Registered Nurses as Professionals

Accountability for Education and Practice

Barbara Zittel, PhD, RN; Edtrina Moss, MSN, RN-BC, NE-BC; Ann O'Sullivan, MSN, RN, NE-BC, CNE, ANEF; Terry Siek, MSN, RN, NEA-BC


Online J Issues Nurs. 2016;21(3) 

In This Article

Standardized Educational Preparation of RNs at the BSN Level

At the onset of the discussions, Panel members queried Steering and Advisory Committee members via a poll regarding their perceptions of barriers to RNs performing to the full scope of their practice. From a long list of barriers, poll participants identified that the major barrier to RN practice at the highest level of the legal scope of practice is non-standardized educational preparation of RNs at the BSN level, either through initial education or educational progression post diploma or associate degree. A subcommittee, consisting of three members of the Steering Committee and 21 members of the Advisory Committee, was then formed to consider this information. The work of the subcommittee was guided by one overarching theme: Nurses pursuing a baccalaureate degree in nursing, either directly or through educational progression, to practice clinical nursing. The subcommittee was charged to identify evidence to support the need for a BSN to practice clinical nursing; to identify barriers; and to offer guiding recommendations to provide guidance to advance the BSN as the essential educational component of RN practice.

Supporting the Need for RNs to Pursue a BSN

The seminal work of Aiken, Clarke, Cheung, Sloane, and Silber (2003) documented that each 10% increase in the proportion of BSN-prepared RNs decreases the risk of patient death and failure to rescue by 5%. These findings resulted in significant forces that quickly thrust the nursing profession into a new era of change. Initially, some in the profession refuted the research methodology, challenged the assumptions, and discredited the conclusions. However, additional evidence by multiple researchers, both national and international, has been gathered to validate the initial findings—that there is a strong and positive relationship between RN level of education and patient outcomes (Aiken, Clarke, Sloane, Lake, & Cheney, 2008; Aiken et al., 2014; Estabrooks, Midodzi, Cummings, Ricker, & Giovanetti, 2005; Friese, Lake, Aiken, Silber, & Sochalski, 2008; Kane, Shamliyan, Mueller, Duval, & Wilt, 2007; Tourangeau et al., 2007). Subsequent research by Blegen, Goode, Park, Vaughn, and Spetz (2013) demonstrated the positive impact of higher levels of BSN-prepared staff members for patients in acute care facilities with specific diseases, such as congestive heart failure, decubitus ulcers, postoperative deep vein thrombosis, and pulmonary emboli.

Concomitant with these findings was change in the acute care facility reimbursement model utilized by the Centers for Medicare & Medicaid Services (CMS, 2013). Instead of reimbursing acute care facilities for the volume and diagnoses of patients, the new scheme would reimburse by value-based purchasing (i.e., the quality of care received as evaluated by patient outcomes and patient perceptions of care). In this new Inpatient Prospective Payment System, participating acute care facilities would be penalized for the development of hospital-acquired conditions. Research has demonstrated that most of these hospital-acquired conditions are directly influenced by nursing care and impacted by a staffing model comprising of a higher percentage of BSN-prepared RNs. These conditions include such complications as decubitus ulcers, postoperative deep vein thrombosis, pneumonia, urinary tract infections, and ventilator-associated pneumonia.

In 2010, the Institute of Medicine (IOM, 2011) released its report, The Future of Nursing: Leading Change, Advancing Health. The result of a 2-year partnership among the Robert Wood Johnson Foundation, the American Association of Retired Persons (AARP), and IOM, the report recommended an action-oriented blueprint for the future of nursing, including changes in public and institutional policies at the national, state, and local levels. One of the eight major recommendations in the IOM report was the need to increase the proportion of nurses with a BSN to 80% by 2020. The recommendation has been termed the "80-20 proposal."

Chapter 4 of the IOM report provides compelling evidence to support a greater number of nurses either entering the workforce with a BSN or progressing to achieve this degree earlier in their career. While the report acknowledged that a BSN education will not solve all challenges brought about by future changes in healthcare delivery, it contended that such education does provide nurses with a greater range of competencies in such areas as research, leadership, systems reasoning, quality improvement, community care, health policy, and health policy financing. These are skills essential for all nurses to meet increasingly complex healthcare needs of the world's diverse population.

Accountability for Educational Progression

Standard 12 (Education) of the Scope and Standards of Practice (ANA, 2015) emphasizes the RN's responsibility to seek knowledge and competence, including ongoing educational activities and lifelong learning. In considering the standard on education and the issue of educational progression, Panel subcommittee members felt that RN education is fragmented, not standardized, and confusing to the public. For example, when one of the authors informed a group of state legislators that persons graduating with a diploma, associate, baccalaureate, or entry-level master's degree all completed the same examination for licensure, they responded with disbelief and puzzlement (personal communication, B. Zittel, March 2015). In comparison, all other major healthcare professions require one entry point, at the baccalaureate level or above. In the last several years, the professions of physical therapy and pharmacy have moved to doctoral education as the entry level requirement.

Despite strong evidence to support the need for RNs to pursue a BSN degree, despite all of the recommendations and reports, despite the many discussions, progress has been slow. A culture change is needed in which persons interested in pursuing RN practice will commit to lifelong learning, with the BSN degree as the minimal educational attainment. One subcommittee member shared the following comment in this regard:

Nursing has been talking about the BSN as entry level since 1965 and has made little progress. Leadership in other disciplines focused on what was best for patients. Nursing needs to do the same. It is time that we as a profession look at the evidence—and make the important choice to be advocates for our patients and in a timely manner develop a system that best prepares nurses to meet the needs of the patients we care for. (personal communication, C. Lee, February 2016).

