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Escalating the Pathway from the Associate's Degree in Nursing To INVITED COMMENTARy Escalating the Pathway From the Associate’s Degree in Nursing to the Bachelor of Science in Nursing and/or the Master of Science in Nursing: What Is Standing in the Way? Elaine S. Scott, Helen Brinson For more than 25 years, promoting higher levels of education an increased use of hospitals [9]. In response to the press- for registered nurses (RNs) has been a strategic theme in ing need for nurses, a proposal for a 2-year, technical nurs- national reports. yet, only 42.2% of RNs in North Carolina ing degree was created, with the recommendation that the hold a bachelor of science in nursing, a master of science in education takes place in community colleges [9]. The initial nursing, or a doctorate in nursing. Creating a seamless edu- vision was for technically trained nurses to assist BSN-level cational pathway for RNs is essential for achieving this goal. nurses in practice, much in the same way that physical ther- apy assistants work with physical therapists. Instead, nurses with a 2-year ADN gained equal licensure status and soon or more than 25 years, promoting higher education for became the largest pool of US nurses. In North Carolina, Fregistered nurses (RNs) has been a theme in national during 2004-2009, 21,052 new nurses entered practice. reports [1, 2]. One reason for this recurring recommenda- Of these, 14,073 (66.9%) graduated from ADN programs, tion is evidence that nurses with a bachelor of science in 6,257 (29.7%) received a BSN, and 722 (3.4%) received a nursing (BSN) more often pursue education at the master’s diploma in nursing [8]. On the national level, 45.4% of RNs and doctoral levels, an essential component for sustaining begin practice with an ADN, compared with 34.2% who an adequate supply of nurse practitioners, midwives, and begin practice with a BSN [7]. clinical nurse specialists, as well as nurse educators [3, 4]. Answering the current call by the Institute of Medicine Another justification for increasing education levels of RNs of the National Academies (IOM) to increase the number is the growing research that links patient safety and out- of BSN-level nurses to 80% of the nursing workforce by comes to the percentage of BSN-level nurses on a unit [5, 2020 will require tremendous effort, united vision among 6]. Nurses, unlike all other health care professionals, can nurse educators and leaders, and major strategic commit- enter practice via 3 different degrees: a hospital diploma, ment by organizations that employ nurses [2]. At present, a community college associate’s degree in nursing (ADN), only 42.2% of RNs in North Carolina hold a BSN, MSN, or or a BSN. Graduates of all programs take the same licens- PhD in nursing (Table 1). In North Carolina, during 2004- ing examination to practice nursing. Many historical factors 2009, only 2,998 ADN-level nurses used the RN-to-BSN have contributed to this situation, and many political factors articulation option to achieve a BSN [8]. On average, that make its resolution complex. Historically, nurses—who are is 500 ADN-level nurses per year returning to school, while predominantly white and female—were educated in hospi- an average of 2,345 new ADN graduates enter nursing prac- tal diploma programs. As nursing care became more com- tice. Nationally, only 16%-20% of ADN-level nurses go on to plex and university education became a norm for women, pursue a higher degree [4]. the movement to a baccalaureate was recommended by The IOM’s recommendation that a seamless educational the profession. At present, 20.4% of nurses in the United pathway be established for RNs has been a vision in North States completed a diploma program as their initial educa- Carolina since 1991, when the University of North Carolina tion [7]. In North Carolina, only 7.2% of nurses report having received a hospital diploma as their first degree [8]. Since Electronically published September 23, 2011. 2004, less than 3.5% of new-entry nurses have graduated Address correspondence to Dr. Elaine S. Scott, College of Nursing, East from diploma programs [7, 8]. As diploma programs closed, Carolina University, 3138 Health Sciences Bldg, Greenville, NC 27858 schools of nursing were created in universities; however, ([email protected]). N C Med J. 2011;72(4):300-303. ©2011 by the North Carolina Institute supply did not match the demand for nurses arising from of Medicine and The Duke Endowment. All rights reserved. World War II, from improvements in medicine, and from 0029-2559/2011/72411 300 NCMJ vol. 72, no. 4 NCMJ vol. 72, no. 4 ncmedicaljournal.com ncmedicaljournal.com review program developments. Many regional AHECs have table 1. Degrees Held by Working Registered Nurses annual advisory meetings to discuss strategies to increase (RNs) in North Carolina enrollment of ADN-level nurses in BSN and MSN programs. In 2007, the NCIOM reviewed the