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3 Obstacles to Higher Education Levels in Nursing

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   August 23, 2011

Evidence shows that patient outcomes improve when nurses have baccalaureate degrees. The Future of Nursing, the influential IOM and Robert Wood Johnson study, has called for 80% of RNs to have a baccalaureate degree by 2020.

Patients are sicker and healthcare is more complex than ever and we need a highly educated nursing workforce to cope. At the grassroots level, however, there is little impetus to change.

Only 56.4% of nurse leaders believe that entry into practice should be at the baccalaureate level, according to a recent survey by Nursing Management. The national survey questioned more than 2,800 nursing leaders across the U.S. and Canada.

Another survey last week on www.StrategiesForNurseManagers.comasked the same question and only 43% responded that four-year degrees should be required for entry into practice. This survey also asked whether nurses should be required to obtain a BSN within a few years of entry into practice. Forty-one percent said yes and only 15% said associate degrees were sufficient.

Why aren't nurse leaders keen to have staff prepared at a higher educational level that will result in better patient outcomes?

1. Supply and demand.

The nursing shortage is real. In a few years we'll be struggling to find enough nurses to fill vacancies. Nurse leaders worry that if BSN becomes a requirement for entry into practice it will be impossible to find enough nurses.

This is a huge problem for nursing and healthcare in general and we need to find a multitude of ways to fix the impending nursing shortage. With the looming disruption caused by retiring baby boomers, it's admittedly a bad time to call for a requirement that will limit the number of RNs.  

That's not a reason to abandon it entirely. Nurse leaders can read the evidence as well as anyone. If we recognize that BSN nurses result in better patient outcomes, then let's start planning for how to get there. Some hospitals have a requirement that nurses obtain a BSN within a certain number of years after entry to practice. More hospitals need to start this.

We need to place higher value on further education and make it easier for nurses to work and study. Many hospitals offer tuition reimbursement, which helps make the prospect of further schooling manageable. Hospitals must ensure that education is emphasized and valued and that nurses are encouraged if they want to do this, for example by being flexible with scheduling.

2. We don't want to hurt anyone's feelings.

The majority of RNs don't have a four-year degree. And most of these nurses are dedicated, accomplished clinical professionals. They point out that most new associate degree nurses have more clinical experience coming into practice than those with BSNs. It's arguable that associate degree nurses are actually better nurses in the first year of practice because they've had more clinical experience. But here's the rub. This isn't evidence, its observation. It's not scientific data collection and analysis of patient outcomes over the long term.

If you're not a nurse, you cannot comprehend the level of passion this topic engenders. I have been flamed by nurses for appearing to suggest that BSN-educated nurses are in some way "better" than associate degree nurses.

There is no "better" or "worse." Most of what makes a good nurse is learned on the job, caring for patients and gaining practical experience. The average age of nurses is 46 and they have decades of experience that have made them competent professionals. I would guess that years of on-the-job experience trump classroom education.

Imagine, though, what additional education could do.

Nurse leaders need to have a sensible discussion about this without being overly concerned about hurt feelings among staff.  

3. We ignore evidence.

Much of rank-and-file nursing lags in incorporating evidence-based practice. When you're a nurse in the trenches putting patients needs before your own and helping get them well—or at the least, trying to stop them dying on your watch—there's little time to worry about the latest evidence.

The profession, however, needs to become more comfortable with evidence as a basis for daily practice. Nurse leaders should take the lead so that nurses become confident and comfortable with evidence, both clinical and non-clinical issues. To support their arguments for safe patient care and the importance of having enough time at the bedside nurses must be comfortable with research so they stop talking from the heart and talk from the head.

If nurse leaders aren't comfortable with evidence-based practice and research they are letting down their organizations.

Many argue that it's easier in urban settings to encourage nurses to pursue higher education as there are more options. Nurse leaders in rural hospitals shouldn't take that as an excuse to give up. Subscribe to professional journals, read them, and encourage staff to read them. Have the medical staff invite nurses to clinical meetings so they are exposed to the latest research and discussions about patient care.

Make sure staff has Internet access on worksite computers so they can conduct professional literature searches. You don't want them checking Facebook when they are supposed to be working, of course, but if you hold staff to a high degree of professionalism, they're not going to do that anyway. 

Consider professional development activities that promote evidence-based practice. Don't think that being a small, rural hospital precludes such activities. Look at Barbara "BJ" Hannon, MSN, RN, CPHQ—chosen as one of the 20 people making healthcare better in 2009. She regularly travels to small hospitals around rural Iowa to educate staff on evidence-based practice and how to get started.

Having more nurses educated at a higher level isn't an either/or choice. The choice isn't between having enough nurses to meet demand OR having more highly educated nurses. If nurse leaders get behind the cause, hospitals can have both.


Rebecca Hendren is a senior managing editor at HCPro, Inc. in Danvers, MA. She edits and manages The Leaders' Lounge blog for nurse managers. Email her at

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