Position Statement: Rapidly expanding clinical knowledge and mounting complexities in health care mandate that professional nurses possess educational preparation commensurate with the diversified responsibilities required of them. As health care shifts from hospital-centered, inpatient care to more primary and preventive care throughout the community, the health system requires registered nurses who not only can practice across multiple settings - both within and beyond hospitals - but can function with more independence in clinical decision-making, case management, provision of direct bedside care, supervision of unlicensed aides and other support personnel, guiding patients through the maze of health care resources, and educating patients on treatment regimens and adoption of healthy lifestyles. In particular, preparation of the entry-level professional nurse requires a greater orientation to community-based primary health care, and an emphasis on health promotion, maintenance, and cost-effective coordinated care. Accordingly, the American Association of Colleges of Nursing (AACN) recognizes the Bachelor of Science degree in nursing as the minimum educational requirement for professional nursing practice. (See also our fact sheet on Associate Degree in Nursing Programs and AACN's Support for Articulation.)
For U.S. health care delivery, the traditional role of the nurse as bedside caregiver - and of the hospital as traditional site for health care delivery - no longer can support a health system that demands expanded delivery of outpatient and primary care throughout the community, greater numbers of clinical specialists to treat an array of acute and chronic illnesses, and wider use of nurse practitioners and other advanced generalists to provide citizens, especially underserved populations, more accessible and affordable care.
Nor will merely producing more direct care providers be sufficient to meet the accelerating need for nurses in other areas, such as health promotion and disease prevention, case management, and managed care settings.
As health care shifts increasingly away from hospital-centered, inpatient treatment, other points of delivery - health maintenance organizations, community health and other outpatient centers, homes, the workplace, public schools, and nursing-school-operated nursing centers - have emerged to provide a continuum of health care services outside the hospital. Many of these facilities are part of new integrated health networks that provide and coordinate care among a host of facilities within a community.
These accelerating changes in how and where health care is delivered have created demand for nursing personnel who can function with more independence in clinical decision-making and case management, performing the traditional role of clinical caregiver, and teaching patients how to comply with treatment regimens and maintain good health. Indeed, today's registered nurse not only must communicate effectively with patients and other health care professionals, but also must have broad competency as a provider, designer, manager, and coordinator of care. 1
Such responsibilities include skill at delegation and, increasingly, will require planning and integrating treatment for patients as they receive care across multiple settings. As such, registered nurses at the entry-level of professional practice should possess, at a minimum, the educational preparation provided by a four-year Bachelor of Science degree program in nursing (BSN).
The BSN Nurse Is Prepared For A Broad Role
Unlike graduates of diploma or associate-degree nursing programs, the nurse with a baccalaureate degree is prepared to practice in all health care settings - critical care, outpatient care, public health, and mental health. Accordingly, the BSN nurse is well-qualified to deliver care in private homes, outpatient centers, and neighborhood clinics where demand is fast expanding as hospitals focus increasingly on acute care and as health care moves beyond the hospital to more primary and preventive services throughout the community.
In addition to the liberal learning and global perspective gained from a four-year baccalaureate education, the BSN curriculum includes clinical, scientific, decision-making, and humanistic skills, including preparation in community health, patient education, and nursing management and leadership. Such skills are essential for today's professional nurse who must make quick, sometimes life-and-death decisions; design and manage a comprehensive plan of nursing care; understand a patient's treatment, symptoms, and danger signs; supervise other nursing personnel and support staff; master advanced technology; guide patients through the maze of health care resources in a community; and educate patients on health care options and how to adopt healthy lifestyles.
