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


Specializes in Critical Care. Has 10 years experience.

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.

ThePrincessBride, BSN

Specializes in Med-Surg, NICU. Has 5 years experience.

My big concern with making the BSN the new standard of entry is that I think result in a domino effect (i.e. making DNP the new requirement for Nurse Practitioners which I am thoroughly against this push). I would love to be an NP (eventually) but I'm not going to put myself through four or more years that a DNP might require. I could have gone to med school and make more than triple the amount and gain far more respect for it.

I'm currently in a BSN program and tbh, a lot of it is fluffy **** that isn't going to help someone be a better nurse. The amount these BSN programs are charging are too outrageous to justify, especially since most places don't pay BSN nurses anymore than the ADN prepared nurses. If "they" are going to raise the requirements to a college-degree, then they better raise the starting salary as well. Regardless of the "degree," a nurse has a person's LIFE in his/her hand's and therefore the pay needs to reflect that level of responsibility.

As for "second careers", there are accelerated BSN programs for that. But again, they charge WAY too much. I know nursing students who are going to be in over 30k in debt when it is all said and done.

What kind of committee was this? Was it a representative of your state's BON or the ANA? The findings you're posting here claim to be an investigation on Mrs Aiken's work, but I don't see any studies sourced. What gives?


Specializes in Telemetry. Has 1 years experience.

This is really interesting. I'm a BSN nurse, but I work w/ mostly ADN nurses. And they are great! They have to learn the same things that we do and take the same NCLEX. I think it's just a preference of learning styles, in my opinion.

and theprincessbride, you are right- in my state I'm already seeing it- you need to become a doctor of nursing to work as an NP (Rutgers for example).


Has 36 years experience.

I have always been concerned about who stays at the bedside. Why would someone pay 40 - 60 - 80 thousand dollars for a BSN to stay at the bedside working shifts, weekends, holidays? How many people are staying in 24/7 positions 10 years out?

Salaries have not kept pace with the cost of a quality education, and some nurses are finding their salaries are topped out at less than what they paid for their education. In other words, they may not ever make a yearly base salary of 60 grand even though they paid that or more for their education.

I am all for making BSN the requirement for entry to practice, but I think hospitals need to look at the education system. I am a second degree student. My first degree is a Bachelor's degree in Biology. By the time I decided I wanted to go back to school for nursing, the California State budget was a mess, and the California State University System was rejecting second bachelor applicants. (After two years of this policy, they decided to start accepting second degree applicants in Fall of 2012, but it is too late for me since I already graduated and have my RN license).Anyways, I was told that I could either go to a junior college and get an ADN, go to a private school for a BSN (anywhere from $40,000 to $70,000 for tuition alone), or try to get into a Master's entry program. I got into two private schools, but decided to be financially responsible and went to the junior college.

It is true that schools and their curriculum vary drastically. I took my pharmacology class over the summer at a community college with several other students taking the same class who were in a BSN program at California State University Long Beach.

Anyways, now I can't get a job. I would be fine with doing a one year RN-BSN. But the director of my nursing school said that the school district can't afford to do that, since they are still struggling with budget cuts. The State schools offer a year and a half RN-BSN that is full time, and it would be very hard to work full time. I really just need public health, critical care and research (I took leadership, pathophysiology, nutrition, health assessment 2 years of chemistry, statistics, etc, etc for my ADN and Biology degrees). But there is no school that will let me take just those courses and get a BSN.

If the BSN is to be the entry level requirement, I dont think that the middle class should be punished because they can't afford to go to a private school when the state schools are cutting their budgets.

MunoRN, RN

Specializes in Critical Care. Has 10 years experience.

What kind of committee was this? Was it a representative of your state's BON or the ANA? The findings you're posting here claim to be an investigation on Mrs Aiken's work, but I don't see any studies sourced. What gives?

We were formed under a consortium of public and private universities, community colleges, and the Department of Health (BON).

I only summarized the Review of Aiken (and others) work that was done, this review was completed by a subcommittee.

Her work is readily available and I would encourage you to review it if your interested. The initial purpose of the subcommittee was to determine the reason why BSN prepared Nurses produce better outcomes. Their attempts to drill down the cause of better outcomes produced some significant concerns with methodology.

brandy1017, ASN, RN

Specializes in Critical Care.

