Phasing Out ADN?

[Candi Williams]

Should We Hire ADNs? or Phase It Out?

The national nursing shortage has caused a crucial call for nurses. Nurses are a core part of the healthcare industry. They are the largest professional sector within the healthcare workforce and are essential to patient care. One solution to the nursing shortage is to hire Associate Degree in Nursing (ADN) graduates, but will the growing trend pushing for all nurses to have a Bachelor of Science in Nursing (BSN) for hire, phase out ADN programs? Let's bring to light the nursing shortage and the advantages and disadvantages of ADN and BSN degrees.

The growing trend in the healthcare industry pushing for all nurses to have a BSN degree for hire will not phase out ADN nurses anytime soon. The demand for nurses is too high. Approximately 40 percent of new nurse graduates earn their degrees from associate degree programs. An advantage of ADN programs is bringing new nurses into the workforce sooner. ADN programs prepare students to take the NCLEX-RN exam and become Registered Nurses (RN) in two to three years versus four-year BSN programs.

Why ADN?

ADN programs are more appealing to many because of the low cost and shorter time frame it takes to become a Registered Nurse; it grants them the opportunity to start working as a nurse sooner. Being introduced into the nursing workforce sooner affords them income as a nurse and a chance to gain experience while pursuing a BSN degree. In 2010 the Institute of Medicine (IOM), now the National Academy of Medicine, recommended that 80% of registered nurses earn a BSN degree by 2020. As a result, medical institutions prefer to hire nurses with a BSN degree or higher. Some institutions require a BSN degree for hire, and if they hire a nurse with an ADN, a condition of employment is earning a BSN degree within a certain length of time.

Why BSN Degree or Higher?

Better Pay

Nurses with BSN degrees have the possibility to generate higher income compared to those with ADN degrees. They can obtain positions offered to nurses who hold BSN degrees or higher. These positions come with more responsibilities and higher pay—positions such as managers, administrators, and educators.

Improve Patient Care

Research has shown that medical institutions that have a higher percentage of qualified BSN nurses on staff deliver quality patient care. They contribute to decreased medication errors, better patient outcomes, lower hospital-acquired infections, decreased mortality rates, and a decline in failure-to-rescue rates.

Magnet Certification

Healthcare organizations have begun seeking nurses with higher education and aspire to Magnet Certification. A major requirement for earning certification is the educational level of the nurses on staff. The higher the percentage of nursing staff with a BSN or greater, the better their chances are of Magnet certification. Magnet Certification yields outstanding nursing processes with notable quality, safety, and patient satisfaction.

Ramifications of Nursing Shortage

Discussions about concerns over the nursing shortage were taking place prior to the Covid-19 Pandemic. The Bureau of Labor Statistics predicted a shortage of over one million registered nurses by the year 2022. Cutbacks in nursing are attributed to one of the reasons for the shortage. Nurses fall victim to reductions in labor costs because they make up the largest labor force in the healthcare industry. Those reductions are decremental to the safety of patients and nurses. Another cause for the shortage is not enough educators. Nursing programs routinely turn down applicants because they have a limited number of nursing educators to train them. Other causes for the shortage are nurse burnout, an increase in the aging population, and an aging workforce.

Covid-19 escalated the nursing shortage. Covid caused an increase in patient volume, a rise in nurse burnout, early retirement from nurses who were close to retirement, and nurses leaving the profession altogether.

Nursing shortages give rise to medication errors, patient falls, increased morbidity, and increased mortality rates. When organizations lack appropriate staffing levels, the patient-to-nurse ratio is higher. This leads to nurse burnout and discontent. A suitable amount of nursing personnel reduces errors, increases patient safety, improves patient satisfaction, and enhances nurse retention.

Healthcare organizations, nurse leaders, and government officials must devise solutions to the nursing shortage. They must strive to engage and keep nurses. Retention of nurses brings about quality nursing care, improved patient care, and patient satisfaction.

