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More nurses asked to get baccalaureate degrees

Specht, Dawn M. PhD, MSN, RN, APN

doi: 10.1097/01.CCN.0000471003.09579.84
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Why should RNs get a BSN? This article focuses on what's required for the degree and how additional education helps nurses advance in their careers and reduces patient mortality.

Dawn M. Specht is an assistant professor in the Department of Nursing at Rowan University in Glassboro, N.J.

Advanced nursing education improves patient care.

The author has disclosed that she has no financial relationships related to this article.

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This article will review the baccalaureate degree for nursing, realizing the bachelor's of science in nursing (BSN) degree is the most frequently studied degree.1 The research that supports the need to earn a BSN will be summarized, as will options to pursue a BSN. Focusing on what it is and why it's important will help nurses embrace the need for change.

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Healthcare changes

It's no surprise to any practicing nurse that patients are more complex, living longer, and requiring more expertise in care. Patients who were once hospitalized are now managed as outpatients. Families require more patient education for more advanced care techniques. The need for even more complex care and support increases as the number of patients age 65 or older grows. The bedside provider who's an expert in hospitalized patient care needs to develop methods that assist with new modes of care. Forward-thinking clinical nurses must predict transition sites and begin planning to successfully transfer care back into the community from inpatient facilities. This interest in improving healthcare through patient and community engagement requires a commitment to lifelong learning.

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Getting started

The clinical nurse should begin the advanced education journey by first acknowledging the fact that many organizations consider the BSN imperative for nursing. Organizations that support the BSN degree for nurses include the American Association of Colleges of Nursing (AACN), American Nurses Association (ANA), the American Nurses Credentialing Center (ANCC) Magnet Recognition Program®, The Institute of Medicine (IOM), and The Robert Wood Johnson Foundation (RWJF). Other organizations describe their commitment to evidence-based practice and improving healthcare through education.

The AACN promotes a vision to enhance nursing education, research, and practice by setting standards and developing leadership in nursing schools.2 The AACN defines essentials for professional nursing practice that must be met by each BSN program, whether a 4-year program or a post-licensure program.

A post-licensure program is sometimes referred to as a degree completion option for RNs who have graduated from a diploma or an associate's degree program. In 2014, the National Council of State Boards of Nursing (NCSBN) reported that 1.7% of first-time applicants for the NCSBN RN Licensure Examination were diploma graduates, 54.9% were associate degree graduates, and 43.3% were baccalaureate degree graduates. In 2004, 3.6% of first-time applicants were diploma graduates, 61% were associate degree graduates, and 35.2% were baccalaureate degree graduates. In 10 years, there was a substantial decrease in diploma graduates, a slight increase in baccalaureate graduates, but the largest preparer of entry-level nurses was associate degree programs.3

Key factors are used to design and evaluate the curriculum in many programs. The content of an RN-to-BSN program should complement the education received in a diploma or associate program. The AACN has developed an Essentials of Baccalaureate Education document that's infused into leadership, informatics, ethics, healthcare policy, finance, research, and evidence-based practice courses. The practice focus is population-or community-based and builds on both professionalism and interprofessional collaboration. These themes differ greatly from the typical bedside practice. Most nurses have been forced to learn about many of these topics through “on the job” experience. The BSN encourages investigation along with research. Through clinical practice reflection, open-minded learning, and caring environments the clinical nurse may have additional opportunities to grow personally and professionally. A new vision of health promotion, improved patient health outcomes, and government support provide vast opportunities to drive the care of the future.

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Choosing the right school

Accreditation of a nursing program is important when considering which school to attend. Accreditation is a sign of the school's commitment to continuous quality improvement. Schools may pursue accreditation from The Commission on Collegiate Nursing Education (CCNE) or The Accreditation Commission for Education in Nursing (ACEN). Each accrediting body is committed to insuring quality nursing education. Accreditation is a requirement for students to participate in some federal and state funding programs. Additionally, completion of an accredited program is required to continue education in another accredited program. For instance, graduation from an accredited BSN program would be required to attend an accredited graduate nursing school for a master's degree.

