1. Hader, Richard PhD, NE-BC, RN, CHE, CPHQ, FAAN

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The debate has raged for decades: What level of education should be required for professional nurses? As early as 1965, the American Nurses Association House of Delegates proposed a baccalaureate entry level. More than 45 years later, this issue still looms, despite the fact that our professional colleagues in disciplines such as physical therapy and pharmacy have implemented a doctoral level minimum requirement. This begs the question: Do nurse leaders believe educational preparation matters?

Figure. No caption a... - Click to enlarge in new windowFigure. No caption available.

To uncover opinions and beliefs about education, Nursing Management conducted a national survey of more than 2,800 nurse leaders from every geographic region in the country and Canada. Strikingly, only a small majority (56.4%) of us believe that the entry level into professional nursing practice should be at the baccalaureate level.


In October 2010, the Institute of Medicine published a report on the future of nursing, funded by the Robert Wood Johnson Foundation, in which it called for nurses to achieve higher levels of education and training through an improved education system that promotes a seamless academic progression.1 Although the nursing profession is one of the largest contributors to healthcare in the United States, it remains the least formally educated of all the health professions. Given the complexity of nursing science, coupled with the more acute and chronic health needs of an aging population, the report recommends that more nurses enter the workforce with a baccalaureate degree or complete the requirements for the degree as soon as possible.1


Despite recommendations from this report, 47.3% of us believe that the entry level into practice should be at the associate or diploma level of education. Interestingly, the older the respondent, the greater the preference for baccalaureate entry levels. Nearly 59% of you older than 55 and more than 62% of you older than 60 affirm that a BSN should be the minimal requirement.


All about you

Of our 2,868 respondents, 93.2 % are women, 87.1% are older than 45, and an overwhelming majority (83. 4%) are Caucasian. Seventy-seven percent of you have been in your current position for less than 10 years; 44.3% of you hold the position of nurse manager, director, or vice president; and a large majority (69%) of you have been in nursing more than 20 years. The largest percentage of respondents are from the East North Central region of the country (17.5%), followed by South Atlantic (16.9%), Middle Atlantic (15.3%), West South Central (10.3%), Pacific (9%), West North Central (8.2%), Mountain (7.2%), New England (5.5%), East South Central (4.7%), and Canada (1.8%). The remainder (3.7%) of you represents Greece, the Netherlands, the Philippines, the United Kingdom, Australia, Puerto Rico, Kenya, and Iran.


An overwhelming majority (72.8%) of you work in hospitals or health systems, followed by an academic or university setting (10.7%), with smaller percentages representing outpatient clinics, community home healthcare, and long-term, sub-acute, and rehabilitative care. More than 15% of you work in Magnet(R)hospitals, and an additional 21.9% of you are actively seeking this designation.


Notable numbers

Salaries ranged from less than $40,000 to $130,000 per year. Twenty-three percent of you earn between $90,000 and 120,000, whereas the majority (59.2%) of you earn less than $90,000; a minority (11%) of you earn more than $120,000. The highest reported regional salary was from the Pacific, where 44% of respondents earn greater than $100,000 per year, compared with the lowest paid region, East North Central, where the majority earn between $70,000 and $74,999 per year.


Men reported higher salaries than their female colleagues. Nearly 30% of male respondents earn greater than $100,000 per year, compared with 19.2% of the female respondents. Those of you who work in Magnet hospitals appear to be paid at a higher rate; 25% of you from Magnet facilities earn more than $100,000 per year, compared with your non-Magnet hospital colleagues, of which 18.9% earn greater than $100,000 per year.


The position you hold within your organization is definitely reflected in the amount you earn. Almost 61% of CNOs earn greater than $100,000 per year, whereas 45% of directors and 16.6% of nurse managers earn that amount. A small percentage (13.6%) of assistant nurse managers and 5.2% of supervisors earn greater than $100,000 per year.

Figure. What should ... - Click to enlarge in new windowFigure. What should the educational entry level be for managers?

Although a large majority of respondents (76.6%) believe that their organization doesn't economically incentivize them for holding a higher educational degree, educational credentials absolutely matter when comparing salaries. More than 47% of you with a doctorate degree earn greater than $100,000 per year, compared with those of you with a master's degree (26.3%), a BSN (15%), and an associate degree (10.1%).

Figure. Whats your l... - Click to enlarge in new windowFigure. What's your level of education?

National certification also significantly impacts earned income. More than 24% of you who are nationally certified earn more than $100,000 per year, compared with the 16% of non-certified nurses who earn more than $100,000 per year.


To what degree?

The largest majority (47.4%) of us have earned either a master's degree in nursing or a related field. Nearly 39% of us have earned a bachelor's degree, and 21% are educated at the associate or diploma level, with 4% at the doctoral level.


A higher educational credential is likely to afford us the opportunity for promotional advancement. Over 91% of responding CNOs hold a master's or doctoral degree, whereas 61.2% of the directors, 40% of the nurse managers, and 23% of the assistant nurse managers reporting in hold a graduate degree or above.


