Current Strategies for Reaching the 80 Percent Goal

Since the release of the IOM report in 2010, the share of registered nurses with a bachelor’s degree has risen from 59 to 66 percent. While still well shy of the 80 percent goal, a shift of seven percentage points in a workforce of three million is evidence of the profound impact the recommendation has had on the field.

This increase was the result of expanded enrollments in three types of bachelor of science in nursing degrees: “entry,” “accelerated,” and “bridge.” The entry BSN—so-called because students complete it before taking the license exam to enter registered nursing—is a traditional, four-year bachelor’s degree. Since it is prelicensure it requires a variety of clinical experiences and practicums, similar to the associate degree in nursing. But since it is a four-year program, it also includes more general education classes as well as more academic coursework on nursing, health care, and the health sciences. The accelerated BSN is designed for graduates of other bachelor’s degree programs who want to become registered nurses. The programs are shorter and limited to core nursing requirements, in recognition that students have already completed the general education requirements of a bachelor’s degree. Since they are also prelicensure, they require the same clinical experiences as entry BSN programs. The bridge programs, also called “RN-BSN” programs, are designed for registered nurses who already have an associate degree. These are post-licensure programs, and therefore do not require the same amount of clinical experience. Instead, the programs are made up of general and academic courses that are not included in the shorter and more practically focused associate degree programs. A typical program will include courses on leadership, research, health care policy, and culturally competent care, along with deeper dives on topics like pharmacology or gerontology. Most of them are also accelerated, in recognition that students have completed many of the core requirements of a prelicensure nursing program.

All three types of degree programs have expanded since the IOM report, causing a 74 percent jump in the number of BSN degrees awarded since 2010.¹ There are now more RN-BSN than entry BSN programs, and while there are only about one-third as many accelerated as entry BSN programs, that number is climbing fast.² Both RN-BSN and accelerated BSN programs are also producing a significant share of overall BSN degrees, with the accelerated BSN at 9 percent and RN-BSN completers at 47 percent of total BSN degrees awarded in 2016.³

The lion’s share of the growth in BSN graduates has come from RN-BSN programs.⁴ A big part of the reason the RN-BSN programs have grown so much more than the other two types of bachelor’s degree programs is because they are post-licensure, and therefore do not require the same clinical experiences necessary for a pre-licensure program. The need to secure clinical placements for students is a major constraint on the growth of pre-licensure nursing programs. According to AACN, in 2017 nursing schools turned away more than 60,000 qualified applicants to bachelor and graduate degree programs.⁵ A survey of nursing school leaders indicated that lack of clinical placements was the primary reason for turning away qualified applicants.⁶

The fact that RN-BSN programs require less in the way of clinical experiences makes them easier for schools to deliver. The general and academic nature of the coursework also makes them ideally-suited for online delivery. The online format, in turn, allows schools to enroll far more students than could fit into their physical classrooms. It also enables a faculty member to serve many more students than is possible in an in-person setting. A shortage of qualified faculty was the second most commonly-cited constraint on expanding enrollments in the National League for Nursing survey of school leaders, ⁷ and online programs expand the capacity of existing faculty.

Any internet search will quickly reveal that RN-BSN programs are widely available and easy to find. Since 2010, they have significantly expanded their share of BSN graduates. There are now approximately 750 RN-BSN programs operating in the country, more than the number of entry BSN programs.⁸ Over half of them are entirely online and over 80 percent are at least partially online.⁹ Some are high-enrollment programs like the one delivered by Western Governors University that serves more than 7,000 students a year or the University of Texas–Arlington program that enrolls over 3,000 students from all parts of the country. Others, like St. Catherine’s University in Minneapolis, are smaller and focused on local markets. But whether designed to serve national or local communities, they all aim to help registered nurses who are already working complete their bachelor’s degrees as quickly as possible. The compressed course schedules, open start dates, and online content that many programs offer are all designed to help students fit school around full-time work.

RN-BSN programs are not new, but since 2010 they have moved from the sidelines to the very center of nursing education and become the solution to the profession’s most ambitious goal. For advocates of the programs, they exemplify Clay Christensen’s theory of “disruptive innovation” in which products or services on the margins of a market eventually overtake the less flexible and more tradition-bound incumbents: in this case, entry BSN programs. The online programs have provided an elegant solution to the constraints of pre-licensure programs and allowed the field to advance toward its 80 percent goal without closing down the associate degree pathway into the profession. As a strategy for increasing access to BSN programs, these programs have been highly successful.

