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 NY Board Claims and Community College Responses 

December 9, 2003

On December 7, 2003, the New York State Board for Nursing voted in favor of implementing a requirement that future associate degree registered nurses practicing in New York obtain a bachelor’s degree in nursing within 10 years of entering practice as a registered nurse or face demotion to serve as a licensed practical nurse (LPN).  AACC opposed the proposal, responding to the Board’s claims as follows:

 New York State Board for Nursing Claims  Community College Response
 The purpose of the proposal to require RNs to earn a bachelor’s degree in nursing is “related to advancing the education of registered professional nurses in New York State.”  For more than 50 years, associate degree RNs have practiced nursing alongside their counterparts from bachelor’s schools of nursing, proving to be professionals valued by health care providers and patients.  RNs graduating from associate degree programs pass the NCLEX-RN at the same rate as do four-year graduates; all RNs share the same scope of practice.  
 The Board for Nursing’s proposal to advance the educational preparation of nurses is by no means a denigration of those fine nurses prepared at the Associate Degree level.  This is not another version of the 1984 Entry to Practice.   Nurses prepared at the Associate Degree level are the backbone of nursing care in hospitals and nursing homes.  The proposal would not affect the licensure of those already licensed as RNs.  Most importantly, it would continue to permit nurses to be prepared at the associate degree level. If implemented, AACC believes that the Board’s proposal would negatively impact currently licensed RNs who practice under the authority of the associate degree in nursing, possibly causing them to leave the profession, by creating a two-tiered RN workforce.  In addition, the proposal would increase both the time and costs of nursing education, discouraging students from choosing nursing as a profession.  Furthermore, New York residents may chose to leave the state to pursue nursing education and practice as North Dakota recently learned. (North Dakota—the only state in the nation requiring a bachelor’s degree to practice as an RN—recently overturned this requirement after more than 200 students left North Dakota in 2002-03 to study nursing in Minnesota.) 
 Late or deferred entry into nursing has become typical for nurses graduating since 1990.  However, the later pursuit of the basic education credential is far more pronounced among those entering via the associate’s degree career path than those entering via the longer four-year bachelor’s path.  Bachelor degree entrants to the profession are younger than their associate degree counterparts by about 6 years and thus available to the workforce for a longer period of time.   This conclusion is illogical.  The Survey of New York State Registered Nurses recommends focusing recruitment efforts on bachelor’s programs to improve career longevity, not requiring associate degree graduates to earn a baccalaureate for that reason.   The older associate degree graduate who continues her or his education to the BSN level is not going to get any younger in doing so, and will not be "available to the workforce for a longer period of time."
 Nurses entering the profession with a baccalaureate degree are much more likely to be a member of a minority group than RNs with other basic credentials.  Thus, the argument that a baccalaureate degree requirement would prevent access into the profession for persons historically underrepresented, does not reflect the reality of education pursued by many minority nurses.    Nationwide, more minorities practice with the AD than with the BS in nursing.  The 2002 IPEDS Completions survey preliminary data indicate that 11.3 percent of ADN and 11.0 percent of BSN graduates of U.S. colleges and universities were African American, whereas 7.0 percent of ADN and 6.4 percent of BSN graduates were Hispanic.  Even if it were true that more minority graduates held BSNs, ADN graduates are not going to become minorities by obtaining the BSN.  New York’s large proportion of foreign-educated nurses, 84 percent of whom are minorities, provides the state with a larger percentage of minority BSNs than is represented nationally.  The Survey of New York State Registered Nurses reports “RNs educated outside of the U.S. account for 45.8 percent of the State’s minority RNs.”   Foreign-educated nurses are disproportionately educated at the bachelor’s level or higher, accounting for 19.2 percent of nurses with a baccalaureate as their initial degree and 20.6 percent of nurses with a master’s as their initial degree.  However, foreign nurses represent only 12.4 percent of New York’s nursing workforce. 
 RNs whose basic credential is a bachelor’s degree are 2 ½ times more likely to advance to a higher degree than their associate degree entrant counterparts.  For example, 27% of RNs prepared at the bachelor’s degree level also hold a master’s degree and about 23% report planning to pursue a master’s degree within the next two years, while only 9% of RNs prepared at the associate degree level have advanced to the master’s level and 11% report plans to obtain a master’s degree within the next two years.   Forcing ADNs, who have chosen the most efficient path to receive the education necessary to care for patients, to obtain a BSN is unlikely to result in their pursuing a master's degree.  The Survey of New York State Registered Nurses reports that “thirty percent of those whose initial preparation was an associate degree also hold a higher credential [including bachelor’s degrees], while over a quarter (27 percent) of bachelor’s-prepared RNs hold a higher credential.”  This shows that most ADNs who obtain the bachelor’s degree do not continue on to obtain a master’s degree.
 When respondents were asked what course of study they would recommend to future entrants into the profession, close to 80% pointed to a bachelor's degree program or higher.  It would appear that nurses understand the worth of the baccalaureate degree.     Overall, nearly 70 percent of respondents to the Survey of New York State Registered Nurses recommended that nurses obtain bachelor's degrees initially.  This does not translate to the bachelor's degree being necessary to enter nursing and is most likely attributable to status in obtaining a higher degree.   In reviewing this finding by degree and by year of graduation, only 56 percent of associate degree-prepared nurses, and only 55 percent of nurses who graduated since 2000, recommended the baccalaureate as the initial nursing degree.  Forty-one percent of recent graduates recommended the associate degree as the initial degree.  As a result of these findings, the authors of the report note that “as policymakers weigh the desirability of the extensive educational investment required by bachelor’s degree programs, they must also weigh the risks to the nursing supply that could come with a heavier reliance on [these] programs….[H]ow many of the nurses who entered with an associate degree would have opted for a career in nursing had they been obliged to complete a bachelor’s degree instead? It does seem likely that many mid-life entrants to the profession would balk at such a sharp increase in their investment of time and money to become a nurse.”  A four-year commitment at significantly greater cost—$3,746 compared to 1,379—is likely to drive away mid-life entrants to nursing.  

