1 Running Header: BSN as Entry-Level to Nursing

Educating Public Health Professionals for the Twenty-First Century: A Case for Requiring a BSN as Entry-Level Education to the Nursing Profession Arn Prince Accelerated Nursing Student SUNY Downstate Medical Center College of Nursing NRBS360 December 13, 2011

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Abstract The Healthcare industry is currently in turmoil, awaiting a clear directive as to the direction it will take toward a future that will meet the needs of the many without compromising quality of care, and also contain costs. Over the past couple of decades an issue has emerged, the resolution of which will impact not only the industry, but the lives of thousands of healthcare professionals. Indeed, the proper resolution of this issue could direct the course of the entire healthcare industry for the foreseeable future. This issue is contained in the ongoing, as yet unresolved question: What should the minimum educational requirement be for those seeking to enter the nursing profession? This paper will: review the history of nursing education, describing how the original intention of the Associate Degree in nursing was ignored and usurped for the sake of convenience; take a look at the state of the nursing profession today, outlining issues impeding respect for the role of the nurse in both the healthcare industry and society in general; and present a perspective of the impact on the profession and the healthcare industry that would occur as the result of requiring a Bachelor of Science, Nursing, as the entry level of education to the field.

2 BSN as Entry-Level to Nursing

Educating Public Health Professionals for the Twenty-First Century: A Case for Requiring a BSN as Entry-Level Education to the Nursing Profession

Throughout history, the nurse has been the primary care-giver to the ill, the infirm, and the dying, and the role has been filled by both men and women alike, although over the centuries it came to be defined as a female role. Beginning with the advent of Protestantism, in countries wherein religious orders were largely disbanded, public hospitals were viewed as a refuge of last resort for those needing medical care, due to the high mortality rates as compared to home care, and the role of the nurse, no longer deemed appropriate for women of culture, and was undertaken in large part by women alcoholics and former prostitutes ( Zerwekh & Claborn, 2009). While the role of the nurse was always ancillary to the role of the physician, this change in who filled the role began the designation of the role of the nurse as being subservient to the physician in thought, word and deed. This concept of nurse as handmaiden to the physician was significantly reinforced even by Florence Nightingale, who singlehandedly changed the nursing profession into what it remained until only the last few decades, when change began to happen. During the Crimean War, the young Nightingale, an educated and cultured woman of the time, had a religious epiphany, rejected the wishes of her father and determined to help the sick and suffering soldiers of England on the battlefield (Zerwekh & Claborn, 2009). Her astute, scientifically based observations of the conditions she met with in the field hospitals led to her implementation of methodical and documented procedures and practices. Though knowledge of microorganisms was

3 BSN as Entry-Level to Nursing unknown to her, common sense and basic aseptic protocols resulted in much lower rates of mortality and morbidity, for which she was praised and employed by the British government to institute in hospitals nation-wide. Once she understood the ramifications of her work upon the field of medicine, she realized that the role and responsibilities of the nurse could no longer be left to incompetent and impaired individuals, and she began the first modern training program for nurses (Zerwekh & Claborn, 2009). In America, the nursing profession was decidedly impacted by Nightingale's work, and formal nursing programs began here as well. These programs were most often associated with hospitals, but colleges and universities also began to offer training, mostly in conjunction with hospitals, and conferred degrees in nursing upon women. When it became apparent how significantly superior was the care rendered by those who received this formal training, and how tenuous and often dangerous was the service performed by those who merely assumed the title of nurse, the legal certification of the Registered Nurse began in North Carolina, in 1903, and was fully instituted by 1923, when all 48 states had licensing requirements for nurses to practice (Comer, 2007). Until the 1960s, the majority of registered nurses held either a Bachelor degree, with some achieving a Master's level, or a certificate/diploma from hospital programs, which also trained nurses at a lower level, who received the title of Licensed Practical Nurse (LPN). In the early 1950s, Mildred Montag, Professor of Nursing Education at Teacher's College, Columbia University, began developing programs in Community Colleges around the country, to train nurses (Zerwekh & Claborn, 2009). This was in response to a shortage of qualified nurses. Dr. Montag viewed these programs as being accessible to a wider spectrum of individuals than could otherwise attend college, and indeed, found that a large number of those who enrolled were women over the age of 35, as well as men. Dr. Montag had clear views of the function these AA degree nurses were to have in the field of nursing, describing them as nurse technicians, specifically trained to perform the hands-on aspects of patient care. She