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Improvement with education

A qualitative descriptive study showed that the completion of a BSN positively influences clinical nurses.4 Recent RN-to-BSN graduates were interviewed utilizing open-ended questions to determine how their professional behavior had changed since completing the BSN. The questions were based on the AACN's Essentials of Baccalaureate Education document and investigated effective learning activities. This qualitative study had a relatively small sample size of 10 subjects but demonstrated data saturation. Data saturation is a determination by the researchers that the number of subjects meets the standards to represent a generalized finding. For instance, a theme is occurring with each subject interviewed. The recent BSN graduates reported increased collaboration, patient advocacy, confidence, research use, political activism, and professional organization participation. Interestingly, the study's subjects didn't anticipate this change.

The BSN is a much-needed degree for the RN.5 Support for this argument is directly related to the changes healthcare is now experiencing. Healthcare will continue to change more rapidly than ever before, and nurses must be well prepared. As future leaders, graduates of RN-to-BSN programs need to create solutions for the unique and changing population's healthcare needs.6 Additional education helps practicing nurses incorporate evidence and develop creative solutions that build on their past experiences and patient-centered caring practices. Healthcare institutions, in response to these changes, are seeking ways to increase brand recognition, improve nursing care, and decrease costs. Many hospitals have turned to Magnet® certification. (See Magnet overview.)

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Support for the BSN

The BSN degree has been linked in research to decreased patient mortality and increased patient satisfaction.9,10 One landmark study led to ongoing studies that examined the association of educational levels of nurses and surgical mortality.9 Specifically, the group accessed a database of 232,342 patients who underwent surgical procedures over a 19-month period. This database contained data that allowed the examination of 30-day mortality with or without complications. Nurse data were obtained by surveying RNs in Pennsylvania who self-reported educational level, workload, and years of experience. This information was then compared to hospital association data for agreement. Regression modeling was used to determine if the educational level would statistically impact mortality. The authors demonstrated that employment of nurses with BSN's or higher degrees improved patient outcomes. Specifically, failure to rescue was impacted by nurse education level.9 This may be interpreted to mean the higher the educational level of the nurse the less risk of failure to rescue. Many criticisms of this study such as the lack of separation of associate degree nurses from diploma nurses may be found. However, the true test of a study is whether the findings may be replicated. There's no denying that research exists today that proves mortality is impacted by having nurses with a bachelor degree.9 Which brings us to the discussion of the IOM.

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What role does the IOM play?

The IOM is an independent nonprofit organization that provides advice to policy makers.10 The advantage of having a consulting group outside of government is that the risk of bias is reduced. The IOM is a division of the National Academies of Sciences, Engineering and Medicine. The goal of the IOM is to influence health decisions by providing reliable evidence.11 If the U.S. Congress would like a study performed then it can mandate the study be performed and the IOM will be responsible to meet the mandate.

One important report that nurses should read was prepared by the IOM, entitled “The Future of Nursing: Leading Change, Advancing Health.” This report was released in 2010 and identified the need for nurses to attain competencies to deliver high-quality care in a complex environment.12 The need for interprofessional collaboration, technology utilization, and evidence-based practice supports the call for nurses to attain higher levels of education. The most widely discussed recommendation is increasing the proportion of nurses with baccalaureate degrees to 80% by 2020. At the time of the report, only 50% of nurses were reported as having BSN degrees. The IOM further recommended that the number of nurses with doctorates should be doubled by 2020 and all nurses should commit to lifelong learning.11 The committee members identified the need to have more baccalaureate prepared nurses not just to improve patient outcomes, but also to be in a position to continue their education and replace graduate educated nurses as they retire. It's more likely to have more faculty, NPs, and researchers if a pool of well-prepared BSN nurses exists. These nurses can step up to the next level of education and replace those who are retiring or just meet the additional primary care needs of our patient populations.