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References/Resources

ADN vs BSN Debate: These Are the Real Differences Between ADN and BSN Prepared Nurses: Nightingale College

The Staffing Shortage Pandemic: Journal of Radiology Nursing

Are ADN & ASN Programs Needed to Meet the Nursing Shortages at Hospitals?: Advocate Search Group

Nursing Workforce Challenges in the Postpandemic World: National Library of Medicine

Nursing Fact Sheet: American Association of Colleges of Nursing (AACN)

Nursing educators: Stress the importance of a BSN in nursing, your students will thank you: Wolters Kluwer N.V.

Nursing Shortage: (Stat Pearls) National Library of Medicine

Reaching beyond 80% BSN-prepared nurses-One organization's journey to success: Nursing Management

[subee, MSN, CRNA]

Asystole RN said:

I agree with you that there should be different board exams. 

I disagree about the shortage however. I think there is a potential shortage in the future but I have not seen great evidence for an existing shortage. 

Proponents of the shortage cite an aging population and aging nursing workforce, while true, this does not seem to have panned out in current hospital admission rates. Excluding the x-factor event of COVID, hospital admission rates up to 2019 have largely been rising at low single digits, largely only equaling admissions in the early 80's. 

It is true that we should expect higher rates of admissions in the future we should also keep in mind healthcare has greatly improved with an increase in preventative care and an incredible increase in ancillary and tertiary care. The variety of care and the use of technology has greatly influenced healthcare. I am not certain, at least I have not read great rationales, as to why there is/will be a shortage. 

While hospitals are struggling with filling positions salaries have largely been stagnant over the past 1-2 decades and working conditions if anything have decreased, all the while organizational profits have increased. I have recruiters calling me hiring for positions that pay LESS than what I was paid as a new grad over a decade ago. 

There is a strong desire for hospital, medical, and yes even nursing associations (largely run by corporate nursing leaders) to scream there is a shortage. If they can significantly increase the supply of nurses they can reduce compensation. Adequate supply means they have to keep up with inflation at least or else nurses will look for alternatives to the hospital bedside for inflation standard compensation. 

My biggest source of evidence that there is no shortage is that if there was we would see a significant increase in compensation and benefits for nurses as the demand remains the same or increases as patients increase. I am not aware of anywhere in the country where bedside nurses are reporting significant compensation increases, let alone keeping up with inflation. 

We just put a  bid on a house that we would rent to the hospital to house travelers so we aren't experiencing adequate staffing here.

[Asystole RN]

toomuchbaloney said:

MDs seized professional power and nurses did not.  MDs are largely esteemed by hospitals based upon profit generated and reputation within the community.  

The supply has almost always exceeded the demand because the demand has, for very many years, been below what the data says it should be.  That's the chronic understaffing.  What was normal pre-pandemic was nurses accepting unsafe staffing levels because (fill in current budget or admin concern). Now post pandemic, there's some expectation that you will work harder than you worked in 2019 but it's not as bad as 2000 so you should be good.  

Until nurses organize themselves AND we step away from this failing profit focused health system the trends won't change in favor of nurses. 

Personal seizure of power has very little to do with scarcity other than power is an output of scarcity. When something is scarce it can demand power. Power and compensation are nearly the same thing, different elements of the overall benefits of being a scarce resource. 

[Asystole RN]

subee said:

We just put a  bid on a house that we would rent to the hospital to house travelers so we aren't experiencing adequate staffing here.

Adequate staffing according to who? Of course not the nurses. 

If the hospital leadership, in particular the CFO, thought there was a scarcity of nurses they would increase the overall compensation package for nurses to increase recruiting and retention. 

Hospitals never want to be 100% staffed. Similar to turnover, you never want 0% turnover. There is a certain balance that is struck and you always want to err on the side of slightly too few staff. Staff is a reoccurring cost that is not as flexibly adjusted as travelers. You always want a certain percentage of travelers, per diems, etc., its a balance. 

Unless you are seeing retention bonuses, increased hiring bonuses, and overall salaries greatly increasing you are likely sitting in the CFO's sweet spot. 

[toomuchbaloney]

Asystole RN said:

I 100% agree with you that they have been underpaying nurses for decades and overworking them. This is a reflection of a supply of nurses that meets or exceeds demand. 

As someone who travels the world assessing healthcare professionally I would partially disagree about the quality of healthcare. Too complex of an issue to cite a "best" but we are the best in many factors (by default) but worse in many other factors. I can speak for ages about quality of healthcare between different countries but your point is taken. 

