Career Center » Fuss

What’s all the Fuss? Working Towards a Baccalaureate or Graduate Degree in Nursing
by Liana Orsolini-Hain

You worked hard to get into nursing school. You struggled through 2-3 years of completing pre-requisites to enter an associate degree in nursing (ADN) or diploma program and are in the midst of at least another two years to complete it. You look forward with nervous anticipation to your first job as a registered nurse (RN) after you pass the state board exam. You also look forward to the increased quality of life that a substantial salary increase will mean for you and your family. So why continue on with school? Aren’t all nurses who pass the same exam competent to practice nursing? Why fuss over different nursing degrees?

Does My Degree Level Really Affect Patient Safety?

Earning an ADN or diploma in nursing and passing the board exam to practice nursing is a great beginning for what will be a longer journey. Many voices are calling for a more educated nursing workforce to better meet complex patients needs. Motivating factors for these voices are likely related to the results of three studies that took place recently in the United States and Canada that consistently linked an increased proportion of RNs with baccalaureate degrees in acute care hospitals with significantly decreased patient mortality rates (Aiken, Clarke, Cheung, Sloane & Sliber, 2003; Estabrooks, Midodzi, Cummings, Ricker & Giovanetti, 2005; Tourangeau, et al., 2006). Combined, these studies examined almost 300 hospitals, about 300,000 patients and almost 23,000 nurses. The data is compelling and cannot be ignored. No one to date is able to explain why having at least a baccalaureate degree in nursing was associated with a lower mortality rate, but there are some possible explanations based on other studies of RNs returning to school.  

Returning to School Was Worth It

Although many RNs who consider returning to school do not believe advancing their degree in nursing will change their practice, several studies show otherwise. RNs reported transformative experiences when returning for their baccalaureate degree in nursing, which included raising their potentials, changing their perspectives about nursing practice, and being able to finally “see the big picture” (Delaney & Piscopo, 2004 & 2007; Hillsmith, 1978; Lillibridge & Fox, 2005; Rather, 1992; Rush, Waldrop, Mitchell, & Dyches, 2005). RNs reported noticing subtle changes in their perceptions which included changes in thinking, reasoning and questioning skills (Delaney & Piscopo, 2007; Leonard, 2003). Although RNs felt they returned to school as skilled, knowledgeable and professional practitioners, they reported growing beyond their expectations in areas of knowledge and professionalism, which they felt led them to become more effective change agents and patient advocates (Delaney & Piscopo, 2007; Leonard, 2003; Lillibridge & Fox, 2005; Rush, Waldrop, Mitchell, & Dyches, 2005; Zuzelo, 2001). Nurses also reported that they changed the way they practiced nursing and felt more like a nurse than ever before because of how differently they were thinking after earning a baccalaureate degree (Delaney & Piscopo, 2007). These nurses felt returning to school for a baccalaureate of science in nursing (BSN) directly benefited their patients (Delaney & Piscopo, 2007).

Forces Pushing For a Better Educated Nursing Workforce

Is there anything else motivating the voices that are calling for a better educated nursing workforce? The Institute of Medicine’s (IOM) report, “To Err is Human: Building a Safer Health System,” reported that up to 98,000 patients die needlessly in the US each year due to medical error (Kohn, Corrigan, & Donaldson, 1999). Since most of these errors were due to system and process problems, it would seem that BSN and higher educated nurses are prepared the best to implement solutions because the curriculum emphasizes leadership and management (American Association of Colleges of Nursing [AACN], 2007).  In the years following the IOM report there has been a renewed call for either a higher percentage of BSN prepared nurses or for making the BSN entry level into nursing practice (AACN, 2000; National  Advisory Council on Nurse Education and Practice [NACNEP], 2001; Reams & Stricklin, 2006).

Where are these voices coming from? The American Nurses Association (ANA) has been calling for the BSN as entry level into nursing practice since 1965 (Haase, 1990). Moreover, ANA developed the Magnet Recognition Program® to promote quality and excellence in patient care delivery in hospitals by nurses in professional practice (American Nurses Credentialing Center, 2008).  Magnet hospitals have a significantly greater percentage of BSN prepared nurses than AD prepared nurses and many hospitals are seeking Magnet Recognition (Aiken, Havens, & Sloane, 2000).  One of the forces of magnetism, professional development, encourages the formal educational development of nursing staff, which includes higher degree attainment in nursing. The National Advisory Council on Nurse Education and Practice (NACNEP), an advisory board to the Secretary of the U.S. Department of Health and Human Services (USDHHS), has repeatedly called for increased percentages of BSN and higher degree nurses in practice (NACNEP, 2001; Reams & Stricklin, 2006). The AACN and the American Organization of Nurse Executives (AONE) believe that BSN education prepares nurses for the expanding role of the nurse, the acceleration of health care delivery changes, and the increased emphasis on community centered care (AACN, 2000, AONE, 2008).

