BSN as entry into practice; why we decided against it.

[MunoRN]

While hopefully avoiding stoking the ADN - BSN debate unnecessarily, I thought I'd share my experience with my state's consideration of BSN as entry into practice, as well as the BSN-in-10 initiative.

About 3 years ago I sat on a council charged with evaluating and making recommendations on the educational requirements for Nursing. We worked closely with both employers and schools of Nursing to evaluate needs and capabilities and to coordinate the two.

We initially reviewed the evidence, most notably Linda Aiken's work on the relationship between educational level and quality of Nursing care. On the surface her work seems to clearly support the BSN model, however upon closer inspection we could not show that improved Nursing specific outcomes were due to higher proportions of BSN nurses, at least in terms of a BSN being causative rather than just correlative. While her studies did show a relationship between better outcomes and Hospitals with a higher proportion of BSN Nurses, she failed to adequately account for the fact that Hospitals with higher proportions of BSN nurses also have many factors that would be likely to contribute to better outcomes. For instance, predominately BSN hospitals (teaching hospitals) tend to have better staffing ratios, better support systems, better funding, and are more likely to be "early adopters" of practice improvements. Aiken's accounting for the effects of these differences were grossly inadequate. When her data was properly corrected for these differences, there was no clear difference between ADN and BSN prepared Nurses in areas examined.

We then looked at differences in curriculum between ADN and BSN programs and found surprisingly few differences. Pre-requisites varied among both ADN and BSN programs, with the only consistent difference being that BSN programs required a Nutrition class. We had assumed that the Statistics requirement was also a universal difference, but what we found was that this was only different in older ADN programs, newer ADN programs carried the same statistics requirement with some requiring a higher level of statistics than even the top BSN program in the state. In the program itself, the curriculum is closely regulated by both accreditation groups and the State Board, both of which hold the curriculum of both types of program to the same standards, minus the BSN program's additional leadership and community health classes.

Considering the minimal differences between ADN and BSN curriculum, we questioned whether there might be differences related to the 'caliber' of student admitted to each type of program, we were particularly surprised by what we found. Two of the ADN programs in the state required a previous bachelor's degree to even apply, more were considering this. The typical minimum GPA in core prerequisites for competitive entry ADN programs was 3.8, for BSN programs it was 3.6.

The biggest factor was what we would need to do to move to only BSN programs. Our current BSN programs already have a shortage of clinical spots, so expanding our current BSN programs was not an option. The only viable option was to take our ADN programs and simply start calling them BSN programs by adding community health and leadership classes and requiring the additional "general" credits needed to fulfill the credit requirements of a bachelors. To do this, community colleges would have to partner with Universities who would then grant BSN's for a (large) fee. This would essentially mean the only difference between an ADN and BSN would be 8 core credits, about 35 general credits, and about $18,000.

The other concern with limiting RN education opportunities to BSN programs by expanding BSN programs was the demographic makeup of Nursing students. More than half of those currently going into Nursing are "second career" students. These students typically are not in positions where attending a direct BSN program is feasible. In my state, BSN programs are only available in two urban areas. It's much easier for an 18 year old to drop everything and move to one of these two areas than it is for someone who has kids in school, owns a home, has a spouse with an immovable job, etc. As a result we were concerned about the effect such a drastic change in Nursing student demographics might have.

A survey of employers found no glaring preference for BSN prepared Nurses in my state, in fact we were surprised at the number of Hospitals that expressed a preference for ADN new grads as they found their bedside training requirements were less, this was likely due to the limitations in clinical experience in BSN programs. Only one hospital in the state expressed a preference for BSN graduates, although they did not require a BSN, this was the Hospital associated with the state's largest BSN program. They did express that their preference for BSN's was somewhat self-serving; when part of the job market is "BSN-only", it helps maintain demand for a degree that's fairly similar yet typically 400% more expensive than the ADN option. This would seem to shed some light on why "BSN-only" employers are primarily hospitals associated with Universities.

In the end we determined that we could not support the goal of BSN as entry to practice at this time. We did however endorse the concept of BSN-in-10 through ADN to BSN programs. Although we didn't go so far as to advocate BSN-in-10 as a requirement. This was partly due to reviewing North Dakota's failed BSN-in-10 attempt, as well as the demographics involved in the Nursing workforce. The number of experienced Nurses who leave the workforce is a real problem. This attrition often occurs between 5 and 10 years. Adding a requirement that will take additional time as well as cost, in many cases, up to half of their yearly salary would too often serve as the primary factor in a decision to leave Nursing. There are huge advantages to additional schooling after a period of time in the workforce, one could argue advantages that exceed that of direct BSN programs, however it was not felt that the loss of experienced Nurses outweighed those advantages. But when feasible, all ADN Nurses should be actively encouraged to pursue an ADN to BSN.

As a BSN prepared Nurse, I was expecting confirmation that my money was spell spent, and I'm not saying it necessarily wasn't, however many of the assumptions I held may have been overstated or just incorrect. For many, direct BSN programs are worth the expense, for other's it's not. What's most important is that students can make an informed decision.

