Skip to main content

NY Health System’s Bold Stance on Nurse Preparation

 |  By  
   July 20, 2010

Why do you need so little education to be a nurse? Physical therapists are required to have a doctoral degree for entry into practice. Speech therapists need a master's. But the most important figures in patient care can enter practice with only an associate's degree.

It's an issue that has puzzled me for the last five years as I have devoted my professional career to writing for and about nurses. I am not a nurse, no surprise there, and as I've studied, befriended, and generally immersed myself in the world of nursing, I am amazed that an associate degree-level education is all that's required for entry into practice.

Before you start sending me hate mail, let me be clear that I am not denigrating associate degree nurses. I applaud you. In an increasingly complicated healthcare environment, where nurses care for multiple patients with more complex needs than ever before, it takes a lot of intelligence, skill, mental agility, resourcefulness, empathy, and courage to be a good nurse, and I commend those of you who do this—and who learn to do it well—without years of education and training.

The debate about entry to practice is almost as old as the profession itself. Studies have shown that if you test associate and baccalaureate nurses at graduation they are relatively equal in their skill sets. But modern nursing requires more from nurses than simple task completion. It requires critical thinkers who can operate in a high-tech environment as skilled professionals who practice based on best evidence and research.

I asked Maureen White, RN, senior vice president and chief nurse executive of 15 hospital North Shore-LIJ health system, what she thought the main difference is between associate and baccalaureate-prepared nurses.

"I think it's their level of critical thinking," says White. "The inquisitive nature that you tend to get in a baccalaureate program as opposed to other kinds of programs. I just think it's a different mindset, a different focus that you learn at the baccalaureate level because of the number of years you have to go through for a baccalaureate as opposed to an associate program. You get a longer period to really hone your critical thinking abilities in a baccalaureate program."

North Shore-LIJ has just made the decision that all newly hired nurses will have a baccalaureate degree or they will earn one within five years.

Although professional associations and researchers have called for baccalaureate to be the entry level, the profession has always resisted it. Most recently, the biggest stumbling block has been the chronic nursing shortage. How can we limit entry when the nation is about to be desperately short of caregivers? I don't have an answer for that, and so it surprised me to see a large New York State healthcare system make such an announcement. Where will they get enough nurses?

White said they're not focusing on that. They simply made the decision that baccalaureate nurses provide better patient care.

White cites the work by Linda Aiken, which examined patient outcomes and how they are linked with educational preparation of nurses. White says the study has been duplicated several times and always produced the same results.

"This is something we have been discussing for quite some time now," says White. "There have been many studies done, all coming up with the same results that the more highly educated the bedside nurse is, the better the quality outcomes for the patients. Mortality is reduced, adverse events decrease, there are decreases in failure to rescue. For myself that was true evidence that there is something to be said for higher levels of education."

White says the organization felt a responsibility to provide patients with the best care possible. "If there are studies that have shown that having staff nurses at a baccalaureate level reduced adverse events and improved quality of care, then we have a responsibility to follow that study," she says.

The area North Shore-LIJ serves is not suffering a shortage right now. "Within our health system we have less than a 3% vacancy rate for our positions," she says. "Our turnover rate is less than 6% for RN positions."

She expects to see the shortage return once the economy picks up. An aging baby boomer generation may also bring the shortage back to her area.

"It wasn't for an economic reason that we did it. It wasn't because it was politically the correct thing to do. It wasn't based on what if we can't find them," White says. "We believe that no matter how many nurses we have, even if there comes a point in time down the road where there will be fewer nurses in the workforce, that doesn't detract from the studies that have been done that show whatever nurses you have you would want them to be as highly educated as possible in order to provide the highest level of care to your patients. This is something we felt was the right thing to do, the right thing for our patients, and we were going to do it."

If North Shore-LIJ hires non-baccalaureate nurses, it will provide tuition reimbursement and requires those nurses to obtain their baccalaureate within five years.

The requirement goes into effect on September 1. Existing staff are grandfathered in and exempt. White says that the system has more than 460 nurses enrolled in baccalaureate programs and another 200 or so are enrolled in master's degree programs. "We have for years had a very good tuition reimbursement program in which we've encouraged our nurses to go back to school to achieve their baccalaureate, if not master's and doctoral degrees. We have put a tremendous amount of money and effort into advanced education even prior to this new policy change," says White.

I hope North Shore-LIJ will inspire other systems that have the resources to support nurses through further education to follow suit. We know that healthcare delivery will only become more complicated and will need an ever more educated workforce to provide it. It's time for nurses to keep up.

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

Tagged Under:

Get the latest on healthcare leadership in your inbox.