Nursing Shortage: ADN vs. BSN Competencies Compared

Introduction

In the early 2000s, national strategies to improve the nursing workforce profile were largely focused on increasing the number of nurses at the bedside through the use of sign-on bonuses and travel nurses. While these strategies tended to provide local short-term solutions, they did little to address long-term issues affecting the nursing shortage. With nursing education programs challenged to increase student enrollment, many colleges were confronted with a limited financial infrastructure, a shortage of qualified faculty, and difficulty establishing the clinical sites needed to support additional students. Thus, they found themselves turning qualified applicants away (Clark & Allison-Jones, 2011).

According to the American Association of Colleges of Nursing (AACN, 2010), there are three routes to becoming a registered nurse (RN): a three-year diploma program typically administered in hospitals, a three-year associate degree usually offered at community colleges, and a four-year baccalaureate degree offered at senior colleges and universities.

This paper will examine the past and current issues surrounding the nursing shortage, compare the competencies of associate degree nursing (ADN) graduates with those of Bachelor of Science in Nursing (BSN) program graduates, and explore the concept of differentiating competencies.

Historical Background of the Nursing Shortage

A quick review of the literature reveals that the current nursing shortage is nothing new. Roberta Spohn wrote, "Although there are recurring reports of manpower shortages in many other professional fields, nursing seems to enjoy the dubious distinction of continually suffering from this condition" (Spohn, 1954, p. 865, in Fox & Abrahamson, 2009). Though this quote sounds as though it fits into the contemporary nursing dialogue, it was written over fifty years ago. Despite short-lived periods of adequate nurse availability, the nursing shortage has endured for a variety of reasons.

Research reveals that there was concern about a nursing shortage between 1930 and 1950. The number of hospitals in the United States changed very little during that period; however, what did increase was the number of beds within hospitals — 52% more beds were reported in 1952 than in 1932, and the daily patient census increased at the same rate. At first glance, it would appear that the increase in hospital capacity alone could account for the shortage of nurse caregivers during this period; however, the problem was far more complex. A closer examination showed that this increase could not single-handedly have caused the shortage, because average length of stay had decreased significantly during the same time frame. As a result, many more patients were being seen annually but were staying for shorter periods, which did not increase the average number of patients requiring care on any given day. Investigators cannot simply consider admission statistics as an accurate measure of nursing demand; the number of nurses necessary to adequately care for a population is a far more complex question (Fox & Abrahamson, 2009).

Early research revealed that a number of societal factors influence the number of nurses entering or exiting the U.S. labor market, including accreditation policy, educational opportunities, U.S. entrance into foreign conflicts, and the cultural image of the profession (Fox & Abrahamson, 2009).

A shortage of nurses was instrumental in the development of the associate degree (ADN) level of nursing. According to Lauren Huber (2006), after the Second World War many nurses who had been in military or civilian practice were leaving the profession, and fewer students were choosing nursing as a career. To exacerbate the problem, those who did enter the profession were leaving after only a few years.

Meanwhile, advances in medical science, improved medical facilities, and an increase in the number of insured individuals worked together to create greater demand for nurses. Simultaneously, growth in junior colleges, increased availability of federal funding, and public concern led to the inclusion of nursing in the junior college curriculum. Initially, the ADN was foreseen as a temporary solution to address this shortage and was not intended to replace the professional level of nursing education. However, ADN programs, first introduced in 1958, became instantly popular and expanded throughout the 1960s. Raines and Taglaireni (2008) report that there are currently about 940 ADN programs nationwide, with approximately 600 of these offered in the community college system. The typical ADN program is a two-year commitment and prepares graduates with the clinical competence and technical proficiency needed to practice safely in multiple settings and to fully assume the RN role.

Present Research: Factors Sustaining the Shortage

In the 1980s, attention focused on organizational factors when it was found that the prospective payment system introduced to hospitals in the late 1970s had an effect on the availability of nurses. Research indicated that this legislation had a dampening effect on nurse salaries at a time when other professional salaries were rising, influencing nurses to leave the profession.

During the 1990s, hospitals experienced two major RN shortages. The first began in 1990 and was marked by an 11% vacancy rate of unfilled, full-time RN positions. By 1992, the shortage appeared to have subsided and the outlook for nurse supply was optimistic. Only five years later, in 1997, hospitals began to feel the pressure of a shortage again, and by 2001, the national average hospital RN vacancy rate stood at 13%. Unlike the shortages of the past, this one has not receded and remains a topic of current policy discussion. Although some interested parties have tried to isolate a single cause — such as low pay — the reality may be that a web of dysfunction exists that is far more complicated than any one factor.

Shortages in other skilled professions tend to be short-lived, with supply catching up with demand as soon as potential employees learn of available incentives. That this is not the case in nursing encourages further examination of the forces that allow the shortage to endure. The biggest factor in any labor shortage — lack of qualified potential applicants — is surprisingly not a problem in nursing. In fact, nursing schools are turning away qualified applicants because of a lack of available faculty and resources. There are enough licensed RNs and qualified nursing school applicants in the United States that the country has the potential to independently staff its healthcare facilities without drawing from foreign nurse labor markets. Hundreds of thousands of RNs have removed themselves from the active nursing workforce, while an insufficient number of younger nurses are selecting nursing as a profession. In order to alleviate staffing shortages, the societal and occupational factors that discourage people from choosing to practice nursing must be examined.

Members of the baby-boomer generation were born roughly between 1946 and 1964. The high birth rate during this period resulted in a large population increase; however, after 1964, the birth rate dropped dramatically for the next eleven years. In the 1990 census, there were 77 million baby boomers compared with 44 million in the following generation, sometimes referred to as Generation X. This population imbalance creates a challenge for the nursing profession: as baby boomers age, their demands upon the healthcare system increase. The resulting rise in patient census, along with the multi-system medical needs and function-based care required by an aging population, puts pressure on the professional nurse workforce. Conversely, nurses who are themselves members of the baby-boomer generation are also aging. Nearly half of all RNs were projected to be over age fifty by 2010, and the average age of nurses had risen above forty-five. Retirees and aging nurses leaving the workforce are not being replaced in adequate numbers by newly trained, younger nurses, making an examination of current nurse training mechanisms essential.

Hospital-based diploma programs once served as the United States' primary mechanism for training nurses. Hospitals came to depend on student nurses who were required to spend long hours providing care on the wards. As nursing education moved from a primarily hospital-based system to colleges and universities, a larger paid nursing staff became necessary to provide the same level of patient care. This put pressure on university-based programs, which struggled — and continue to struggle — with attaining adequate numbers of graduate-degreed nurse faculty. In the 2005–2006 academic year, at least 41,683 qualified applicants were turned away from baccalaureate, master's, and doctoral nursing programs, a major increase from the approximately 32,797 turned away in 2004. Of the schools that turned applicants away, more than 74% cited lack of faculty as the primary reason.

Female college graduates — historically the population most likely to select nursing as a profession — have seen their educational options and professional opportunities expand considerably in recent decades. A recent survey of adult Americans found that although 83% of respondents would encourage a loved one to pursue a career as an RN, only 21% would consider this career for themselves, and only one in ten male respondents would consider a career in nursing. Increased diversity of career options, coupled with tightened admission structures in nursing programs due to a lack of university-level resources, has produced an educational system that is actively contributing to the shortage of available nursing staff (Fox & Abrahamson, 2009).