I love that you say nurses were only paid more when it is a crisis! Its true! Scarcity of resources in action! Evidence that there is no shortage of nurses. 

We are a divided profession and unfortunately we are victims of a sustained propaganda campaign by those wishing to profit off an excess of nurses (schools, hospitals, healthcare organizations, etc). 

In which measured health outcomes is the USA #1? 

Only those content with current workload and nursing unit staffing feel that there are to many nurses.  I have yet to work on or be a patient in an acute care nursing unit that employed adequate staff to cover illness, vacations, LOA, etc.  The normal is to expect nurses to work more because of normal staffing patterns that administration just doesn't want to hire staff to cover.  

https://www.commonwealthfund.org/publications/issue-briefs/2023/jan/us-health-care-global-perspective-2022

Quote

Highlights

Health care spending, both per person and as a share of GDP, continues to be far higher in the United States than in other high-income countries. Yet the U.S. is the only country that doesn't have universal health coverage.

The U.S. has the lowest life expectancy at birth, the highest death rates for avoidable or treatable conditions, the highest maternal and infant mortality, and among the highest suicide rates.

The U.S. has the highest rate of people with multiple chronic conditions and an obesity rate nearly twice the OECD average.

Americans see physicians less often than people in most other countries and have among the lowest rate of practicing physicians and hospital beds per 1,000 population.

Screening rates for breast and colorectal cancer and vaccination for flu in the U.S. are among the highest, but COVID-19 vaccination trails many nations.

 

[Asystole RN]

toomuchbaloney said:

In which measured health outcomes is the USA #1? 

Only those content with current workload and nursing unit staffing feel that there are to many nurses.  I have yet to work on or be a patient in an acute care nursing unit that employed adequate staff to cover illness, vacations, LOA, etc.  The normal is to expect nurses to work more because of normal staffing patterns that administration just doesn't want to hire staff to cover.  

https://www.commonwealthfund.org/publications/issue-briefs/2023/jan/us-health-care-global-perspective-2022

 

Well lets take something specific we can measure like CLABSI (or any of the other alphabet health metrics).  

Up until about 2 years ago we were the only country in the world that mandated CLABSI reporting and publicly published those rates. The other country which recently adopted it was Australia. Most hospitals in most countries do not believe they have any infections related to catheters, something with a 25-50% mortality rate. 

I was in a European hospital (top tier country and facility) that was large and fancy a bit ago. This hospital had never recorded an SSI, ever. I walked by a case where they had a child's skull open (head trauma of some kind) along with my colleagues in all street clothes while they operated on him literally in the hallway because the OR was so small anesthesia was the only one who could fit. I was within arm's reach of touching the inside of his skull, along with all of the other random people walking down the hall. No history of SSI. Primarily because they did not track or report SSI.

Did you know many countries do not count mortalities from children up to 1 year of age in their mortality reports? You know, because babies just naturally die? Whether you count sub 1 year olds or not makes a big difference on country level mortality rates. Did you know many countries consider someone over the age of 60-70 (varies upon the country) who dies, regardless of cause, to have died of old age (or other similar local terminology)? Hard to compare outcomes when people are playing games with what they will and will not track.

There are many, many countries with amazing healthcare but honestly it is very hard to tell when no one is tracking and reporting outcomes and when they do, how they measure those outcomes may vary. Thats why I say the U.S. wins by default in some areas because the U.S. will actually track and publicly report certain elements of healthcare and is open about it. We are far from perfect but at least we do not hide that fact. 

Believe it or not but the U.S. healthcare system is looked up to in most of the world. Most of the standards and guidelines, along with research, comes out of the United States. 

(We're getting off topic here but I can literally write a book about the differences of healthcare around the world, how Latin America differs from Canada, how the UK differs from Germany, how China differs from Thailand, etc.) Things are very different on the ground. 

[toomuchbaloney]

Asystole RN said:

Well lets take something specific we can measure like CLABSI (or any of the other alphabet health metrics).  

Up until about 2 years ago we were the only country in the world that mandated CLABSI reporting and publicly published those rates. The other country which recently adopted it was Australia. Most hospitals in most countries do not believe they have any infections related to catheters, something with a 25-50% mortality rate. 