4 BSN as Entry-Level to Nursing stated that the associate degree nursing program aims to prepare for those functions which lie in the technical area They prepare the graduate to give direct care to patients with knowledge and understanding as well as with technical skill. They do not prepare her for management or for supervision. (Montag, 1963). In fact, she makes a clear delineation between the technical nurse and the professional nurse: the professional nurse must have a truly professional education if the services she renders are to be truly professional. This education can be achieved in no less than a baccalaureate degree program. It was for the preparation of the nursing technician that the associate degree program was initiated. (Montag, 1963). Unfortunately for the field of nursing, Dr. Montag did not involve the government licensing offices in the process, to impose a different level of scope of practice upon these AA graduates (ADNs), perhaps separating registered nurses into two categories: Registered Professional Nurses (RPNs) and Registered Technical Nurses (RTNs). The result was that these AA nursing programs were producing an overwhelming number of graduates when compared to the traditional programs (which included diploma programs, but which Dr. Montag saw as fully preparing the nurse for the role of professional). The increased numbers of Registered Nurses that ensued came as a great relief to the healthcare system at the time, which was being taxed by numerous causes, of which two, the Vietnam War, and the institution of Medicare, created a significant need for nurses. At the time, the supervisory and managerial positions in nursing were the firm domain of what Montag considered professional Registered Nurses, and institutions simply filled their nursing positions with whatever Registered Nurses they could obtain. As a result, the ranks of nurses employed in the vast majority of institutions were comprised of, mainly, ADNs, and when, in the 1970s, nurses began demanding more autonomy, the imperative of gaining ground in the healthcare field took precedence over the educational background of the individual (Mitchell, Ferketich & Jennings, 1998). Subsequently, a culture of nursing began in which seniority, tenure and cumulative years of experience are largely perceived as equal or superior to the level of education achieved, especially in the new

5 BSN as Entry-Level to Nursing graduate. This paradigm resulted in large numbers of AA prepared nurses acquiring supervisory and managerial positions in hospitals and institutions, quite contrary to the vision put forth by Dr. Montag! Nursing Today In the intervening years since the advent of the AA degree Registered Nurse (ADN) and the shift toward autonomy by the nursing field, advances in the public perception of the nurse has changed only slightly. Although the external appearance has changed, with few nurses now wearing the traditional dress/skirt based uniform with cap, the public perception of nurses still remains more undefined than refined. Even with the fact that The Gallop Poll shows nursing to be the most trusted profession (Zerwekh & Claborn, 2009, p. 179), the pervasive idea that nurses merely carry out, in a blind fashion, the directives of the physician, seems to still resonate with much of the public. Certainly, in most entertainment-media portrayals, this is the concept conveyed. However, it is not the only reason this is so. The main issue impeding public perception of nurses, in the mind of this author, is the lack of public observation of nurses as true collaborators in the process of patient care, most especially in the decision making process. Part of the reason for this lack of observation is that this phenomenon has yet to become an across-the-board reality in the healthcare setting. I find numerous reasons for this, which include: the resistance of physicians to view nurses as equitable partners in the overall care of patients; the lack of cohesiveness within the ranks of nurses across the spectrum; and the disparate educational backgrounds and preparation within the field of Registered Nurses. The relationship between doctors and nurses has undergone significant changes in the past 50 years, with nurses emerging from the role of handmaiden. However, the current role of the nurse, as viewed from the perspective of the doctor, has yet to be clearly defined. At the core of each field, the imperative for performance is guided by different motivations: doctors are guided by the incentive to perform as many procedures and other billable actions in as short a time as is possible, while nurses are