Thank you! It's a vindication for all of us ADN's out there doing the same job as a BSN. If the hospitals really want BSN's let them pay for them ie full tuition reimbursement, not a piddly $2,000 year!


Specializes in Psychiatry, ICU, ER. Has 4 years experience.

I have a MSN and am a nurse practitioner, but I also earned a BA before I became an RN. I worked for 3 years as an RN while obtaining my MSN.

I could never, and still can't, see what the big deal about having a BSN was/is. It's a freaking bachelor's degree, like every Tom, Dick, and Harry has these days... almost embarrassing that we as a profession are arguing about it.

Edited by apocatastasis

Not sure how true this is, but the College that I am currently working towards My ADN with claims that they have a significantly higher pass rate of the NCLEX than the 4 yr University's BSN graduates do. So I guess the real question would be "How accurately does the NCLEX test those entering the nursing profession?" If the NCLEX is a fair gauge of a new grads knowledge, then I would the imagine that the BSN would not be necessary for an entry level Nursing position. It MAY, however be necessary to pick up a management position...

Esme12, ASN, BSN, RN

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma. Has 40 years experience.

Thank you! It's a vindication for all of us ADN's out there doing the same job as a BSN. If the hospitals really want BSN's let them pay for them ie full tuition reimbursement, not a piddly $2,000 year!
Of course you do.....you all passed the same boards.

I have always felt that the BSN push was financially motivated.

thumbs20upoe4.gifThanks MunoRN!!!!

SummitRN, BSN, RN

Specializes in ICU + Infection Prevention. Has 8 years experience.

Without going on for 1000 words, OP's state is very different than my state on almost every point:

  • Significant prereq differences in BSN favor
  • Large GPA difference in BSN favor as BSN programs are merit based while nearly all ASN programs are minimum->waitlist admission
  • Slightly more to massively more clinical hours in BSN programs
  • Massive hospital BSN preference or requirement, especially for NG RNs
  • Major or exclusive preference for BSN students in clinical placement and internship offerings
  • Accelerated, traditional, and flexible BSN programs for professional and second career students
  • etc etc etc.

That said, I'd love to see how OP "properly" corrected Aiken's "failed" math and upon what OP based the correction factors?

Edited by SummitRN

CapeCodMermaid, RN

Specializes in Gerontology, Med surg, Home Health. Has 30 years experience.

The Massachusetts Nurses' Association does not support BSN as entry level....at least they didn't the last time I researched it. I went to a diploma/hospital based school and have never been denied a job because I don't have a BSN (I do have a BA but that's another story). I was asked once years ago to go to work for the VNA. When I told the woman who asked me I didn't have a BSN and all their ads said it was a requirement, she laughed and said "I'd rather hire nurse who knows what they're doing than hire someone just because they have 3 more initials." There is room in our profession for all levels of education. We all have to pass the same boards. I am in favor of education for all of us, but let's not deny someone a job because they can't quote Shakespeare or don't know where the Yangtzi River is.


Specializes in Peds/outpatient FP,derm,allergy/private duty. Has 33 years experience.

Not sure how true this is, but the College that I am currently working towards My ADN with claims that they have a significantly higher pass rate of the NCLEX than the 4 yr University's BSN graduates do. So I guess the real question would be "How accurately does the NCLEX test those entering the nursing profession?"

If ADN nurses were truly less safe practicing nurses BSN-only would certainly be the law in New York and Pennsylvania by now, and North Dakota wouldn't have repealed theirs, the onlyIf the NCLEX is a fair gauge of a new grads knowledge, then I would the imagine that the BSN would not be necessary for an entry level Nursing position.

It MAY, however be necessary to pick up a management position...

You bring an interesting point up here, because the concerned parties involved haven't proportionally weighed in to the degree the advocates of BSN laws have. The ANA has had over 40 years to convince state governments to change the law. The state is charged with keeping it's citizens free from harm, which they can do with zest when they are lobbied to death by a special interest group, like azar on your apples. I think it's fair to ask why they haven't, except for North Dakota, who repealed their law.

To the "entry-level" designation In it's original position paper, the ANA proposed that there be two categories of RN with separate scopes of practice - the "professional" RN and the "technical" RN. Since the NCLEX is still the same for both, there is no evidence-based way to separate the groups by adding questions only the BSN nurse is expected to know earn a separate designation and wider scope of practice.

