that there is currently minimal opportunity for the nursing profession to engage in clinical or healthcare policy development, because "under-educated members of the health team rarely sit at policy tables or are invited to participate as members of governing boards".4

As the largest healthcare profession by far, nursing has great potential to have major influence on the shape and nature of healthcare reform in this country. Until it can find a unified voice, however, nurses will be "left behind while other members of the healthcare team influence the advancement of their professions and the face of healthcare in this country."4

References for this article can accessed here.

Jay Rosenberg is Director of Nursing & Ancillary Services at Kessler Institute for Rehabilitation, West Orange, NJ

Articles Archives

I entered a diploma program in 1952 and here 60 years later the same battle still rages. I don't have any answers as to which program is best, but i was encouraged to go back to school for my BSN. I feel that I received the practical education i needed for basic nursing in my diploma program, but I received what I needed for the advanced nursing that I moved into over the years from my baccalaureate program.

Helen  Bills RETIREDNovember 21, 2012
Woodridge, IL

i have worked the length and breadth of this country in many many hospitals as both staff nurse and manager as well as an educator. i do not have a bsn, almost finished it 30 years ago but found until the last few years it made no difference and i am too old to go back and finish now, besides it would take away from my child's college fundsand i cannot see how it would affect my practice, which has been exemplary. I can freely state that over the years i have found diploma and associate grads to be much more prepared to provide patient care, though after a year or so the bsn grads catch up and possibly surpass them.
i believe the requirement of a bsn to enter nursing is wrong, but can agree with the caveat to acquire one within a set reasonable time. but financial aid must also be avalable and employers must cooperate with school schedules to accomplish this. i also believe that some people in authority need to get off their high horse and recognize that the diploma and associate grads were the backbone of nursing for a long time and our contributions are valuable, sadly an often ignored and disrespected resource.
i have personally been employee of the year at 3 different hospitals in my career, interestingly one of those during a recent job search rejected my application because they required a bsn of all new hires. so funny it is sad.

Steven  Buckman,  RNNovember 19, 2012

I am a Diploma grad from the early 70's. It has provided me with a career that I love. The education I received as a Diploma grad sent me to Perioperative Nursing because of the background. I think it is unfortunate that schools of nursing are not providing the facts of future employment. I always advice anyone currently wanting a nursing degree to go for the BSN. Lets hope that those of us who don't have the BSN will be grandfathered in when changes are made. It seems those of us who truly want to go into nursing, want to be with the patient. Do you really think that the goal when you start is to be in administration and make policies?

Carol VanderWaal,  RN CNORNovember 18, 2012
Edwardsville, IL

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