6 BSN as Entry-Level to Nursing remunerated based upon their time, rather than their actions. This lends to nurses the ability to view the total-patient care paradigm as a seamless process performed within the scope of their time-defined shift, whereas doctors tend to value less those actions that are not clearly defined within the parameters of remuneration. Therefore, many doctors devalue collaboration across disciplines due to the fact that it takes them off-task, which is to perform revenue-generating procedures. (Garman, Leach & Spector, 2006) Additionally, any basic course in Sociology reveals the propensity of individuals to cohort within somewhat clearly defined lines, even within larger social or institutional frameworks such as churches and businesses. While it is true that race/ethnicity is one of these factors, it is far more common to find that level of education and socio-economic status are more common determinates of cohort selection (Hughes, M., Kroehler, C. J., & Vander Zanden, J.W., 2002). That there is such clear disparity between the members of the M.D. field and the field of nursing, on both accounts is, to this author, an important and valid point when looking at reasons for resistance to the collaborative process. Finally, but not least, is the fact that physicians perceive nurses as a threat due to the increased frequency of nurses walking on their turf, in being licensed, hired, and allowed to perform (more cheaply) procedures once relegated only to M.D.s (Garman, Leach & Spector, 2006). Within the nursing profession, there is an increasing tension at many levels. Although nurses tend to support each other, there is less of a sense of protectiveness in the profession than is seen in physicians (Garman, Leach & Spector, 2006). Perhaps as a result of this, within the industry, all too often a performance problem is, all else being equal, more likely to be framed as an individual performance issue if related to a nurse, and a systems issue if related to a physician (Garman, Leach & Spector, 2006) . The same phenomenon of educational disparity that occurs between doctors and nurses also exists within the ranks of nursing, which will be discussed in more detail later. The purpose at this juncture is to point out that anecdotal evidence received by, and personal observations made by this author reveals that, for varying reasons, and as a generalized view, nurses with levels of education

7 BSN as Entry-Level to Nursing above that of the ADN tend to cohort, and interact with doctors on a higher level of parity than do ADNs, who tend to cohort, and to display more affinity toward Unlicensed Assistive Personnel (UAPs). This dynamic sets up a natural line in the sand within the nursing ranks. In addition to the fractured nature of the nursing field, powerlessness, imposed on an institutional level, largely in the attitudes of doctors toward nurses, has taught many nurses not to be assertive in the workplace, both individually and collectively (DeMarco & Roberts, 2003). This may be a remnant from the age in which nursing was seen definitively as a woman's field, but the slow change in the demographics of nursing has not served to hasten a change from this view. Indeed, the aggregate reflection of this condescending attitude toward nurses on the part of physicians has led to manifestations of oppressed group behavior, in which nurses, as a workforce, put the needs of others before the needs of themselves (DeMarco & Roberts, 2003). This includes incidences of managerial decisions, including those of Nurse Managers, to elevate the status of individual nurses (promotions) based on the nurse's ability to be accepted personally by the doctors with whom the nurse would interact, rather than on the individual nurse's overall competency, skill level or educational background (DeMarco & Roberts, 2003). These self-defeating actions and attitudes within the ranks of the nursing field significantly serve to impede public perception of the nurse as a true professional. The above-referenced educational disparity within the ranks of nursing is not insignificant. Beyond preparation, this disparity is seen in the performance and attitudes of ADNs when compared to BSN nurses, as measured by rates of disciplinary action, and ambition to further one's career through education. In the Institute of Medicine's report To Err is Human: Building a Safer Health System, the authors state that the majority of medical errors do not result from individual recklessness .... [but] more commonly, errors are caused by faulty systems, processes, and conditions that lead people to make mistakes or fail to prevent them. (Institute of Medicine, 1999). Interestingly , however, in a random survey of nurses who received disciplinary action from New York State in the year 2000, only

8 BSN as Entry-Level to Nursing a third of the nurses disciplined held a Bachelor's degree or higher (LaDuke, 2000). If we are not to blame the individual, then surely the only system/process that can be targeted to explain this result is that of education and preparation for the role of nurse. The Institute of Medicines follow-up report, Crossing the Quality Chasm (Institute of Medicine, 2001) drew attention beyond the clinical aspects of care, to highlight the critical role that organizational systems play in ensuring or preventing patient safety and patient care (IOM, 2011, FON). Certainly, educational institutions that grant nursing degrees are considered organizational systems. As of 2008, only 35% of all registered nurses held Bachelor degrees, compared with 45% with an Associate degree and 20% with a diploma (HRSA, 2010). This means that Community Colleges, which grant the ADN degree, have, in general, a broader influence upon the field of nursing than other institutions, specifically as it relates to clinical practices and outcomes. Yet, by revisiting the earlier concept of the principles of cohorting, one must look more closely at the institution that is the Community College to gain insight into the environment in which ADN nurses are produced. As of 2003, only slightly less than 16% of those enrolled in community colleges transferred to a four year college or university (Mullen, 2011), while only 25% of those that enroll in community colleges actually earn a degree within 3 years, and the average time for those who earn a (2-year) degree is a full 5 years ("Raise the community," 2010)). Additionally, studies have shown that the difference in critical thinking ability, and performance is higher in students who have achieved four years of education than those who have only achieved two (Giancarlo & Facione, 2001). To this author, who completed all science prerequisites for nursing school at a community college, and can provide a personal perspective, it is clear that the brightest and most motivated students will find it difficult to be consistently and successfully challenged on an intellectual/motivational basis, if surrounded by a cohort of under-motivated peers. Statistics from 2008 reveal that although 30% of ADN nurses held prior LPN/LVN licensure, only 12% went on to achieve a BSN, as compared to 21% of BSN nurses who went on to attain higher degrees (HRSA, 2010). Certainly there are numerous