Changes in the health care field require practitioners with highly specialized, "deep" content knowledge.  Accordingly, organizations such as the American Association of Critical Care Nurses (AACCN) have acclaimed the bachelor's degree program as the standard of nursing preparation.   

 All nursing program graduates take the same licensure exam (NCLEX-RN) to practice as Registered Nurses which ADNs pass at the same rate as their counterparts from four-year nursing programs.  In addition, all RNs are educated to perform the same responsibilities—BSN programs do not educate specialty nurses.   The majority of new nurses, approximately 60 percent, are educated in associate degree programs, and the Survey of New York State Registered Nurses report “suggests that having a relatively quick and low-cost entryway to nursing will enhance [the] labor market’s ability to respond to shortages while encouraging a broad range of individuals to consider a career in nursing.”  While we do encourage nurses to continue their education, we do not believe it should be mandatory. 
 The bachelor's degree is required to be employed as a public health nurse.      Each Health Department sets its own hiring practices and many do hire associate degree nurses (ADNs).  For example, at the Montgomery County Maryland Health Dept., with a highly educated populace, ADNs serve in Public Health roles. 
 The bachelor’s degree is required by the Armed Services.    Approximately half of all nurses practicing in military hospitals are civilian nurses who may practice with diplomas, associate or bachelor’s degrees.  Military nurses are all officers, and all officers are required to have bachelor's degrees. 
 The bachelor’s degree is required by Veterans Health Administration facilities for promotion by 2005.      This may be changing as the U.S. House of Representatives has passed legislation to overturn the bachelor’s degree requirement for promotion in the VHA system.  A waiver system allows ADNs to receive promotion without the BSN.
 The bachelor’s degree is the standard of education among many foreign countries.     Approximately 45 percent of all U. S. undergraduate college students attend community colleges whereas associate degree programs are less prevalent in foreign countries.  Additionally, foreign associate degree programs generally have a technical rather than an academic focus.  
 The most acute shortages of experienced nurses now faced by the profession are in specialty areas where more advanced education and skills are required.     All RNs are educated to perform the same responsibilities—BSN programs do not educate specialty nurses.   Advanced education is available to ADNs who may enroll in over 150 RN to MSN (Registered Nurse to Master’s of Science in Nursing) programs without obtaining a bachelor’s degree, including  13 New York colleges and universities:  Adelphi University,  Columbia University in the City of New York, Daemen College, D'Youville College, Excelsior College, Long Island University, Molloy College, Pace University, The Sage Colleges, State University of New York Institute of Technology at Utica-Rome, State University of New York at Buffalo, Syracuse University, and the University of Rochester.
 Studies such as that by Aiken, et al, (September 2003, JAMA) show a relationship between the number of nurses employed in a hospital, educated at the baccalaureate level or higher, and mortality and failure-to-rescue rates of surgical patients.     Aiken’s study is inconclusive and does not warrant implementing changes in nursing education.  (See analysis of study.)  Other studies indicate no effect of education on quality of care while others show that some aspects of care are performed better by AD nurses.  By far the most significant finding from the Aiken study—a retrospective study based on a secondary analysis of data collected in a study designed for another purpose (to look at staffing ratios)—was that receiving care by board-certified surgeons increases patient survival following surgery.  
 The need to advance the educational requirements of nursing is needed now more than ever before as patient care becomes more and more complex.   I ask for your consideration and support for this proposal.      For more than 50 years, associate degree RNs have practiced nursing alongside their counterparts from bachelor’s schools of nursing, proving to be professionals valued by health care providers and patients.  RNs graduating from associate degree programs pass the NCLEX-RN at the same rate as do four-year graduates; all RNs share the same scope of practice.  

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