I was in a European hospital (top tier country and facility) that was large and fancy a bit ago. This hospital had never recorded an SSI, ever. I walked by a case where they had a child's skull open (head trauma of some kind) along with my colleagues in all street clothes while they operated on him literally in the hallway because the OR was so small anesthesia was the only one who could fit. I was within arm's reach of touching the inside of his skull, along with all of the other random people walking down the hall. No history of SSI. Primarily because they did not track or report SSI.

Did you know many countries do not count mortalities from children up to 1 year of age in their mortality reports? You know, because babies just naturally die? Whether you count sub 1 year olds or not makes a big difference on country level mortality rates. Did you know many countries consider someone over the age of 60-70 (varies upon the country) who dies, regardless of cause, to have died of old age (or other similar local terminology)? Hard to compare outcomes when people are playing games with what they will and will not track.

There are many, many countries with amazing healthcare but honestly it is very hard to tell when no one is tracking and reporting outcomes and when they do, how they measure those outcomes may vary. Thats why I say the U.S. wins by default in some areas because the U.S. will actually track and publicly report certain elements of healthcare and is open about it. We are far from perfect but at least we do not hide that fact. 

Believe it or not but the U.S. healthcare system is looked up to in most of the world. Most of the standards and guidelines, along with research, comes out of the United States. 

(We're getting off topic here but I can literally write a book about the differences of healthcare around the world, how Latin America differs from Canada, how the UK differs from Germany, how China differs from Thailand, etc.) Things are very different on the ground. 

Our outcomes are not looked up to around the world when we pay 18% of our GDP for a system that doesn't even provide basic primary care for all citizens.  

In my view, your opinion is in conflict with the data.  

You didn't answer my question.  In which measured health index are we #1?

https://www.healthsystemtracker.org/chart-collection/quality-u-s-healthcare-system-compare-countries/

[Asystole RN]

toomuchbaloney said:

Our outcomes are not looked up to around the world when we pay 18% of our GDP for a system that doesn't even provide basic primary care for all citizens.  

In my view, your opinion is in conflict with the data.  

You didn't answer my question.  In which measured health index are we #1?

https://www.healthsystemtracker.org/chart-collection/quality-u-s-healthcare-system-compare-countries/

CLABSI. We are #1 in CLABSI (and pretty much every other alphabet metric). CLABSI/CRBSI/CABSI is something that is a very specific, global, and directly related to the care provided in acute healthcare.

Tell me, what foreign owned and managed standard or guideline do you follow? Can you honestly name one without Googling? Don't you think that is strange? Pretty much every American standard or guideline (in that speciality) is followed around the world (where they follow standards or guidelines). In school, what percentage of studies did you read that were foreign published? 

You must have been exposed to a variety of foreign born providers, when providers are looking to train, what are the top 5-10 facilities in the world you hear about? Think about what they say/said. Don't take my word for it, ask your foreign born colleagues. 

I say this stuff as being someone who professionally spends significant time throughout the year in hospitals all around the world. The U.S. is far from perfect but it isn't garbage, that's for sure, and in many areas it leads. 

[toomuchbaloney]

Asystole RN said:

CLABSI. We are #1 in CLABSI (and pretty much every other alphabet metric). CLABSI/CRBSI/CABSI is something that is a very specific, global, and directly related to the care provided in acute healthcare.

Tell me, what foreign owned and managed standard or guideline do you follow? Can you honestly name one without Googling? Don't you think that is strange? Pretty much every American standard or guideline (in that speciality) is followed around the world (where they follow standards or guidelines). In school, what percentage of studies did you read that were foreign published? 

You must have been exposed to a variety of foreign born providers, when providers are looking to train, what are the top 5-10 facilities in the world you hear about? Think about what they say/said. Don't take my word for it, ask your foreign born colleagues. 

I say this stuff as being someone who professionally spends significant time throughout the year in hospitals all around the world. The U.S. is far from perfect but it isn't garbage, that's for sure, and in many areas it leads. 

Yes, we have great schools and wonderful technology and it is providing us with lower life expectancies and terrible outcomes in the vast majority of the measured areas.  What are our maternal morbidity and mortality rates? How do we compare in overall access or affordability? How do our treatment outcomes compare? I mean, we do better in immediate hospital care of MI patients but we have more hospitalizations for poorly managed cardiac care.  