Unfortunately, culture change is typically a slowly evolving process with many barriers to change.

Barriers to Earning a BSN

RNs have documented for many years that time and cost are the two major barriers to continuing their education to the BSN level (Altmann, 2011; Bahn, 2007; Delaney & Piscopo, 2004). Barriers related to time are inflexible schedules and the demands of family. Cost barriers, in addition to tuition, include loss of or a decrease in salary and loss of healthcare benefits during the time the nurse is in school. Additionally, there is the low- or no-pay differential between diploma or associate degree-prepared RNs and BSN-prepared RNs.

In recent years, two additional major barriers have been identified: a) absence of mentoring and guidance, and b) lack of exposure to evidence supporting the importance of a BSN or higher degree, specifically how patients benefit. Some within the profession have argued that the only way to assure that all RNs earn a BSN is to mandate it. In most states/jurisdictions, that can only be accomplished through a bill passed by the state legislature. In a few states, that can occur by regulatory action of the State Board of Nursing. While Ohio, Rhode Island, Illinois, Vermont, and New Mexico have or have had coalitions to consider such a mandate, only New York and New Jersey currently have bills in the legislature that require future RNs to obtain a BSN within 10 years of graduation from a diploma or associate degree nursing program. It should be noted that in New York, letters of support for the legislation have been received from over 120 organizations including the medical society, the healthcare association representing acute and long term care facilities, and from the councils for both the associate degree and baccalaureate degree and higher programs (personal communication, B. Zittel, January 2016).

Faculty and deans from associate degree programs have been some of the strongest supporters of the legislation. Opposition has come from unions who believe that a baccalaureate of science (BS) in Nursing is not essential; that is, the BS could be obtained in any major. Such unions also wish that the legislation include a provision for funds to reimburse costs to RNs who continue their education to earn the BS. (personal communications, B. Zittel).

Despite these barriers, many changes are occurring. Some examples of recent changes include:

  • As of 2013, the American Nurses Credentialing Center requires all nurse managers and nurse leaders to hold a BSN or higher degree in order to obtain Magnet® status. Further, hospitals applying for Magnet designation must have specific plans to achieve the IOM 80-20 recommendation (ANCC, 2013).

  • Chief Nursing Officers (CNOs) in acute care facilities are providing a strong business case for BSN education, including evidence of economic benefits (Yakusheva, Lindrooth, & Weiss, 2014). These benefits include improved patient outcomes that reduce healthcare costs and avoid payment reductions per new CMS guidelines, and offer an argument to increase the number of BSN-prepared RNs in their organizations. Based on a recent New York state survey (Zittel, 2016), 77% of the acute care facilities sampled preferentially hire BSN-prepared RNs.

  • Funding to pursue the BSN degree available for RNs in acute care facilities continues to increase. The New York state survey (Zittel, 2016) found that 97% of facilities provide funding for RNs to continue their education to the BSN level (93% in 2013) while 94% provide funding for RNs to pursue graduate education (88% in 2013).

  • Zittel (2016) also found that select New York state acute care facilities demonstrated an increase from 27% in 2013 to 71% in 2015 in facilities requiring diploma- or associate-prepared new hires to complete the BSN within a prescribed number of years as a condition of continued employment.

  • An unexpected finding of the New York state survey (Zittel, 2016) was that almost 70% of acute care facility respondents indicated that higher pay is provided to staff RNs with BSNs. That figure in 2013 was 54%. While the amount of that differential was not determined, the increase in the number of facilities providing this benefit is significant.

  • The Tri-Council for Nursing (2010), including the American Association of Colleges of Nursing, ANA, the American Organization of Nurse Executives, and the National League for Nursing (NLN), published a consensus statement calling for all registered nurses to advance their education in the interest of enhancing quality and safety across healthcare settings. The statement encouraged all nurses, regardless of the initial education that resulted in licensure, to advance their education to the baccalaureate, master's, and doctoral degree levels. The statement asserts that, "A more highly educated nursing profession is no longer a preferred future; it is a necessary future in order to meet the nursing needs of the nation and to deliver effective and safe care" (p. 1).

  • In 2010, the Organization for Associate Degree Nursing (OADN) and the ANA committed to partnering with nursing and healthcare leaders, state legislatures and regulatory agencies, universities, colleges, and other stakeholders to support and adopt innovative and emerging strategies to assure that all nurses have access to seamless academic progression programs.

  • In 2012, the Joint Statement on Academic Progression for Nursing Students and Graduates was issued by the American Association of Community Colleges, the Association of Community Colleges Trustees, the American Association of Colleges of Nursing, the NLN, and the Organization for Associate Degree Nursing (OADN). This collaborative statement indicates understanding that the partnering of these organizations can foster and inspire academic progression for nursing students and RNs to meet the common goal of "…a well educated, diverse, nursing workforce to advance the nations' health" (American Association of Colleges of Nursing, 2012, para. 2).

  • In 2015, ANA and OADN issued a joint position statement, Academic Progression to Meet the Needs of the Registered Nurse, the Health Care Consumer, and the U.S. Health Care System (ANA & OADN, 2015). The joint statement is a commitment to partner among themselves and with other stakeholders to support seamless academic progress with an emphasis on reaching IOM's 80-20 recommendation.