recommendations from RNs, no. (%) 2004 and provided a detailed update that outlined the leg- Degree (N = 92,495) islative and organizational responsibilities needed to meet Diploma in nursing 8,147 (8.8) the recommendations [11]. The report noted that significant Associate’s degree in nursing 36,843 (39.8) progress had been made but that there were still inadequate Bachelor of science in nursing 30,263 (32.7) numbers of BSN-level nurses in North Carolina. Baccalaureate in other field 5,041 (5.5) Numerous studies on the educational progression of Master’s degree in nursing 8,441 (9.1) ADN-level nurses demonstrate the common challenges fac- Master’s degree in other field 3,043 (3.3) ing students, including role strain, cost, access, and lack of Doctorate in nursing 327 (0.4) rewards [12, 13]. Because the nursing workforce consists Doctorate in other field 381 (0.4) predominantly of women, role strain stems from compet- Unknown degree 9 (<0.1) ing priorities among the family unit, work, and school [12]. Another challenge is cost. Educational expenses for return- (UNC) president convened a nursing transfer study com- ing to school vary depending on the number of prerequi- mission. Yet, only 32.7% of current nurses in North Carolina sites that must be taken before entering the pathway from hold a BSN [8]. The university and community college sys- RN to BSN and/or MSN (hereafter, RN-BSN/MSN). Current tems have a comprehensive articulation agreement (CAA) economic conditions often make the RN the primary wage that has existed for many years. However, there is not a earner, and even when organizations provide financial sup- statewide nursing articulation agreement. The CAA pro- port for education, the RN must find the funds to pay for vides a readily accessible way to evaluate community col- the courses upfront. Before online education, geographi- lege courses for university transfer credit. In 2001, the cal access was a major deterrent to RNs’ return to school, Helene Fuld Health Trust awarded a 2-year grant to the particularly in rural areas. Even with the increased availabil- North Carolina Center for Nursing with the goal to create “a ity of online education, many nurses reside where Internet seamless articulation plan for North Carolina nursing edu- access and speed limit the use of this educational mode. A cation programs such that RNs who wanted to further their final significant barrier is the lack of rewards in health care education were assured that previous learning and work organizations for advanced degrees [12, 13]. Offering finan- experiences would be valued and recognized.” A project cial incentives to pursue a higher degree strongly affects steering committee formed, including representatives from the decision to return to school [13]. RNs must consider the community colleges, universities, the North Carolina Area costs and benefits associated with continuing education, Health Education Centers (AHEC), the North Carolina Board and often, there is no benefit to offset the cost. Even with of Nursing, the North Carolina Nurses Association, and the the demonstrated improvement in patient safety and out- North Carolina Association of Nurse Leaders. By 2003, the comes seen with higher ratios of BSN-level nurses, health group had drafted a statewide nursing articulation plan; held care organizations rarely offer pay differentials for a BSN a meeting to disseminate findings; and, using an RN-BSN or an MSN. In September 2010, Eastern AHEC conducted a consortium, developed a method for fully implementing the regional survey that evaluated nurses’ interest in returning work. But funding issues and the dissolution of the North to school. Of 583 respondents, 39% indicated an interest Carolina Center for Nursing challenged the development in RN-to-BSN education. Only 3% desired a classroom-only and continuation of the consortium (J. Kuykendall, personal program, with the remaining seeking a 100% online program communication, May 31, 2011). or a blended (ie, classroom and online) program of study. Of After the work of the North Carolina Articulation Task the 122 responses from students who offered suggestions, Force, the North Carolina Institute of Medicine (NCIOM) 21% were related to finances. Sixteen of the 148 ADN-level convened a task force to address the North Carolina nurs- nurses stated that excessive prerequisites and duplicate ing workforce shortage. In 2004, the NCIOM task force courses were major deterrents to returning to school. These released a report that included many recommendations and findings parallel those in the literature and those determined strategies made by the North Carolina Articulation Task by the 2001 task force in North Carolina. Barriers and facili- Force [10]. Despite a lack of funding, AHEC, North Carolina tators in the ADN-to-BSN or ADN-to-MSN journey are sum- educational systems, private nursing programs, the North marized in Table 2.
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