More nurse leaders in the South Atlantic region (53.9%) have earned a minimum of a master's degree in nursing or a related field. The lowest percentage (18.8%) of master's-prepared leaders lives in the West North Central region.

Figure. What percent... - Click to enlarge in new windowFigure. What percentage of your reports havea bachelor's degree or higher?

The more highly educated leaders work in hospital or health settings. Over 43% of the leaders in hospitals and health settings have earned a master's or doctoral degree; less than 1% of you who work in a sub-acute setting have equivalent credentials.


Magnet hospitals appear to either attract or require a minimum of a master's degree at the nursing leadership level. Over 63% of nurse leaders in Magnet- recognized facilities have earned a master's degree, compared with 57% of nurse leaders from non-Magnet settings.


The longer we work in the nursing profession, the greater the likelihood that we attain a higher educational degree. Sixty-six percent of us who've been in the profession more than 20 years have earned a master's degree or higher, compared with 43.8% who've worked for 11 to 20 years and 34% who have less than 10 years of tenure.


The higher degree that's attained correlates with a higher percentage of national certification. Of the respondents holding a master's or doctoral degree, 68% have also earned a national certification, compared with 33% who hold a bachelor's degree and 8.8% with an associate degree.

Figure. If you arent... - Click to enlarge in new windowFigure. If you aren't currently attending school for a higher degree and you would like to, what are the barriers?

Back to school

Twenty-six percent of us are currently attending school. Of this group, 42.5% are working to attain a master's degree in nursing, 4.8% a master's degree in business administration, 8.6% a PhD, 5.4% a DNP, and 19.7% a BSN. Over 20% are working toward the following degrees: EdD, MHA, MPH, DNS, DM, or post-master's certificates. It's evenly split between those going to school either full or part time.


Those of you returning to school report receiving encouragement primarily from yourselves (69.7%), followed by your colleagues (38.7%) and supervisors (28.5%). Many of you shared that your greatest source of encouragement is from family and friends.


Money is the largest barrier to returning to school. Seventy percent of respondents who want to go back for a higher degree can't because of financial concerns. Other barriers included family issues, lack of organizational support, time constraints, older age, and lack of financial incentive to attain the degree.


Several nurse leaders also expressed that more education isn't equivalent to better performance. As one respondent noted, "A degree isn't needed to confirm that I'm knowledgeable and competent in the role. Seems like a lot of bother to get one for the paper when negligible extra money is attached." Another responded shared, "I don't need a higher degree to be a better RN. We already have too many RNs who are full of theory."


So, who's footing the bill? Nearly three quarters of the organizations pay tuition reimbursement. The low range is $1,000 per year to a high of 100% of all costs. It appears that the average is between $2,500 and $5,000 per year. Over 93% of Magnet hospitals offer tuition remission versus 69.7% of non-Magnet hospitals. Over 82% of the employers in the South Atlantic region offer tuition reimbursement, compared with 65% in the Pacific region. Only 37% of responding Canadian organizations offered tuition reimbursement. And only 37.3% of the organizations provide scholarship support for those attending school for a higher degree in nursing or a related field.


Those organizations that offer tuition reimbursement have a higher percentage of nurse leaders who've attained a master's degree. Seventy-seven percent of those working in organizations that afford tuition reimbursement have attained a master's degree, whereas only 23% have attained a master's degree in organizations with no tuition reimbursement.


Implications for practice

Nurse leaders were asked two questions regarding their immediate supervisor's educational credentials: "Does your supervisor hold a higher degree than you do?" and "Is your supervisor certified?" Alarmingly, 62% of respondents don't have a higher degree than their direct reports nor are they nationally certified.


It's evident that nurse leaders aren't role modeling the importance of attaining higher degrees in nursing. Many of us are content with the status quo; sadly, we don't encourage our team members to return to school. Nearly half of us hold nursing leadership positions but don't have a master's degree either in nursing or a healthcare-related field. Of those who haven't achieved this level of education, a majority aren't returning to school.


It's also evident that the primary reason nurses aren't returning to school is related to economics. Salaries after receiving a higher degree don't typically raise, so many nurse leaders don't feel that the sacrifices of tuition costs and loss of personal time are justified.


The data suggest that employees of organizations that value formal degree attainment are more likely to return to school. A strong infrastructure both in tuition costs and organizational commitment and encouragement are necessary to promote a culture of continuing education.


Lastly, it's evident that a paradigm shift from skills training education to academic learning is necessary for nurses to remain current with new delivery systems, translation of evidence-based care into practice, and the implementation of appropriate treatment modalities.


As nurse leaders, we need to foster an environment of formal degree attainment. Advocating for tuition assistance, conducive scheduling, and programs that meet the needs of the adult learner will promote a more positive culture for higher education in nursing. Although the challenge at hand is daunting, we need to move ahead with strategic plans to elevate our education. Nurses at all levels should expect that they'll forever be students of nursing, accept this responsibly, and engage the challenge.




1. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. [Context Link]