Across the United States, nurses everywhere are facing a dilemma. Many registered nurses came into the profession through the two-year degree, or Associate’s Degree in Nursing (ADN). The ADN allowed them to sit for boards and have all the rights and privileges of any other registered nurse. Great nurses came from this program, but now all of that is in jeopardy.

The Bachelor of Science in Nursing (BSN) is now the preferred degree of a majority of hospitals. This degree requires four years of college study as opposed to the two required for an ADN. Nurses coming into the profession with an ADN can’t get a job and those who are working with an ADN are at risk of losing their jobs.

What’s So Great About a BSN, Anyway?

Part of the reason for the increased interest in BSN degrees is that hospitals are now required to have a certain percentage of four-year degree nurses to achieve Magnet status. This status is designed to draw more attention to the hospital and increase better patient outcomes.

“The American Nurses Credentialing Center (ANCC) devised the Magnet Recognition Program to draw attention to top health care facilities,” says Nancy Brook, RN, MSN, NP, a health and wellness coach and author of The Nurse Practitioner’s Bag. “This recognition means that 100% of the organization’s nurse managers have a BSN or graduate degree. Achieving Magnet status also means that there are generally a higher number of nurses holding a BSN degree for jobs in direct patient care. Approximately 50% of all nurses associated with direct patient care in a Magnet-recognized hospital currently have a BSN.”

In general, this designation increases the prestige of hospitals, and that means they are eager to comply with the strictures determined by the ANCC. It also means that those who have an ADN have to get a BSN or risk losing their jobs. Many hospitals will now no longer consider a nurse without a four-year degree.

“According to Magnet, increased professional development means increased proficiency in direct patient care, as well as more successful outcomes for patients,” says Brook. “Investing in BSN education means that an organization’s nurses are kept more up-to-date with the rapid evolution of newer technologies that are becoming more commonplace in hospital settings.”

Magnet status isn’t the only reason that ADNs are in the hot seat. Research has shown that patient outcomes are better when the nurse treating the patient has an advanced degree. In a 2003 study published in JAMA, Linda H. Aiken and her colleagues found a 10% increase in the proportion of hospital staff nurses with baccalaureate degrees is associated with a 5% decline in patient mortality following common surgical procedures. A 2008 follow-up study published in the Journal of Nursing Administration confirmed that BSN-prepared nurses improve patient outcomes.

Why are these numbers showing that the BSN is superior? Isn’t a nurse a nurse? Not necessarily. “You want someone to have a bachelor’s degree,” argues Wendie A. Howland, MN, RN-BC, CRRN, CCM, CNLCP, LNCC, a legal nurse consultant and owner of Howland Health Consulting. “They get a better education. They learn more things. They get classes like psychology. Trying to get full semesters of some of these specialties is impossible in two years. I know a lot of diploma nurses who can’t do an assessment. They don’t think like nurses. They do tasks and follow orders. They don’t realize scope of what you can do as an RN. Nursing is not what you do with your hands. It has to do with the nursing plan of care. Task-focused programs like the ADN will not give you those skills.”

The ADN vs. the BSN

Many nurses feel that there is no difference between the ADN and the BSN. Nurses claim that the BSN is only for managerial work or that the same information is compressed into two years instead of four. Marilyn Stoner, RN, PhD, explains the difference: “The additional coursework for BSN focuses on four primary areas: research/evidence-based practice, community/public health, leadership, and nursing science in the form of theories and models that guide practice.” With this additional teaching, the BSN is far more than just an expanded ADN. It is a different animal, and now hospitals are seeing it as superior due to the research studies.

For reasons such as these, the profession is changing. The studies and the relative lack of education in an ADN program are making the designation untenable in the hospital. “Nursing experts and national organizations agree that a registered nurse (RN) needs at least a baccalaureate degree to meet these demands, “says Melissa DeCapua, DNP, PMHNP, a health care adviser for telenursing startup PointNurse. “In 2010, about 50 percent of RNs possessed a bachelor’s degree. Since then, both the Institute of Medicine (IOM) and the Robert Wood Johnson Foundation (RWJF) have developed initiatives to increase this number to 80 percent by 2020.”