9 BSN as Entry-Level to Nursing factors involved in these figures, but one must consider the effect on attitudes and motivation that is happening at the Community College level in the training programs for ADNs. Perhaps it is merely a reflection of the times in our society, when it seems the majority prefer the status quo to intellectual curiosity and actively seeking self-improvement. Within the nursing profession, a case can be made that, if all avenues for advancement which require only an RN license have thus far remained open to all RNs, regardless of educational preparation, what true incentive is there for ADNs to pursue a higher level of education? This is also true when one considers the financial remuneration of nurses, which has such a small margin of difference between ADN and BSN RNs as to be negligible when compared to the time factor alone involved in attaining a higher degree (The registered nurse, 2010). Today, magnet status hospitals are fully staffed by RNs holding a Bachelor's degree or higher, which indicates the industry recognition of the superiority of the educational preparation of the nurses. Additionally, studies have shown that hospitals granted Magnet status by the American Nurses Credentialing Center (ANCC), a function of The Joint Commission (TJC), have nursing staffs that suffer less burn-out, higher job satisfaction, and significantly higher patient approval ratings than those not granted Magnet status (Aiken, Havens & Sloan, 2000). These facts, while important to the future of nursing, can have no significant impact on the current state of the profession until the healthcare industry reaches a tipping point, beyond which ADNs will find it difficult to gain sufficiently remunerative employment to justify their decision not to pursue a higher level of education. This will be true unless and until something is done within the industry, and via legislation, that provides an imperative for seeking an education to, at the minimum, the level of the BSN. Discussion: The Future of Nursing Education In its newly released report, the Institute of Medicine (IOM) states that The nursing profession itself must undergo a fundamental transformation.... the ways in which nurses were educated and practiced during the 20th century are no longer adequate for dealing with the realities of healthcare in the 21st

10 BSN as Entry-Level to Nursing century. Outdated regulations, attitudes, policies, and habits continue to restrict the innovations the nursing profession can bring to healthcare at a time of tremendous complexity and change (IOM, 2011). In the report is Key Message #2: Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression, and Recommendation 4: Increase the proportion of nurses with a baccalaureate degree to 80% by 2020 (IOM, 2011. These sentiments seem to bring full circle the sentiments expressed by Montag almost 50 years ago. While the direction of teaching of nursing students has undergone changes, inspired by now decades old growing interest among nurse educators in developing the critical thinking skills of students, [with] ethical and moral issues being seen as an important theme underpinning the entire course (Harbison, 1992), without legislation to make these messages and recommendations into imperatives, it is unlikely that more than a small portion of the nursing profession will be prepared to undertake the challenges ahead. Today, a social worker must have a Master's degree to work in a hospital (Shapiro, 2002). Is the job of the social worker more important than that of the nurse? Obviously not. The healthcare industry is now under the paradigm of evidence based practice. In Leading the Revolution, Gary Hame talks about 4 critical components of the new innovation solution (Swan & Baruch, 2004). Each has an essential role to play to empower nurses to use evidence in practice, as well as create the capability for assessing the quality of evidence. These components are skills, information, metrics, and management processes (Swan & Baruch, 2004). All these components require education, either during the nurse's initial training, or later during the nurse's practice. The evidence presented here has shown us that, in the majority, the ADN nurse has a lower level of motivation, a higher rate of negative incidents, a lower level of competence in achieving cohort status with doctors, and yet the same opportunities, in the main, for advancement as BSN nurses. If, as the IOM, the American Academy of Nursing, the American Nurses Association, congress, etc., etc., all stress, safety and quality of care are paramount to the healthcare industry and to the public, in the 21st