However, there are reasons to doubt they will be enough to close the remaining 14 percentage point gap anytime soon. In fact, at the current rate of degree production, the field will not reach 80 percent for another two decades. While the rate could go up (along with the retirement rates of associate-degreed nurses), that is still a long way to go. And there are signs that the online RN-BSN may be reaching its peak enrollment level. According to AACN, after 13 years of positive growth, enrollments in RN-BSN programs increased by just 1 percent in 2017.¹⁰

Two factors appear to be constraining their growth: 1) many nurses do not feel the programs are worth the time or effort and 2) many employers offer few reasons to change their minds. Going back to school while working as a registered nurse is difficult, particularly for adults with families. Surveys of associate-degreed nurses who have chosen not to advance their education cite family obligations and a lack of flexibility from the employers for time off as a key barrier.¹¹ Registered nurses who come through the associate degree path are, on average, older than their counterparts in entry BSN programs and much more likely to have children. Sixty percent of students enrolled in RN-BSN programs are over 30 years of age.¹² While the online format can help students juggle work and home schedules with school, that does not make the coursework any easier. In fact, as anyone will tell you who has completed an online degree, it is demanding and time-consuming. And despite claims by providers that the RN-BSN degrees can be completed in just nine months, students may require more time or need to complete a variety of pre-requisite courses before they can enroll in the actual program.

The economic benefits of completing the degree are also far from clear for many nurses, particularly those who are older and/or have been practicing for some time. Demand for registered nurses is strong, regardless of degree level. Experienced nurses with an associate degree will not struggle to find work or keep their jobs in today’s labor market. They may not move up the career ladder, but for many nurses who are earning decent salaries, that is not a bad tradeoff. Add to that the fact that most graduates of RN-BSN programs receive little or no wage increase for their trouble, and it is not hard to understand why many associate-degreed nurses are content to stay where they are. While the long-term wages of BSN nurses are higher, due primarily to their ability to move into management positions and graduate education, many nurses are focused on the more immediate costs and benefits of returning to school.

Finally, the health care employer community is sending mixed signals on just how much it values the bachelor’s degree. While the AACN touts the fact that 94 percent of employers prefer to hire nurses with bachelor’s degrees, according to the same survey, only half require it. Other research casts doubt on that number. A recent survey of acute care hospitals in Massachusetts that included six Magnet hospitals and 11 teaching hospitals revealed that just 41 percent required their nursing staff to obtain a BSN. Among the non-acute care hospitals in the survey, none required a BSN.¹³ A similar study by the University of California–San Francisco indicated that fewer than 5 percent of health care employers in the state require a bachelor’s degree for hire.¹⁴

Not only do relatively few employers require a bachelor’s degree for hire, the University of California—San Francisco study shows that the majority do not make any salary distinction between registered nurses with an associate or bachelor’s degree.¹⁵ Just over half of the acute care hospitals in the Massachusetts survey rewarded degree completion with a salary increase, and only 14 percent of other health care providers did so.¹⁶ And even among those institutions that do award a salary increase, the amount is often quite low—less than $3,000, according to one national study.¹⁷ Outside a relatively small number of teaching hospitals, labor management training partnerships, and hospitals seeking Magnet status, employers appear to be doing little in the way of targeted strategies to upskill their associate degree workforce. The survey of California employers indicated that just a quarter provided paid time off to nurses in RN-BSN programs, and just 35 percent were willing to provide unpaid leave.¹⁸ The most common support strategy is to offer tuition reimbursement, which rarely covers the full cost of the degree. While tuition reimbursement can help, it is primarily used as a recruitment and retention strategy, not a talent development strategy. As one study of employer practices put it:

This implication is suggested by the fact that most institutions offer tuition reimbursement—which is a well-proven retention strategy—regardless of whether nurses actually use the program or complete their studies. On the other hand, salary differentials—which are, by definition, linked to achieving educational progress rather than achieving lower turnover rates—are far less commonly applied.¹⁹

Given the lack of clear incentives and rewards, it is not surprising that many nurses prefer to stay at the associate degree level. The ability to take programs online still does not address many of the downsides of returning to school, including the considerable time and cost involved. What is missing from these RN-BSN programs are designs that make it easier to combine work and school and that more directly engage employers in the talent development process. In fact, when considering the online RN-BSN program, what distinguishes it from other degree programs may be precisely what keeps it from meeting the needs of more nurses and employers. The programs are designed to be completed outside of work, even though the students are working as nurses. The ability to access the program at home, at night, and on weekends, is often touted as its greatest strength. But for many nurses, it might well be its greatest deficit.

Given the lack of clear incentives and rewards, it is not surprising that many nurses prefer to stay at the associate degree level. The ability to take programs online still does not address many of the downsides of returning to school, including the considerable time and cost involved.

The online designs and fewer clinical requirements also absolve employers of responsibility for creating opportunities for nurses to connect what they are learning to their practice. The courses are generic enough that they can meet the needs of registered nurses working in any health care setting or location: an emergency room in Philadelphia, a family practice clinic in Cedar Rapids, a nursing home in Phoenix. The content of the courses, with their focus on leadership, assessments, health care policy, and cultural competency, may be well aligned with the knowledge and skills needed of a bachelor-degreed nurse, but the program design limits opportunities to connect any new learning to practice. That lack of a linkage between course content and nursing practice makes the programs far less valuable as a talent development strategy for employers than they could be.