[BrandonLPN, LPN]

Oh, not that it's extremely relevant, but another thing that EVERY report I researched had in common was that the MAIN factor in high mortality and violation rates was ALWAYS MOST affected by ridiculous Nurse to Patient ratios. The way they made it sound (and It is likely to be true) is that just adding 2 Nurses per shift would be a tremendous help. If this is true then I just don't see why it isn't being done. I percentage wise, how

badly would this hurt most hospitalsbottom lines?

Hospitals and LTC facilities are always gonna staff as few nurses as

they can get away with. I think that's a reality that simply isn't going to go away. In fact the only state (as far as I know) to have a 5 pt max for med surg nurses is California. And that is also the state that has, by far, the most powerful statewide RN union. Coincidence?

[Esme12, ASN, BSN, RN]

I think right now there is a dumming down of the ADN/ASN programs in general in order to prove their point. Many of these drive through programs have minimized the content while maximizing the cost to obtain a nursing degree.

My niece is in an accelerated BSN program that has the exact same curriculum as my ADN program 34 years ago. Obtaining my BSN added nothing to my practice nor make me a better manager/director for I already had the position and devoted staff members when I "graduated" I got it because the hospital paid for it.

I actually yearn for the day that this argument ends and there is finally a consistent entry level into nursing. I miss the days of respect for the kind of nurse you are and not the kind of nurse that has many degrees. I take serious issue with direct entry master degrees and graduate with advanced degrees to practice advanced nursing when they haven't spent not one second at the bedside in basic nursing skills....but that is just me.

These "studies" that show that the BSN is "the better nurse" are propaganda promoting one persons agenda. That has always been my feeling....this thread proves it!

[PMFB-RN, RN]

ALL the Pro BSN articles did have in common was that the BSN grads were better critical thinkers. So is it true? I dunno, maybe. But I'm just not seeing it by looking at the degree sheet. Perhaps a combination of their classes leads to these better critical thinking skills? It's possible.

*** I would really like to know how critical thinking was measured.

[tewdles, RN]

Oh, not that it's extremely relevant, but another thing that EVERY report I researched had in common was that the MAIN factor in high mortality and violation rates was ALWAYS MOST affected by ridiculous Nurse to Patient ratios. The way they made it sound (and It is likely to be true) is that just adding 2 Nurses per shift would be a tremendous help. If this is true then I just don't see why it isn't being done. I percentage wise, how badly would this hurt most hospitals bottom lines?

This, I believe, is the gorilla in the room in this discussion.

Studies have demonstrated that the risk of the patient for poor outcomes is increased each time they experience a poorly staffed nursing shift while hospitalized.

The education of the nurse MAY affect outcomes, but staffing shortages DO affect outcomes.

[PMFB-RN, RN]

In terms of clinical experience, there's a reason my hospital stopped hiring BSN new grads for two years. While all RN graduates in state need the same number of clinical hours, not all clinical hours are equal. BSN programs often struggle with limited clinical placement opportunities as compared to more dispersed ADN programs, as a result it's not unusual for ADN grads to come out of school closer to being able to take a full load. That's not an observation specific to my Hospital, from an online article "Diploma and Associate Degree RNs will clearly tell you that they can run rings around BSN program graduates when it comes to patient care. Theyll explain that they have more actual clinical experience and patient care know how in their little finger than a new BSN grad, and 99% of the time theyre right about that!" It may just be a myth, but it's a frequently stated myth. As an aside, I don't think time-to-full-load is all that important, potential to progress should be more important.

*** Here in Wisconsin the public ADN programs are 1 plus 1. That means that after a student finishes the first year of the ADN program they are eligible to take the NCLEX-LPN. Most will do so and then work full time over the summer as LPNs and then continue part time LPN during the last two semesters of the nursing program. So it is not unusual at all for a brand new ADN RN to have nearly a year of LPN experience. There are plenty of LPN jobs around here. Mostly in LTCs, but also med-surg jobs in rural critical access hospitals. Many already worked in these small hospitals and LTCs as CNAs, continued for a year of LPN work and are then hired as RNs in the same hospital. The oppertunity to gain valuable nursing experience working as an LPN is not an option for the BSN program students. There are several small hospitals and LTCs in the area that offer Scholarships for their CNAs & LPNs to attend the very inexpensive ADN programs (around $6-7K total) at the public schools.

Not hard to see who is going to initially be the more competent bedside RN,though I suspect that a couple years out there may be little difference between them.

I serve as an instructor in my hospitals nurse residency program. These new grads who have a year of LPN experience have got their priortization and time managment down pat the first week of residency clinical and are ready to hit the ground running. They have already called physicians in the middle of the night to report changes in patient condition, the know the meds (at least the PO ones) well, they have given and taken report hundreds of times, the have preformed chart checks, signed off orders, dealt with lab and pharmacy, dealt with patients, their families and physicians, they have managed a full patient assingment , honed their assessment skills, likely had a chance to at least observe a code, maybe have preformed CPR and a thousand other basic nursing tasks.

I am sitting here with the local weekly shopper covering a 4 county area and count 7 listings for LPNs. 2 at a hospital, 4 at nursing homes, and one at aclinic. Many of these places would love to hire an LPN knowing s/he will soon be an RN.