We are all subject to the vagaries of the economy and public policy, and intangible judgments and beliefs. Aiken's conclusions (agree it's worth reading) haven't been proved or disproved, so it's possible there is a causal relationship. It's intuitive to believe more education = better. We need to know why and how before changing laws that would have such a profound impact on both the employee and the employer.

At the present time hospitals prefer BSNs because there is no nursing shortage, and intangibles are acted on just as hard facts are, so going for the BSN will benefit your job prospects and widen opportunities regardless. They just don't want their hands tied legally should the present situation reverse itself, when they don't see much risk with the ADN nurse, having around 60% of working RNs of recent years ADN nurses.

Edited by nursel56
bad eyesight typo


Specializes in OB.

I'm against BSN as an entry to practice. I'm not against getting a BSN in 10 years. I have never understood the uproar about it. 10 years is plenty of time. Community colleges are a cost effective way to get an RN license. I don't think that should be taken away.

Also, if every "Tom, Dick, and Harry has it these days", then I don't see what the big deal is. In many other professions, you need to get at least a bachelors and even a masters degreee. Nursing shouldn't get left behind.


Specializes in Pediatrics. Has 1 years experience.

The hospital I just signed on with requires a bachelors in 5 years. At their tuition reimbursement rate per year, it may take me 5 years to complete the one year program. After paying for my LPN and LPN to ADN programs out of pocket, I am very interested in having the rest of my education sponsored.

MunoRN- great post. I'm glad some one finally came out with stating an argument against the plausabilty of Akein's recommendation on BSN required. This has shut alot of us out of jobs and in an economy where so many people are going under financially which is making it even more unattainable for alot of us ADN/diploma nurses to get that BSN to get that job to keep the roof over our heads and food on the table. Yes, there are states in this country who have not jumped on this happy crap bandwagon and make BSN the starting requirement for "a Job" But there are states in this country who have! I happen to live in one and have another boardering along side of me which makes it impossible to get a job unless one wants to pull up roots and move to a state where an ADN/diploma can get a freeking job. And like already posted- that is not a relist tatic if one has a home( try selling your old home that needs expensive repairs in this housing market!!) and a bunch of kids in school and a husband with an immovable job. You all may be on the side of road with your pillows and blankets and a "HOMELESS" sign. That is reality!!! The average nurse doesn't have wiggle room for this frivolity of Akein's Ivy league educationals tastes in nursing requirements. Any one look up the cost of tuition in Akein's University of Pennsylvaina Nursing program lately??

I have said many times on this site that going back for a BSN is all nice, but if one doesn't have the financial means to do so than it remains a fantacy. Give the nurse a job first and then ask them to go and spend the money on an expensive education to keep you friends in academia employed! You can't get blood from a rock. A nurse on unemployment can not afford to forego the food on the table or the roof over the families head for college tuition!! That is pretty much common sense. And with the demands made in Akein's study, it pretty much apparent that woman never had a poor day in her life where she had to make such choices- how nice for her!!

I did an agency assignemnt yesterday and came in contact with a nursing supervisor in a LTC facility who stated the same thing I have been yelling about in this site for months- many nurses in this economy can not afford to go back to school for that BSN. So I know I am not alone in this sentiment.

To address the second point of Muno's post- I have sence gone back for my BSN on state aid through the help of unemployment because I cannnot afford it out of pocket.( and what is that doing to the economy Mr/Mrs MBA's) Can I honestly say that these BSN courses are making me a better nurse. NO. are they teaching me anything about Health Assessment I didn't learn in my diploma school and after 32 years of practice experience, NO! What am I learning? "APA format!!!" Which I know all my patients right after surgery and a good boust of diahrrea are really going to ask me about because it is vital to their "outcome"!!!! and eventual discharge to home. The APA police will be transporting them home. I have learned about the readiness of a system to begin a new telehealth program. Here is another must know for a patient who needs to get out of bed to go to the bathroom. if they can click the TV remote, their ready for that ambulation! but first I have to ask all on the unit if they agree a change is needed and then go to the providers and the organization to check and see what level of readiness they are at, because their readiness goals and that of the patient may be different. Happy BSN, ya'all.

tewdles, RN

Specializes in PICU, NICU, L&D, Public Health, Hospice. Has 31 years experience.

I have commented before that we have decades of evidence that demonstrates clearly that a BSN is not required to be a competent and effective bedside nurse.

Should professionals continue their education, surely.