In 2013, The Health Resources and Services Administration (HRSA) released a report that showed a 10% increase in the number of nurses with a bachelor's degree between 2010 and 2013 was 45% to 55% respectively.13 Although this study does show an improvement it also indicates that the profession isn't in a position to meet the IOM recommendations by 2020.

In an effort to reinvestigate educational levels of nurses and postsurgery mortality, another study repeated the initial landmark study and compared factors across two time periods.13 The authors noted that even though the IOM is calling for higher levels of education for RNs more evidence is needed. These researchers compared the two sets of data and examined what influence if any having more BSN-level nurses has on surgical mortality and failure to rescue.

Increasing the number of clinical nurses with a BSN in Pennsylvania hospitals by 10% impacted mortality. Whereas, a 10% increase in years of experience, skill mix, or nurse reported staffing didn't significantly impact mortality rates. The authors assert a reduction of 2.12 to 7.47 deaths per 1,000 patients depending on absence or presence of complications. However, the data only represents two periods in time of a narrow geographic sampling. The authors acknowledge this limitation.14 But, it's enough for private organizations to use this evidence to support BSN education.

The RWJF is dedicated to improving the public's health. The foundation was established through private philanthropy. Its priority is to improve health and healthcare delivery in America. The foundation provides a report on policies that can transform patient care. A description of the need for academic progression also known as higher-level education for nurses is provided based upon the changing healthcare environment, a shortage of both primary care providers and nursing faculty. Additionally, the foundation funds innovative projects to increase access to higher education for present and future nurses.

The message that's being sent by all of these respected organizations is that healthcare is changing at a rapid rate. In order to keep the nursing profession relevant in these changing times all nurses must commit to lifelong learning and higher education. Advancing the educational level of practicing nurses positively impacts patient outcomes.9,14 The decision that follows for nurses is how to advance their educational status. RN-to-BSN programs that communicate caring, respect experience, and form student cohorts positively impact RN-to-BSN student perceptions of returning to school.15–18 The development of web-based learning communities also fulfill cohort supportive characteristics.19 However, nurses must consider both barriers and incentives when deciding whether or not to return to school.

Barriers that are identified by practicing nurses include work and life balance and finances.17 Additionally, nurses report lack of time, fear of failure, lack of support, and previous negative educational experiences. 20When evaluating programs the nurse should consider asking questions that are directed to the barriers and what the program does to alleviate these challenges.

Finally, when considering online programs versus traditional classroom programs research reveals that opinions about online degrees vary. The nurse involved in an online program will need informatics competencies or a support system to develop these skills. Some nurses who self-identify as having online competencies claim that online learning is harder than classroom learning.17 In a study of healthcare recruiters, applicants with RN-to-BSN degrees from colleges with traditional classrooms were most favored whereas online degrees from for-profit colleges were least favored. The nurse must weigh the barriers and investigate supports.21

Incentives offered by employers, partnerships with universities, on-site classrooms, mentorship, and reduced costs may outweigh any barriers. The BSN degree allows nurses to positively impact patient outcomes, adopt new professional behaviors, and become the innovative new leader of tomorrow. Additionally, the BSN degree is a small step on a flight of stairs leading to lifelong learning. You may begin seeking a BSN and finish as the next faculty member, nurse researcher, or primary care provider, but first you have to begin! Delaney and Piscopo studied the actual experience of transitioning from RN to a BSN-RN and report that the reasons for beginning varies and most students are tentative.22 As you move into the program, you'll experience cornerstone courses, become leaders, conquer challenges, and envision the field of healthcare with a fresh perspective. While being able to step back and see the bigger healthcare picture most nurses reported recreating their own practice to value patients even more. They also reported feeling more professional, having more problem solving skills, and critical thinking abilities.22

The “BSN-in-10” initiative has been discussed in legislative circles and is supported by the ANA.23 If a state passes this initiative, an RN will have 10 years from licensure to achieve a BSN or lose their nursing license. Many people rebut and say that a legislative issue isn't necessary, as RNs return to school on their own. Aiken shares some interesting facts with the profession. Associate degree programs are producing 60% of the new nurses. Only 58 out of the 1,000 new associate degree graduates go on to obtain a master's degree.23 It doesn't appear that nurses are returning to school at rates that will assist us with meeting the IOM 2020 goal.

