The Push for the Bachelor’s Degree in Nursing

Fairview Health Services is not alone in its efforts to increase the share of bachelor-degreed nurses working in its hospitals, clinics, and long-term care facilities. Health care providers around the country are pursuing similar goals and, in the process, transforming how nurses are trained, where they can work, and how they can advance in their careers.

The goal of increasing the share of bachelor-degreed nurses has come from the profession itself: national nursing associations, schools of nursing, and the health care research community. The specific target of 80 percent was proposed in a 2010 report published by the Institute of Medicine¹ (IOM) called The Future of Nursing: Leading Change, Advancing Health.² The report included eight core recommendations, each aimed at expanding the capacity of the nursing profession to provide high-quality, evidence-based care to an increasingly diverse and aging population. One recommendation focused on credential attainment:

Recommendation 4: Increase the proportion of nurses with a baccalaureate degree to 80 percent by 2020. Academic nurse leaders across all schools of nursing should work together to increase the proportion of nurses with a baccalaureate degree from 50 to 80 percent by 2020.³

The recommendation was built on a solid foundation of medical research⁴ connecting hospitals staffed with BSN nurses with lower mortality rates, shorter patient stays, and fewer readmissions, all of which improve the care experience for patients and their families and help keep costs down. The findings are not surprising given the tremendous advances in medical science over the last several decades and the growing complexity of our health care system and patient population. Americans are living longer and often managing diseases or injuries that would have ended their lives just decades ago. Nurses are on the front lines across a growing variety of health care settings, from acute care hospitals, to long-term care facilities, to community clinics. They need to recognize a wide array of symptoms and deliver medical interventions for an increasingly diverse patient population. They also often have to coordinate care across different parts of the health care system, ensuring successful transitions from one setting to another. High-quality nursing today is built on an understanding of the intersections between medical science, technology, caregiving, culture, and health care policy, and mastering these complex relationships is made easier with higher levels of education and training.⁵

The IOM’s 2010 report acknowledged these new realities and issued a set of ambitious goals for strengthening the nursing profession, including dramatically increasing the share of bachelor-degreed nurses by 2020. At the time, just 49 percent of all nurses held a bachelor of science in nursing, and only 59 percent of registered nurses did so.⁶ Despite the audacious nature of the goal—or perhaps because of it—the leading professional associations, including the American Nurses Association (ANA), Association of American Colleges of Nursing (AACN), American Organization of Nurse Executives, and the National League for Nursing, embraced it and quickly got to work.⁷ That same year, the Robert Wood Johnson Foundation and AARP founded the Future of Nursing: Campaign for Action to help develop and coordinate strategies for bringing each of the IOM’s recommendations to fruition.

The IOM’s recommendation culminated a generations-long effort to professionalize nursing education. Until well into the 19th century, nursing was seen mostly as a private matter that consisted mainly of providing comfort to the sick and dying. Advocates like Florence Nightingale helped change public perceptions of nursing so it could be recognized as a practice based on scientific principles that required formal training. The 1870s marked the establishment of the first formal nursing schools in the U.S., and their numbers grew steadily over the next few decades. But for most of the late 19th and much of the 20th century, hospitals were the primary locus of nurse education. Hospital-based “diploma” programs provided on-the-job training for aspiring nurses. In the early days, the programs were loosely structured, of widely varying quality, and included little in the way of academic preparation. In some cases, they could be exploitative, as hospitals brought on poorly-paid trainees more to staff hospital wards than to provide education. A nurse trainee might spend all her time in one understaffed ward and fail to learn about other care settings.⁸ But over time, the programs became more structured, with a core curriculum, supervised learning, and a licensure exam at the end. The emphasis, however, remained on practice over theory. Diploma programs prepared the majority of nurses until well into the 1970s and a small number continue to operate today and provide a pathway to a career as a registered nurse.⁹

The two world wars of the 20th century further expanded the size and profile of the nursing profession; modern warfare increased the demand for modern nurses.¹⁰ But it took until the 1960s before nursing advocates finally convinced policymakers of the need to invest in the professional education of America’s nursing workforce. In 1964, Congress passed the Nurse Training Act, which provided federal funding to establish collegiate programs in nursing.¹¹ Over the next several decades, colleges and universities across the country established schools of nursing and degree programs, gradually shifting responsibility for preparing new nurses away from hospitals and toward higher education.

While universities established bachelor’s degree programs in nursing, community colleges and other private institutions of higher education developed associate degree programs. Both types of degrees prepare students for the licensure examination required to become a registered nurse, which makes the field of nursing quite unusual. In most professions, the educational requirements for licensure or certification are the same for all aspirants. But a registered nurse in the U.S. might have an associate degree, a bachelor’s degree, or a diploma from an accredited hospital-based training program. All are eligible to sit for the NCLEX-RN licensure exam and, if they pass it, carry the title of “registered nurse.”

This ability to enter registered nursing from different degree levels has helped make the profession more racially and ethnically diverse than some other professions that require a bachelor’s degree for entry. However, in a workforce that is currently comprised of 65 percent white women,¹² there is still much progress to be made. The proportion of Black registered nurses is approaching their share of the population, though Black nurses are notably overrepresented in lower-paying nursing occupations that generally require less education, such as licensed practical nurse (LPN).¹³ Meanwhile, the significant underrepresentation of Latinx among licensed practical nurses and among registered nurses at both the associate and bachelor’s degree levels poses an increasingly urgent challenge for the field as the Latinx share of the population grows.¹⁴ In order to cultivate a registered nursing workforce that mirrors the U.S. population, the field will need to ensure that aspiring nurses have financially accessible paths into the profession and to further education as their careers progress.

Increasing equitable access to a career in registered nursing will be critical to continued improvements in the quality of care. Just as research has shown that hospitals with more bachelor-degreed nurses generate better patient outcomes, cultural affinity between patients and caregivers may help reduce health disparities among different racial and ethnic groups.¹⁵ In fact, cultural affinity has been shown to have a larger positive effect on patient outcomes than income or whether an individual has insurance.¹⁶ Caregiving is an intimate and delicate exercise. The tacit knowledge that comes with a particular cultural identity can also help caregivers identify behaviors or underlying conditions that may not be obvious to a caregiver from a different background. When nurses and patients share a common language, religion, or other formative experiences, communication between them can be easier.

The challenge, then, is to figure out how to educate many more nurses to the BSN level without closing down valuable on-ramps to the profession that have been so critical for building a large and diverse workforce. While some groups have called for requiring the bachelor’s degree for licensure, current strategies will not be able to produce enough bachelor’s degree graduates to meet the current demand for registered nurses.¹⁷ The associate degree remains the primary path to licensure. According to the Organization for Associate Degree Nursing, 81,633 associate-degreed nurses received their licenses in 2016 compared to 72,637 bachelor-degreed nurses.¹⁸ If the field is to advance toward its goal of 80 percent BSN without undermining its efforts to maintain and expand a diverse workforce, it will need effective strategies for furthering the education of nurses with associate degrees.