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