The number of newly graduated, U.S. educated, first time NCLEX takers from 2004 to 2014, increased from 87,085 to 157,339.3 Kovner, Brewer, Fatehi, and Katigbak described increased enrollment in “formal education” from a sample of nurses newly licensed in 2004 and compared them to those newly licensed in 2011 as significantly different.24 However, it isn't clear if the 2004 sample had completed their baccalaureate, master's, or doctorate degree. Also, even if the reader was clear on the entry-level education and current educational degree being pursued it wouldn't matter. It's clear that in both of these cohorts more than 80% of the samples aren't in formal education programs.25 There's a great need for more nurses with advanced education yet there isn't a great increase in educational pursuit. For instance, nursing schools are turning away qualified applicants due to a faculty shortage. A faculty position requires at least a master's degree. Additionally, the field is wide open for advanced practice RNs to take on new roles in primary care, prevention and population health, but the number of new NPs has remained constant at 8,000 per year. There are so many opportunities for nurses, now is the time to embrace change, continue your education, and lead us into the future.

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Magnet® overview

The ANA supported a Magnet recognition program after studies revealed that despite nursing shortages, there were hospitals that had the ability to attract and retain the best nurses. The Magnet recognition program was developed by the ANCC as an avenue to recognize hospitals that are committed to quality patient care, nursing excellence, and innovations in professional nursing practice.6 The ANCC asserts that the benefits of Magnet certification include having the ability to both attract and retain the top nursing talent, improve patient care, advance nursing practice, encourage collaboration, and improve patient safety.6 A new educational item has been adopted for organizations that want to achieve Magnet status and requires the development of an action plan with a target of 80% of all RNs having a bachelor's degree or higher by 2020.7,8 Additionally, the goal for 100% of nurse managers having at least a BSN is advanced as a key criterion.

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REFERENCES

1. American Association of Colleges of Nursing. 2015. New AACN Data Confirm Enrollment Surge in Schools of Nursing. www.aacn.nche.edu/news/articles/2015/enrollment
2. American Association of Colleges of Nursing. Mission and Values. 2014. www.aacn.nche.edu/about-aacn/mission-values.
3. National Council of State Boards of Nursing (NCSBN). NCLEX pass rates. 2015. https://www.ncsbn.org/.
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5. American Association of Colleges of Nursing. Amos LK 2014. Baccalaureate Nursing Programs. www.aacn.nche.edu/education-resources/bsn-article.
6. Conner NE, Thielemann PA. RN-BSN completion programs: equipping nurses for the future. Nurs Outlook. 2013;61(6):458–465.
7. American Nurses Credentialing Center. Magnet recognition program overview. 2014. www.nursecredentialing.org/Magnet/ProgramOverview.
8. American Nurses Credentialing Center. 2013. Magnet Recognition Program® FAQ: Data and Expected Outcomes. www.nursecredentialing.org/FunctionalCategory/FAQs/DEO-FAQ.html#B3.
9. Aiken LH, Clarke SP, Cheung RB, Sloane DM, Silber JH. Educational levels of hospital nurses and surgical patient mortality. JAMA. 2003;290(12):1617–1623.
10. American Association of Colleges of Nursing. Creating a more highly qualified nursing workforce. 2014. www.aacn.nche.edu/media-relations/NursingWorkforce.pdf.
11. IOM. Institute of Medicine: About the IOM. 2013. www.iom.edu/About-IOM.aspx.
12. Institute of Medicine (US) Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine. 2010. The future of nursing: Leading change, advancing health. http://iom.nationalacademies.org/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health.aspx.
14. Kutney-Lee A, Sloane DM, Aiken LH. An increase in the number of nurses with baccalaureate degrees is linked to lower rates of postsurgery mortality. Health Aff (Millwood). 2013;32(3):579–586.
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