[MunoRN, RN]

There were a limited number of these 1 plus 1 programs in my state until a few years ago. The problem became that these programs required usually more than 1000 hours of experience as an LPN prior to starting the RN portion of the program. As LPN jobs became scarce many of these students were unable to get their 1000 hours in and were having to start over in a direct ADN or BSN program.

[MunoRN, RN]

...I actually yearn for the day that this argument ends and there is finally a consistent entry level into nursing. I miss the days of respect for the kind of nurse you are and not the kind of nurse that has many degrees...

I think it's unfortunate that there's essentially a civil war among RN's, particularly since most of it seems to be based on a concerning lack of knowledge about what the differences actually are.

I think we're already pretty close to a standardized level of entry when you look at curriculum, the name itself of the degree is becoming the main difference. There are two consortiums in my state where ADN and BSN programs have combined, you can take your BSN OB Nursing class at the CC with ADN students, and ADN students can take the same class at the University campus, it's all interchangeable. I'm not convinced that a BSN student and an ADN student are getting significantly different educations when they're sitting next to each other the same classes.

I had a BS in Biology before getting my BSN, so I'm all for upping our educational requirements if for no other reason than to justify my time and money spent on 2 BS degrees. Although I think we've failed to control our own destiny in this regard and as a result we've been taken advantage of to some degree. There's little difference in curriculum between an accelerated BSN and an ADN, except the BSN might cost $85,000 while the ADN is usually less than $10,000. If we figure the average career of a Nurse is 25 years (which is generous considering more than half of Nurses are now "second career"), that's a pay cut of $3,000 per year for the BSN. I really don't believe the idea that we'll get paid more since we already have both ADNs and BSNs in the marketplace, if employers were going to pay BSNs more then we'd already being seeing that, instead employers might pay another $1 an hour and often pay nothing more at all.

[PMFB-RN, RN]

There were a limited number of these 1 plus 1 programs in my state until a few years ago. The problem became that these programs required usually more than 1000 hours of experience as an LPN prior to starting the RN portion of the program. As LPN jobs became scarce many of these students were unable to get their 1000 hours in and were having to start over in a direct ADN or BSN program.

*** Not the case here. There is no requirement for the students to take the NCLEX-LPN but it is encouraged, if for no other reason than as practice for the NCLEX-RN. I am under the impression that the majoriety do take it and work as LPNs.

[IndiCRNA]

Of the 18 people in my CRNA graduating class 12 (including me) started their nursing career as associates degree RNs. A number of them decided to do an associated degree program since it can be a faster path to CRNA school as compaired to traditional BSN programs.

[kcmylorn]

We also have 3 year BSN programs, Chaplain college offers one, it's 1 year of pre-reqs (A&P, micro, Psych, math, etc) and 2 years of the program. Of course this is completely different from an ADN program, which is 1 year of pre-reqs and 2 years of program.

Saying a BSN is better than an ADN doesn't make as much sense when you put it another way; 1 year of pre-reqs and 2 years of program is better than 1 year of pre-reqs and 2 years of program.

Of course Chamberlain's program isn't exactly the same as ADN programs; it costs $85,000.

$85,000 HOLY CRAP!!!

[kcmylorn]

I think it's unfortunate that there's essentially a civil war among RN's, particularly since most of it seems to be based on a concerning lack of knowledge about what the differences actually are.

I think we're already pretty close to a standardized level of entry when you look at curriculum, the name itself of the degree is becoming the main difference. There are two consortiums in my state where ADN and BSN programs have combined, you can take your BSN OB Nursing class at the CC with ADN students, and ADN students can take the same class at the University campus, it's all interchangeable. I'm not convinced that a BSN student and an ADN student are getting significantly different educations when they're sitting next to each other the same classes.

I had a BS in Biology before getting my BSN, so I'm all for upping our educational requirements if for no other reason than to justify my time and money spent on 2 BS degrees. Although I think we've failed to control our own destiny in this regard and as a result we've been taken advantage of to some degree. There's little difference in curriculum between an accelerated BSN and an ADN, except the BSN might cost $85,000 while the ADN is usually less than $10,000. If we figure the average career of a Nurse is 25 years (which is generous considering more than half of Nurses are now "second career"), that's a pay cut of $3,000 per year for the BSN. I really don't believe the idea that we'll get paid more since we already have both ADNs and BSNs in the marketplace, if employers were going to pay BSNs more then we'd already being seeing that, instead employers might pay another $1 an hour and often pay nothing more at all.

The average career of a nurse is 25 years????!!!!! Is that why us who have been a nurse for 32 years can't get a job? Munro, where did you hear this???Is this true???

I knew it- it's soup kitchens and homeless shelters for us What are we supposed to do when we aren't near 65 yet? those of us who had our RN's at age 23and it's 32 years late?

[MunoRN, RN]

$85,000 HOLY CRAP!!!

Chamberlain College of Nursing's Bachelor of Science in Nursing (BSN) degree program enables students to earn their BSN degree in as few as three years of year-round study instead of the typical four years.