How can we produce an educated nursing workforce for the ultimate good of our patients? Currently about 60 percent of RNs are being prepared with an associate degree (National League for Nursing, 2006), and three percent are being prepared at the diploma level (USDHHS, 2004). As of 2004, only 21 percent of associate degree graduates returned to school to pursue a BSN (Spratley, Johnson, Sochalski, Fritz & Spencer, 2000; USDHHS, 2004). Shocking is the statistic that only 13 percent of nurses hold masters or doctoral degrees (USDHHS, 2004). As nurses with more advanced degrees retire, who will be left to replace nursing faculty or work in the role of the advanced practice nurse? Clearly, we need to decrease barriers while increasing incentives so nursing students can easily and seamlessly continue on with their nursing education.

Options for Returning to School

The Oregon Consortium of Nursing Education co-enrolls nursing students from community college nursing programs in the Oregon State University School of Nursing.  Nursing students need not re-apply to stay in school to earn a BSN after completing their ADN. Their financial aid follows them to the University and they can complete their BSN in a little over a year (Gubrud-Howe, et al., 2003; Tanner, 2007). Consortiums that aim at seamless transitions between undergraduate degree programs are being formed across the US (McNamara, 2000; Sizemore, Robbins, Hoke, & Billings, 2007; Williams, Hall, & Papenhausen, 2005).

Students in ADN or diploma programs who already have a baccalaureate degree in another field may find it difficult to earn a second baccalaureate degree depending on state university policy. After graduating, these students may be well served entering a generic master’s degree program to prepare them to sit for the RN licensure. Many healthcare facilities hire master’s prepared new graduates because they know they will eventually catch up with their bedside experience. In addition new ADN and diploma graduates can acquire positions in health care organizations tht offer tuition reimbursement and other incentives for employees to pursue advanced nursing degrees.

Online degree programs in nursing have been increasing in number and in quality. When the School of Nursing at Medical College in Georgia discovered that 80 percent of Georgia’s ADN and diploma prepared nurses were employed full time in rural communities with no physical access to a university, they created an on-line RN-to-BSN program (Bentley, Cook, Davis, Murphy, & Berding, 2003). Graduates of this program were surveyed and reported 100 percent satisfaction overall and were in total agreement that this method of delivery was significantly more flexible than on-site classroom meetings. Every year admissions into this program increase by at least 25 percent, and after just three years, enrollment doubled (Bentley, Cook, Davis, Murphy, & Berding, 2003).

Academic institutions are becoming creative and are bringing BSN programs to the workplace (Cheung & Aiken, 2006). This eliminates the time, hassle and expense required to physically travel to the university. When time is in short supply, these creative solutions make a significant difference.

Pursuing Incentives to Return to School

ADN and diploma graduates should research which potential employers offer incentives to return to school. While tuition reimbursement is helpful, it is even better if tuition is paid up front. Are potential employers and unit managers flexible enough to schedule your work hours around your class schedule? Does the employer offer a sabbatical of one or two days off per week with pay to facilitate the time you need to study and complete school assignments? Will your benefits continue if you need to reduce your work hours to ensure success in completing the program? Once you earn your degree will you receive a pay differential or be rewarded by placing you on a higher rung on a clinical ladder?


I would be remiss if I did not share my own experience of what finally pushed me to return to school for a master’s in nursing after practicing nursing for eight years with my initial degree, a BSN. I discovered I loved teaching undergraduate nurses while a staff nurse in a hospital where they had their clinicals. I soon started teaching an ADN program part-time for a local community college. Although I knew I could not earn tenure in a community college without a master’s degree in nursing, this was not enough to motivate me to return to school. Finally, a PhD prepared nursing instructor told me the magic words, “Liana, don’t do it for job security, do it for you!” It had never occurred to me that returning to school for an advanced degree in nursing was what I needed to do for me. Three years later, I earned a master’s degree in critical care and trauma nursing from the University of California, San Francisco (it took me one year to apply and prepare my life to return to school). I was amazed that getting a master’s degree in nursing felt like someone had opened my brain with a can opener. It was incredulous because what I learned from the program affected my thinking in all aspects of my life. Earning an advanced degree in nursing certainly increased the quality of my life, my nursing, and my teaching practice. Ten years after earning that master’s I returned to school and recently completed my PhD from the same university. I have no regrets and neither will you!


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Liana Orsolini-Hain, PhD, RN, is a Nursing Instructor at the City College of San Francisco.