At increasing numbers of hospitals nationwide, baccalaureate-prepared nurses are being utilized in ways that recognize their different educational preparation and competency from other entry-level RNs. In these differentiated practice models, BSN nurses not only provide more complex aspects of daily care and patient education, but also design and coordinate a comprehensive plan of nursing care for the entire length of a patient's stay - from pre-admission to post-discharge - including supervising nurses aides and other unlicensed assistive personnel, designing discharge and teaching plans for patients, and collaborating with patients, physicians, family members, and other hospital departments and resource personnel. Associate-degree nurses function primarily at the bedside in less complex patient care situations, and provide additional aspects of care such as teaching patients how to cope with their conditions and to maintain their care upon discharge. 2
The BSN Nurse Is Preferred
In 1980, almost 55 percent of registered nurses held a hospital diploma as their highest educational credential, 22 percent held the BSN, and 18 percent an associate degree. By 1996, a diploma was the highest educational credential for only 24 percent of RNs, while the number with BSN degrees climbed to 31 percent, with 34 percent holding an associate degree. 3
A recent report by the National Advisory Council on Nurse Education and Practice, an advisory body to the federal Division of Nursing, urged that at least two-thirds of the basic registered nurse workforce hold baccalaureate or higher degrees in nursing by 2010. 4 Presently, only about 40 percent do.
In addition, a 1995 report by the Pew Health Professions Commission called for a more concentrated production of bachelor's- and higher-degree nursing graduates. 5
Indeed, nurse executives have indicated their desire for the majority of hospital staff nurses to be prepared at the baccalaureate level to meet the more sophisticated demands of today's patient care. 6 For example, chief nurse officers (CNOs) at university health systems report they prefer an average of 70 percent of their staff nurses to be BSN-prepared, according to a recent survey by the University HealthSystem Consortium. More than 70 percent of the CNOs stated they perceive a difference in the practice of baccalaureate- and associate-degree-prepared RNs, citing better critical thinking skills and leadership abilities among baccalaureate nurses. 7
Moreover, with sharp declines in inpatient visits and briefer patient stays increasingly becoming the norm -- shifting more health care delivery to outpatient settings -- the skills of the BSN nurse are essential for practice in other community sites, such as health maintenance organizations, home health services, community clinics, and managed care firms.
(With the continued change and mounting complexity in health care delivery, calls have increased in some circles of nursing for the graduate degree to be the entry-level requirement for professional nurses.)
Many hospitals not already requiring the Bachelor's of Science degree in nursing have established "BSN-preferred" policies for new hires. For example, the Veteran's Administration, the nation's largest employer of registered nurses, has established the baccalaureate degree as the minimum preparation its nurses must have for promotion beyond entry-level beginning in 2005, and has committed $50 million over the next five years to help VA nurses obtain baccalaureate or higher nursing degrees. 8
Recognizing the expanded opportunities, RNs are returning to school in increasing numbers to earn the BSN degree. Between 1975-1999, the number of RNs (with associate degrees or hospital diplomas) graduating from BSN programs rose from approximately 3,700 a year to more than 12,000 annually. 9
(Approved By Board of Directors, July 20, 1996)
(Updated: December 12, 2000)
1 American Association of Colleges of Nursing. (1998).The Essentials of Baccalaureate Education for Professional Nursing Practice, pp. 4-5. Washington, DC: Author.
2 American Association of Colleges of Nursing. (1995). A Model for Differentiated Nursing Practice, pp. 26-29. Washington, DC: Author.
3 Division of Nursing. (March 1996). The Registered Nurse Population: Findings from the National Sample Survey of Registered Nurses, p. 16. Washington, DC: U.S. Department of Health and Human Services, 1995.
4 National Advisory Council on Nurse Education and Practice. (October 1996). Report to the Secretary of the Department of Health and Human Services on the Basic Registered Nurse Workforce, p. 9. Washington, DC: Division of Nursing, Health Resources and Services Administration.
5 PEW Health Professions Commission. (November 1995). Critical Challenges: Revitalizing the Health Professions for the Twenty-First Century, p. 51. San Francisco, CA: University of California, San Francisco Center for the Health Professions.
6 American Hospital Association. (1987). Report of the Hospital Nursing Personnel Survey, p. 36. Chicago: Author.
7 University HealthSystem Consortium. (October 1999). Survey on Educational Preparation of Nurses, p. 2, 8. Oak Brook, Ill: Author.
8 Department of Veterans Affairs. (December 18, 1998). VA commits $50 million to new national nursing initiative [news release]. Available at www.va.gov/pressrel/98nni.htm. Accessibility verified December 12, 2000.
9 American Association of Colleges of Nursing. (2000). 1999-2000 Enrollment and Graduations in Baccalaureate and Graduate Programs in Nursing, p. 11. Washington, DC: Author