But, nurses say, what about experience? Surely experience should count for something and add to a nurse’s worth, regardless of title or degree. A nurse of 20 years with an ADN is a better nurse than one with five years’ experience and a BSN.

Not necessarily, argues Howland. “Experience gives you a better conceptual framework, and it makes it easier to learn more stuff,” she says. “Experience is helpful, but it is only part of being a professional. You have to have both education and experience. Education helped me get the most out of my experience and to ask better questions.”

What should a nurse do if they are at the end of their careers and suddenly facing the need to convert to a BSN? Stoner recommends that, “. . . [N]urses who have less than 5 years to work seriously consider whether it is worth the significant investment in time, money, and disruption to their lives to return to school. I also recommend nurses consider whether their employers will contribute toward the cost of their education and raise their salary once the degree is completed.”

For some, it isn’t worth the time and money. Some facilities are grandfathering in nurses who are close to retirement, but not all. In fact, many experts disagree with this practice, insisting that all nurses have their BSN regardless of age for the sake of the patient’s safety and outcome.

It seems unfair that nurses have to pay for the privilege of having an advanced degree when they are being forced to get it. To work as a nurse, you need to go to school, and that’s almost an ultimatum. It is certainly not the way to make nurses appreciate their facility or their job. When asked to pursue something that may not be in your plans or risk being fired, the nurse gives up the right to make his or her own decisions. It also means a large outlay of money, putting the nurse into debt.

“If you want to be a nurse, then you have to plan for the loans,” says Howland. “You have to do what it takes to be a nurse. If that involves taking out loans, if it is going to cost money, then you will have to pay it back. You have to realize how much you have to know and do. You are paying all of this money and you can make a difference in people’s lives because of it.”

Easy to say when the money isn’t coming out of the pocket of the hospital, although many facilities do have scholarships for those who pursue higher education. They also tend to get paid more. Unfortunately, these measures do not cover the entire cost of pursuing a BSN, and the nurse will still have to sustain some debt to continue working in the profession.

Looking Ahead

In the end, it comes down to professionalism. The ADN nurse is a professional to a degree, but a BSN nurse is now considered the gold standard of professionalism. Would you want someone to work on your loved one who doesn’t have the best degree possible?

Howland has some final thoughts on what it means to be a professional: “Sure, there are good people with lower level education who succeed in life, but don’t let that ‘we all have the same license and sit for the same exam’ fool you. Better education makes you better at what you do. There are any number of people who can give you examples of BSNs or MNs who don’t know how to take a rectal temp and marvelous crusty old LPNs who saved the resident’s butt one dark and stormy night, but for every single one of those, I will see your anecdote and raise you half a dozen godawful errors made by nurses who didn’t take the coursework and didn’t get exposed to the idea of autonomy in school.”

Many ADN nurses will disagree with these experts, and that’s to be expected. Some diploma nurses are still working hard at the bedside, and to hear they aren’t good enough is insulting. Unfortunately, the tide is changing to an all BSN nursing workforce. Despite the awesome nurses out there who have a diploma or an ADN, the accrediting bodies and the facilities will demand the BSN. Does it really make a difference? There are studies pointing to the fact that patient outcomes are better with BSNs, but none that really examine how patients fare when taken care of by an ADN with 20 years’ experience.

In the end, it feels like it is about the letters after a nurse’s name and not the care they give. Despite this dichotomy, this difference of opinion, this body of evidence, it seems the ADN cannot survive. If you are an ADN nurse, it is time to take a good, hard look at what your future means and what you are going to have to do to remain part of the profession.

Lynda Lampert

Lynda Lampert

Lynda Lampert, RN, has worked medical-surgical, telemetry, and intensive care units in her career. She has been freelancing for five years and lives in western Pennsylvania with her family and pets.
Lynda Lampert

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