Nursing education goals must adapt to changes in healthcare policy in order to better serve the needs of patients. Beginning in 1965, the American Nurses Association took a position that promoted academic degree programs as a way to foster the development of an autonomous nursing profession. This position necessarily rejected the value of the hospital-based diploma programs in existence at the time. This policy was based on the perceived need to improve the quality of patient care by creating professional nurses trained to take on a variety of roles, including healthcare management, nursing education, and nursing research. Although there is real value in earning an associate degree in nursing, the BSN degree is the requisite entry point for anyone interested in professional nursing and the many roles that entails. The BSN degree is also a prerequisite for further career development involving graduate studies in nursing and advanced practice training.
BSN Degree: Pathway to Professional Nursing
There are three traditional pathways to becoming a registered nurse (RN) in the United States, a diploma conferred by hospital programs, a two-year associate degree typically offered through community colleges, and a baccalaureate degree (BSN) offered by many four-year colleges and universities (Raines and Taglaireni, 2008). All three pathways allow graduates to sit for the NCLEX-RN exam, thereby becoming licensed to practice nursing in the U.S. As of 2007, 3.1%, 38.4%, and 58.4% of newly-minted RNs chose a diploma, associate degree, or a BSN pathway to licensure, respectively. This essay examines RN pathways and argues for a greater representation of BSN-educated nurses in the healthcare field in order to improve the quality of patient care.
Becoming an RN through the diploma program is equivalent to apprenticeship programs for carpenters and plumbers, but the hospital-based programs may require completion of additional coursework at nearby academic institutions (Raines and Taglaireni, 2008). An actual degree is not conferred, but close to 25% of RNs in practice today chose a diploma pathway to licensure.
The diploma pathway has historically been discouraged by professional medical organizations, thereby explaining why only 3.1% of newly-minted RNs choose this route. In 1965, the American Nurses Association (ANA) published an official position on nursing education (Donley and Flaherty, 2002). This position defined two categories they believed were important for nursing professionals, a technical and professional education. The technical education could reasonably be obtained through a two-year associate degree program for those interested in patient care only, but to become a nursing professional with career aspirations the recommended route was an academic course of study leading to a BSN. The BSN degree would confer both the technical and professional competencies needed by career-minded nurses. It should be noted that the ANA deemed these two degrees the minimum necessary for each career path and rejected the diploma pathway as adequate preparation for RNs back in 1965. This policy position shifted the focus of nursing education away from apprenticeships and towards academic pathways for licensure.
The policy position taken by the ANA in 1965 was in response to hospital nursing schools producing nurses to meet their labor demands without adequate attention to the educational needs of the students to protect patients from harm (Donley and Flaherty, 2002). Attending lectures was often impossible given the workloads placed on students. The amount of time that students would typically be required to work averaged between 24 to 30 hours per week. Students in diploma programs became well-versed in caring for seriously ill and hospitalized patients, which by today's standards would be considered a limited education.
The breadth of training available in academic nursing programs was similarly narrow in 1965, with three quarters of these degree programs emphasizing the roles nurses will play in caring for hospitalized patients (Donley and Flaherty, 2002). However, only 63% of the practicing nurses in 1965 worked in hospitals despite 75% to 85% having received their training in a diploma program. A 1966 report claimed that three years earlier there were 818 hospital programs generating 75% of newly-minted RNs, compared to 324 academic programs producing the rest. Since the majority of nursing graduates were products of hospital programs, hospitals played an influential role in determining what a nurse's role should be. The policy position taken by the ANA in 1965 was one of the first salvos in the battle to create an autonomous nursing profession.
These visionaries could see how patient care benefits from professional nurses making their own independent contributions (Donley and Flaherty, 2002). Rather than simply provide enough trained labor to take care of hospitalized patients and be 'handmaidens' to physicians, the ANA committee could see a future where the nursing profession would establish its own standards of care based on an accumulated knowledge base and research findings from nursing research. Professional nurses, trained at academic institutions, would therefore help usher in evidence-based patient care.
Two-Year Degree Programs
With the almost complete demise of the diploma pathway to RN licensure, there was a greater need for a fast and cost-efficient way for nursing students to get the training and education needed to provide quality care (Raines and Taglaireni, 2008). In 2008 there were about 940 programs offering a two-year degree in nursing and close to two-thirds are based in community colleges. Such programs tend to be more responsive to all nursing needs in a community, rather than focusing solely on caring for hospitalized patients.
BSN programs are offered at four-year academic institutions and provide the education and training necessary for preparing nursing students to become nursing professionals (Raines and Taglaireni, 2008). BSN programs are typically structured to prepare nursing students to work in diverse healthcare settings, including hospitals, and become leaders in their profession. To achieve these goals, BSN programs demand a greater and more in-depth understanding of the sciences, nursing research, public health, healthcare management, and humanities. In 2008, 31% of the nursing workforce had earned a BSN and there were 606 academic BSN programs in existence.
BSN Pros and Cons
If the goal of the healthcare industry is to continuously make improvements in care quality then the BSN degree is the minimum training required to begin this process. As Donley and Flaherty (2002) mention, the degree that has conferred the most autonomy and professional control to nurses is the masters' degree in nursing, together with certification in an advanced practice field. If the underlying assumption is that nurses and the nursing profession have something unique and valuable to contribute to patient care quality, then greater autonomy and professional development is the best way forward. The BSN degree is the first stepping stone towards this goal and is a prerequisite for further career development towards a graduate degree in nursing.
The relationship between nursing education and patient safety is a particularly salient issue after a study by Chang and Mark (2009) revealed that the prevalence of severe medication errors decreased gradually as the percentage of BSN nurses in hospital wards increase to 54%. By comparison, an earlier study found that years of nursing experience was a better predictor of lower medication error rates, but a greater percentage of BSNs correlated with higher medication error reporting rates (Blegen, Vaughn, and Goode, 2001). The discrepancy between the two studies provides an excellent example of why more research needs to be done in nursing, while at the same time revealing that education and experience may both lower medical error rates and improve error reporting. The latter finding is consistent BSN programs instilling nursing students with a sense of professional responsibility and an awareness of the value of error reporting to nursing research.
The Institute of Medicine (IOM) published a report in 2010 that saw an expanding need for better educated nurses in all healthcare settings. As the nation transitions to meet the needs of the Patient Protection and Affordable Care Act of 2010, nursing professionals will play a pivotal role in determining what the new healthcare landscape will look like. As the nation grows older demographically, the education and training needs of nurses will also change. Technological advances will require nurses to have a more in-depth understanding of the underlying science behind these innovations. As the amount of information being generated through nursing research continues to grow, so does the pressure to adequately train student nurses to provide quality care within a relatively short 2-year program. For this and other reasons, the IOM recommends that the percentage of newly-minted nurses with a BSN degree be increased to 80% by 2020. In addition, to promote advances in nursing leadership, teaching, and research, the IOM recommends a doubling of nurses holding doctorates from 1% to 2% by 2020.
Based on the above discussion, a BSN degree is the right choice for anyone determined to make nursing their career. Not everyone may be so certain that nursing is the right career choice and may be reticent about committing both time and money to a four-year program. There is not much of a difference in earnings…
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