1. Clarke, Sean P. PhD, RN, FAAN

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The top nursing credential for the majority of U.S. RNs is currently a baccalaureate degree or higher. Driving this movement are the Institute of Medicine's Future of Nursing report and the Magnet Recognition Program(R) requirement that healthcare organizations track progress toward a primarily BSN-educated RN workforce. In fact, recent commentators point out that if both entry-level baccalaureate and postassociate degree BSN programs are considered, the bachelor's degree is the most awarded nursing degree in the United States. And although the majority of new nursing graduates seeking RN licensure still come from associate degree programs, with each passing year, the proportion of entry-level NCLEX test takers moves closer to a 50-50 split. These developments are the source of much debate in the nursing field. Concerns about the shift toward the baccalaureate degree include its impact on gender, racial, cultural, and socioeconomic diversity in the profession.

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So, how do you manage the challenges of an evolving workforce? We discuss recent trends and research regarding the BSN to help you make the best use of baccalaureate-prepared nurses' knowledge and skills, and ease any tensions related to varying levels of education in the workplace.


Weighing in

Nurses have attended colleges and universities to obtain advanced training for specialized practice, roles, and responsibilities for almost a century. The modern controversy is over which education level RNs should be required to attain in preparation for licensure. Should basic RN education occur at the baccalaureate level, at the technical level, or at multiple levels? Also up for debate: Should a clinical nurse plan to earn a BSN even though the associate degree also currently leads to licensure?


Many professional nurses and others outside of the profession believe that nursing is a mobile occupation: A nurse should be able to move through a career from unlicensed assistive personnel to LPN or LVN to associate, baccalaureate, and even master's and doctoral degrees, building at each point in the education chain with the right to stop at any point. Opinions often mirror nurses' own career paths in the field. As a group, few associate degree educators question the value of baccalaureate education-becoming an educator in an associate degree program normally requires master's-level education-rather, they question whether the baccalaureate degree should be required as an entry-level credential or a near-mandatory rite of passage for RNs.


Although many in nursing support the idea of career mobility and articulation, by the turn of the millennium, many nurse executives began voicing a preference for a predominantly baccalaureate-educated RN workforce. In addition, healthcare organizations in major metropolitan areas are giving priority to hiring nurses with baccalaureate degrees-at least in terms of hiring new graduates.


Potential added value

For nearly a century, nurse leaders have pushed for a uniform level of entry into practice. A large contingent has also rallied for RN education to occur outside of hospital settings, claiming that it's difficult to juggle professional education with the pressing service needs within hospitals. For many years, it's been argued that a background in different academic fields enhances a student's nursing education. Indeed, many currently involved in baccalaureate education believe that a broader liberal arts and humanities education, along with a more rigorous science education, provides a stronger base for nursing careers.


However, there are considerable differences across BSN programs regarding how much content is required outside of nursing. And the debate remains as to whether associate degree science courses are any different in terms of credit requirements and content. Content areas not usually part of diploma or associate degree programs that are fundamental features of baccalaureate nursing education include formal exposure to leadership and management within the profession, nursing research, the use of evidence in practice, societal health concerns, and the notion of the community as a client of nursing services.


Although baccalaureate-prepared clinical nurses may not necessarily use all of this knowledge in a direct form, the content is felt to inform their practice, even when they hold similar positions to nurses who haven't completed baccalaureate programs. Some experts propose that baccalaureate graduates are better able to handle complexity and uncertainty in clinical care; show greater ability to exercise formal and informal leadership, including teamwork and quality improvement; and demonstrate enhanced communication skills and confidence in interacting with peers, colleagues, and leaders inside and outside of the profession.


Is a BSN really worth it?

Research groups working in the United States, Canada, and across several European countries have conducted nearly a dozen studies and found associations between a higher proportion of nurses holding a baccalaureate degree in a hospital or on a unit and better patient outcomes. Although it's tempting to conclude that these patterns are due to baccalaureate-educated nurses providing a higher quality of care, it's also possible that conditions favoring better patient outcomes may be more common in hospitals where there are more baccalaureate-prepared nurses. These conditions may include an attractive labor market, a range of higher education opportunities, and a better professional practice environment.


Research into nurses' practices, education levels, national certifications, and patient outcomes is now possible because of electronic health records. Early research suggests that patients cared for by baccalaureate-prepared nurses may have shorter lengths of stay and show steeper improvements in their health status during their hospital stays. However, no hard evidence currently exists as to the best combination of staff mix, RN education, and practice environment characteristics to achieve the best patient outcomes.


Several nagging questions about the educational backgrounds of RNs linger. If education is so critical to optimizing patient outcomes, why are RN job descriptions and salaries often so similar regardless of educational background? There has also been long-standing controversy over whether clinical nurses' education or experience is more valuable to patients, the profession, and the community. Of course, preferably it isn't an either/or choice. Ideally, nurses from all educational backgrounds mature within their jobs over time.


Although some facilities are working toward a professional practice model that assumes baccalaureate-prepared nurses will use their education to the fullest, in many settings nurses and managers, alike, feel that the clinical nurse job description and position expectations are mostly interchangeable, regardless of education. For this reason, questions emerge regarding whether the BSN is worth it.


Managing workplace tension

Today's nurse managers are dealing with workforce issues inherited from over 100 years of debate within the profession. However, we're rapidly approaching the point where the baccalaureate degree is becoming the dominant credential in our clinical settings. It's challenging to help clinical nurses translate a baccalaureate skill set into their daily work while not underplaying the importance of direct care. Finding ways to enrich clinical jobs with projects and roles that improve unit function and care standards is vital to helping RNs find meaning in their work. It's also important to ensure that nurses with baccalaureate level credentials spend enough time in positions to mature within them.


Having disproportionate expectations of relatively inexperienced nurses' clinical acumen when they haven't had opportunities to apply theory in practice, or pushing them to engage in quality improvement and staff development efforts before they're ready, can create high levels of stress for those still mastering time management and becoming confident in their skills. Moreover, senior staff members may grow cynical and resentful if they feel education is being valued over experience. Nonetheless, all staff members should be encouraged to use their education to grow and develop. Ensure that nurses who complete BSN degrees after working as RNs (in BSN completion programs) are encouraged to expand their scope and vision appropriately.


Although a natural instinct is to steer well-educated and talented staff members toward even higher levels of education, and perhaps away from clinical practice, not all baccalaureate-educated nurses want to move away from direct care.


Questions remain

The consequences of not harnessing the skills of a baccalaureate-educated workforce are by no means small. However, having near-identical scopes of practice regardless of education opens the profession up to the critique that the move toward BSN preparation is costly credential inflation. Many questions remain:


* What components of basic or postbasic baccalaureate education work best for developing clinical critical-thinking and decision-making skills?


* What types of postbasic baccalaureate education lead to the greatest growth in clinical practice and leadership?


* What kinds of staff development and management approaches elicit the best practice from baccalaureate-educated nurses?


* What fit between education and practice will help nurses pursue long and fruitful clinical careers, and encourage a new generation of nurses for the future?



To help answer these questions, we must continue to learn more about baccalaureate education and develop strategies to work with nurses at various experiential and educational levels.