Be Careful What We Ask For...

Nov 10, 2011, 6:00 PM, Posted by

By Kathy Harris, MS, RN, CENP, FACHE, Regional Vice President, Clinical Services, Banner Health


Within the professional lifetimes of many practicing nurses there have been episodic efforts to establish the BSN as entry into professional practice and licensure. It might be argued that these efforts succeeded in “moving the dial” to a greater or lesser extent but there is no argument about the fact that today only 50% of nurses in this country have been educated at the BSN level or higher1.

Concomitant with, and for many years prior to, these efforts, the nation’s health care industry has experienced fluctuations in the availability of licensed nurses with whom to staff sites of care. Consequences of these variations include the establishment of multiple points of entry into practice (AD, Diploma, LPN, BSN, ND, some MSN programs) making it difficult for many to understand and fully appreciate the professional differences among the preparational levels as well as the value each brings to the delivery of patient care.

Today the evidence points quite clearly to the benefits of preparation at the baccalaureate level. The educational requirements of preparation for practice will need to be even more demanding than at present as the complexity of acute care grows and new sites for care are identified.

As more aspiring and practicing nurses begin working toward baccalaureate degrees, academic settings will be stressed to extremes as they attempt to meet the growing demand for nurses prepared at the BSN level while utilizing fewer faculty, enjoying less physical and clinical space, and experiencing growing demands for nurses trained differently than in the past.

It is difficult to imagine the mechanisms that will propel nurses to ever higher levels of educational preparation in the numbers necessary to achieve the objective of 80% of RNs prepared at the baccalaureate level by 2020. As currently configured, our four-year academic centers cannot quickly produce more nurses. Expanding opportunities will take time and will be hampered by a shortage of clinical space and faculty, who find they can make significantly more money in hospital settings. Educational institutions will be forced to “give” somewhere and it may very well be through decreases in capacity or through closed programs, further limiting access to their programs.

In the economic environment of today and as it will continue to be for some time, states find themselves in the difficult position of having to cut funds for higher education. Tuition will increase to cover the reductions and some programs will be cut back to meet fiscal realities. Such tuition escalations may adversely impact some subsets of our population least able to meet the new financial demands.

To increase the percentage of the nursing workforce that has at least a BSN degree, health care organizations will need to create incentives for nurses to take steps to further their education. Nurses who are educated at higher levels will require job descriptions that accurately reflect their professional practice. Organizations will be pressed to clearly distinguish among nurses prepared at different levels. Along with this will be demands for salaries that are aligned with these job differences and which reflect the BSN nurse’s added value to patient care. Organizations will feel the financial impact of these salary demands. In addition, organizations that typically provide financial incentives to return to school will likely find themselves unable to pay for the number of students they employ who are seeking a BSN which may in turn result in reduced benefits for staff or even the elimination of tuition reimbursement. Increased turnover may flow from that.

As nursing educational programs and employers of nurses raise their expectations for the number of staff prepared at the BSN level there will be a disproportionate impact on employees and students who are more vulnerable to economic pressures. This may be reflected in adverse impact on minorities, older workers, and those from less advantaged situations.

Reduced capacity for preparing new nurses, pressure on the nurses to obtain a BSN degree, decreased financial support for students in nursing programs, increased demand for care delivery by larger numbers of sicker patients, and new sites of care may all combine for deleterious impact on patient access to care. We have already seen programs reduced and patient loads increased when demand far outstrips supply. The worst case scenario could be this one.

1American Association of Colleges of Nursing; Nursing Shortage Fact Sheet; Last Updated 4/14/2011.; Last accessed 7/25/2011.

This commentary originally appeared on the RWJF Human Capital Blog. The views and opinions expressed here are those of the authors.