Debate Continues on Nursing Degrees

The argument over which degree should be the decisive credential for entry into the nursing profession has been going on for years.

Should the associate degree in nursing or the bachelor of science in nursing give entry into the profession? While different groups have come out one way or the other on the question, the American Association of Colleges of Nursing, which represents four-year and graduate nursing educators, is bringing the issue forward again.

Although AACN has not issued an official statement, it is circulating a draft position called “The Baccalaureate Degree as Entry-Level Preparation for Professional Nursing Practice” in an effort to solicit public opinion on the topic.

The draft paper says the AACN “strongly believes that registered nurses should be minimally prepared with the bachelor of science in nursing or equivalent nursing degree.”

“This statement does not say that nurses cannot enter the profession with an associate degree,” said Robert Rosseter, chief communications officer for AACN, in an email. “The focus here is on academic progression -- moving nurses on to higher levels of education.”

However, more associate-degree nursing graduates receive state licenses than those who have gone the bachelor’s-degree route. Currently, state licensure boards license graduates with either degree. According to the Organization for Associate Degree Nursing, in 2016, 81,633 associate-degreed nurses received their licenses compared to 72,637 bachelor's-degreed nurses. While many of the associate-degreed nurses will go on to receive their bachelor’s and graduate nursing degrees, the associate-degree route is seen as an important and affordable entry into the field.

The AACN draft does acknowledge the historical role associate degree in nursing programs have played in bringing new recruits into the field, especially as university programs have struggled to expand their capacities to meet the demand for more health-care professionals. But registered nurses entering the profession with a bachelor’s degree see “faster salary growth and higher lifetime earnings over the course of their careers. They also have greater opportunities for employment …” The position paper found that 72 percent of nursing directors identified differences in practice between B.S.N.-prepared registered nurses and those with an associate degree or hospital diploma. The paper also cited research that B.S.N.-prepared nurses had better patient outcomes.

Rosseter said the position paper will be reviewed and edited in January and member institutions will vote in March whether to endorse or dismiss the statement.

AACN’s Academic Progression Task Force has been reviewing several models with a goal of increasing the education level of registered nurses as a response to a national call for increasing the education of the country’s nurses. In 2010, the former Institute of Medicine, which is now the National Academy of Medicine, published a report recommending the percentage of registered nurses with a B.S.N. increase to 80 percent by 2020.

Still, the draft led to a joint statement in opposition from the American Association of Community Colleges and the Association of Community College Trustees.

Both groups stated, “While the [AACN] Academic Progression Task Force’s position statement includes good rationale that supports the value of the baccalaureate degree in nursing, we have seen no evidence that the associate degree as the credential for entry into the nursing profession is not preparing students to successfully handle the responsibilities of the job, and that the baccalaureate degree, with its focus on general education courses, will better prepare a nurse.”

ACCT and AACC also pointed out that the associate degree plays an important role particularly in rural communities, doctor’s offices, nursing homes, and urgent- and acute-care facilities.

The community college groups also noted that the associate-degree route helps address critical nursing shortages. “These programs have educated 39 percent of the 2.6 million registered nurses practicing in rural and urban health care settings across the nation,” according to the statement. The Bureau of Labor Statistics estimates that more than 1.2 million additional registered nurses will be needed in coming years.

The majority of the nation’s community colleges offer associate-degree nursing programs. More than 800 out of 1,100 two-year institutions offer the degree path to becoming a registered nurse.

Donna Meyer, chief executive officer of the Organization for Associate Degree Nursing, said she didn’t see anything new in AACN’s statement, that that’s been their view for a long time, and while OADN respects their view, they instead believe the associate degree is also an entry into the field.

“We totally support academic progression,” Meyer said. “Many of the people that teach in the community colleges with doctoral degrees started at the A.D.N. level. It’s a pathway and not everyone can leave their community and go on to university.”

Nursing is just one of a number of allied health fields that have been posing the question of whether or not to increase entry-level credentials into their respective fields, said Mike Hansen, president of the Community College Baccalaureate Association, which promotes four-year degrees at community colleges. For instance, the Accreditation Council for Occupational Therapy Education is currently considering increasing entry-level degree requirements for occupational therapist assistants from an associate to a bachelor’s degree.

Even outside health care, there is a shift in increasing credentials. Earlier this year a new regulation in the District of Columbia increased entry-level credentials for a child-care center director to at least a bachelor’s degree.

Hansen said while the CCBA doesn’t weigh in on the direction these industries take in deciding their requirement standards for entry, it does want the ability for community colleges to respond to the changes.

“The truth of the matter is that for a larger number of students, they have two barriers to obtaining a B.S.N.,” he said. “One is geographic. They don’t live anywhere near where a traditional university baccalaureate degree is available … and the second issue is finances. For many students, the tuition at a traditional four-year university is not something they will be able to afford.”

So, to address those concerns, CCBA is in favor of strong transfer and articulation agreements between community colleges and four-year institutions, creating distance-learning initiatives between institutions, or, more controversially, allowing community colleges to offer those four-year degrees, Hansen said.

The AACN paper also posits that the growth of community colleges’ offering bachelor’s degree nursing programs “underscores the national need for more programs to raise the education level of the nursing work force.”

While OADN supports two-year colleges that are moving in the direction of offering bachelor’s degrees in nursing, less than 5 percent of community colleges are doing so, mostly because of legislative barriers, Meyer said.

As of 2015, Education Commission of the States counted 23 states that allowed community colleges to award bachelor’s degrees, however, only a few institutions in those states could offer the programs. The main arguments against allowing community colleges to offer nursing bachelor's-degree programs have been the competition it could create with universities and the potential to disrupt existing transfer agreements.

But the demand for registered nurses is only increasing. According to the Bureau of Labor Statistics, employment of registered nurses is projected to grow 15 percent from 2016 to 2026 -- faster than the average for all occupations.

“There are going to be a lot of nurses that retire, and health care is so much more complex,” Meyer said. “That’s why the associate-degree pipeline is important.”

There are some hospitals, mostly in major cities, that are requiring the B.S.N. for employment, but registered nurses -- regardless of whether they have an associate or bachelor’s degree -- are in high demand and will continue to be so, she said.

Despite multiple organizations coming down on the side of the associate degree or the bachelor’s as the entry-level credential into nursing, the final decision resides with the National Council of State Boards of Nursing, which is responsible for developing nursing licensure examinations and allows graduates of either degree program to sit for exams.