I presented citations which outline the metrics and comparisons.  Your opinion seems to be in conflict with the data. 

[Asystole RN]

toomuchbaloney said:

Yes, we have great schools and wonderful technology and it is providing us with lower life expectancies and terrible outcomes in the vast majority of the measured areas.  What are our maternal morbidity and mortality rates? How do we compare in overall access or affordability? How do our treatment outcomes compare? I mean, we do better in immediate hospital care of MI patients but we have more hospitalizations for poorly managed cardiac care.  

I presented citations which outline the metrics and comparisons.  Your opinion seems to be in conflict with the data. 

Access and affordability, preventative care, etc. are more related to overall  system/political issues which encompass things like education, income per capita, etc. I am speaking about specific hospital to hospital metrics, you know things that a specific patient would be concerned about. I am personally not concerned about geopolitical issues. 

How do you normally compare a hospital to another hospital? I doubt you are comparing community obesity rates, access, etc. 

How does the U.S. stack up in terms of surgical site infections? Central line associated bloodstream infections? Catheter associated urinary tract infections? Ventilator associated pneumonia? You know, the specific clinical items that a given hospital has the ability to control. 

You are right though that the U.S. healthcare system is a mess but we have very good care when to comes to many clinical items. Again, I am not saying U.S. healthcare is "the best" (whatever that means) overall, but objectively there are many clinical items in which we really are the best. 

[toomuchbaloney]

Asystole RN said:

Access and affordability, preventative care, etc. are more related to overall  system/political issues which encompass things like education, income per capita, etc. I am speaking about specific hospital to hospital metrics, you know things that a specific patient would be concerned about. I am personally not concerned about geopolitical issues. 

How do you normally compare a hospital to another hospital? I doubt you are comparing community obesity rates, access, etc. 

How does the U.S. stack up in terms of surgical site infections? Central line associated bloodstream infections? Catheter associated urinary tract infections? Ventilator associated pneumonia? You know, the specific clinical items that a given hospital has the ability to control. 

You are right though that the U.S. healthcare system is a mess but we have very good care when to comes to many clinical items. Again, I am not saying U.S. healthcare is "the best" (whatever that means) overall, but objectively there are many clinical items in which we really are the best. 

If we have very good care, why the bad numbers in things like maternal morbidity and mortality? 

Can you provide me with some data?

025 (1).pdf

[MaxAttack, BSN, RN]

Asystole RN said:

We are #1 in CLABSI

Asystole RN said:

Up until about 2 years ago we were the only country in the world that mandated CLABSI reporting and publicly published those rates. The other country which recently adopted it was Australia. Most hospitals in most countries do not believe they have any infections related to catheters, something with a 25-50% mortality rate. 

I really appreciate the nationalism - being American myself - but saying we're number one in something that essentially only we report is kinda funny, right?

And to be honest, wherever you're at sounds miserable. Base rates haven't increased in a decade and there's a 25-50% mortality rate for CLABSIs? As a provider or a patient, I'd be moving. 

Regarding research and guidelines, I reference European guidelines frequently alongside those from here. If you look at the references within our guidelines you'll see we reference other countries quite often and vice versa. I like getting different perspectives even though it's usually a similar evidence base. 

Off the top of my head and something probably anyone in acute care would know of, the Surviving Sepsis Campaign is a collaboration between European and American critical care groups. It's easy to see us in a bubble but I have to give credit where it's due.

[subee, MSN, CRNA]

toomuchbaloney said:

If we have very good care, why the bad numbers in things like maternal morbidity and mortality? 

Can you provide me with some data?

025 (1).pdf

I will interject here to say that the protoplasm we bring to providers contributes to the health statistics.  I think you and Asystole are talking about two different things.  The poorest southern states have the highest rates of diabetes.  Is that because of economic status or because of a lack of providers or because of a lack of education and poor food choices?  IMHO, it's a mix of both and these are variables that occur before a patient even comes into the system.  Asystole is giving stats for conditions that arise in hospitals.  The definition of quality in health care depends on what variables we are measuring and, in the end, means something different to each researcher.