The BSN as the Entry Level to Practice: Time to Reconsider?

A National Council of State Boards of Nursing (NCSBN) and National Forum of State Nursing Workforce Centers study issued on April 13th of this year estimates that 800,000 nurses will leave the profession by 2027. Let me repeat that: 800,000 nurses will leave the profession by 2027. When one combines this number with the mere 100,000 nurses who left the profession during the pandemic, this exodus equates to one-fifth of the 4.5 million nurses currently in today's workforce. Of this 800,000, NCSBN reports that 24% of these are younger nurses, as compared to previous reports predicting that the primary exodus from the profession would be of nurses nearing retirement age. The primary reasons cited for leaving include stress and burnout. While the primary drivers of this stress and burnout are not mentioned in this report, I would wager that understaffing with associated extreme workload levels are to blame.

Given this most recent hailing of the dire state of nursing in the United States, and around the world, I continue to ponder the efficacy, and the simple logic of continuing to advocate for the BSN as the entry level to professional nursing practice. The early exploration of the BSN as entry level to the profession was initiated in 1960, with the first formal recommendation issued in 1965, and last updated in 2000 by the American Association of Colleges of Nursing (AACN). While the primary premises surrounding the ever increasing complexities of health care that have long driven this recommendation still hold true, one wonders if the profession will ever reach, or even be able to survive with a baccalaureate as a single point of entry? Will the national health care system survive with a single level of entry? Does a single level of entry positively impact the quality of nursing care delivered at the bedside? What is the impact of a single, baccalaureate level of entry on the gender, racial, cultural, and socioeconomic diversity of the nursing profession? Can the profession be reflective of the patients we serve if entry to the profession is prefaced on the completion of a 4-year, university degree? If nurses are indeed leaving the bedside, and often the profession after 3 to 5 years of experience, do we not have bigger problems to solve than entry into practice?

There have been numerous studies examining the effect of BSN-prepared nurses on various patient outcomes. These studies, however, were conducted prepandemic, were derived from large data sets, and failed to control for numerous confounding variables. As noted in a 2017 opinion piece, there is no hard evidence evaluating all possible variables associated with the impact of nursing care on patient outcome, to include the combined effect of staff mix and experience, RN education, and work environment. It is time to dig deeper.

It is also time to face the reality that the US health care system, and particularly the acute care delivery system, is on the brink of utter collapse; an event that will be accelerated without the rapid expansion of wider, more diverse and easily accessible avenues to a nursing career. For many years, I advocated that indeed the BSN should be the preferred route of entry into the profession. I do still think that the BSN is the most rapid route to advancement in the profession, if advancement into management, education, advanced practice, or research is what one desires. We must, however, embrace all avenues of nursing education if we are to survive the current crisis and maintain the stability of the US health care system, all while increasing the diversity of the nursing profession. In doing so, however, we should also realize that the Associate degree should never be the end goal. There must be the expectation that the ADN nurse will advance to a minimum of a BSN, ideally within 3 to 5 years of entry into practice, The fundamental content that differentiates a baccalaureate nursing education from an associate's degree includes structured exposure to leadership and to management principles, principles of incorporation of research in practice (evidence-based practice), societal health concerns, as well as community health. This content is critical to the ongoing comprehensive delivery of quality patient care across a wide variety of patient populations and care delivery environments.

We must also re-evaluate traditional pathways to the BSN and advanced nursing degrees (Figure 1). To create a viable, sustainable pipeline into a nursing career, we must consider a pipeline with multiple entry and pausing opportunities (Figure 2). This multifaceted pipeline must begin with early recruitment and exposure to the nursing profession, starting in middle school and accelerating through high school, with structured learning opportunities in the clinical setting. Health care facilities, in collaboration with our academic partners, must explore apprenticeship models to financially support advancement through the pipeline, to include creative approaches to assure that learners can simultaneously work and earn a living wage while pursuing a nursing degree.

The path to the stabilization of the nursing workforce will not be easy. It will require creative thinking and collaboration. Clinical and academic leaders must shed current outdated perspectives in an effort to make way for more creative approaches to career progression, education delivery, and clinical training. Specialty areas, such as perianesthesia nursing, must also learn to think out of the box. Where are there opportunities to provide learning experiences and opportunities for exposure for high school students? How can we incorporate patient care techs/certified nursing assistants and LPNs into our practice setting, and support them as they advance their education while continuing to work and contribute on our units? We have much to offer to the growth of the nursing profession if we are only brave enough to think out of the box and pursue new ways of actualization. The viability of the nursing profession, of the health care delivery system, rests on our shoulders. Are we brave enough to find a new pathway to stability and success?