11 BSN as Entry-Level to Nursing century, then rewarding ADNs with parity of practice and pay, as well as opportunities for advancement in practice and for promotion into supervisory roles and management must stop. There is ample evidence to show that the achievement of a BSN produces a more competent, more professional, more culturally sensitive, and most importantly, a safer nurse. Therefore, it is clear to me that nothing short of a BSN should be allowed as the entry-level requirement for entry into practice. While this may not be immediately practical, certainly imperatives such as the requirement of all currently practicing ADNs to achieve a BSN within a specific time frame is possible. Possible too is legislation that would limit the scope of practice, and also the title of nurses who receive an ADN going forward. It is not too late to remedy the unfortunate result of the co-opting of Mildred Montag's vision.

12 BSN as Entry-Level to Nursing References

Aiken, L. H., Havens, D. S., & Sloane, D. M. (2000). The magnet nursing services recognition program. The American Journal of Nursing, 100(3), 26-36w. Retrieved from www.jstore.org Bridgman, M. (1952). Achievements and potentials in nursing education. The American Journal of Nursing, 52(8), 980-982. Retrieved from www.jstore.org Comer, S. K. (2007). Nursing licensure, legislation and nurse practice acts. Retrieved from http://aam.govst.edu/projects/scomer/resources.htm DeMarco, R. F., & Roberts, S. J. (2003). Negative behaviors in nursing. The American Journal of Nursing, 103(3), 115-116w. Retrieved from www.jstore.org Garman, A. N., Leach, D. C., & Spector, N. (2006). Worldviews in collision: Conflict and collaboration across professional lines. Journal of Organizational Behavior, 27, 829-849. doi: 10.1002/job.394 Giancarlo, C. A., & Facione, P. A. (2001). A look across four years at the disposition toward critical thinking among undergraduate students. The Journal of General Education, 501(1), 29-55. Retrieved from www.psupress.psu/edu Harbison, J. (1992). Gilligan: A voice for nursing?. Journal of Medical Ethics, 18(4), 202-205 Retrieved from www.jstore.org Hughs, M., Kroehler, C. J., & Vander Zanden, J. W. (200.2). Sociology: The core. (6 ed.). New York: McGraw-Hill. Institue of Medicine, National Academy of Sciences. (2001). Crossing the quality chasm: A new health system for the 21st century . Retrieved from National Academy Press website: http://www.nap.edu

13 BSN as Entry-Level to Nursing Institue of Medicine, National Academy of Sciences. (1999). To Err is Human: Building a Safer Health System . Retrieved from National Academy Press website: http://www.nap.edu/books IOM (Institute of Medicine). 2011. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: The National Academies Press. LaDuke, S. (2000). The effects of professional discipline on nurses. The American Journal of Nursing, 100(6), 26-33. Retrieved from www.jstore.org LaRocco, S. A. (2006). Who will teach the nurses? the shortage of nursing faculty is a growing problem that will affect us all. Academe, 92(3), 38-40. Retrieved from www.jstore.org Mullin, C. M. (2011, October). The road ahead: A look at trends in the educational attainment of community college students (Policy Brief 2011-04PBL). Washington, DC: American Association of Community Colleges. Raise the community college graduation rate. (2010, April 26). The Christian Science Monitor. Retrieved from www.csmonitor.com Shapiro, S. E. (2002). Viewpoint: In favor of the bachelor's degree. The American Journal of Nursing, 102(10), 11w. Retrieved from www.jstore.org Stokowski, L. A. (2011, January 28). Overhauling nursing education. Retrieved from www.medscape.com Swan, B. A., & Boruch, R. F. (2004). Quality of evidence: usefulness in measuring the quality of healthcare. Medical Care, 42(2), II12-II20. Retrieved from www.jstore.org U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality. (2010). 2009 national healthcare quality report (AHRQ Publication No. 10-0003).

14 BSN as Entry-Level to Nursing Retrieved from website: www.ahrq.gov U.S. Department of Health and Human Services, Health Resources and Services Administration. (2010). The registered nurse population: Findings from the 2008 national sample survey of registered nurses. Retrieved from website: www.jstore.org Zerwekh, J., Claborn, J.C., Nursing Today: Transitions and trends (2009)(6thed.), St. Louis, Saunders/Elsevier