IT IS 50 YEARS since the 1965 Position Paper on Nursing Education was published in the American Journal of Nursing. Since 1965, nursing has continually struggled with attaining and maintaining a BSN-prepared workforce. The most recent HRSA (Health Resource and Service Administration) data report a BSN-educated national nursing workforce at 55.2%, which is the highest in history.1

The authors of the Position Paper did not address the important 1965 legislation of Medicare and Medicaid and what its impact on future nursing demands and workforce needs might be. Essentially, the authors envisioned an orderly transition from hospital-based diploma nursing education programs to a 2-tier system that was based in higher education institutions. These were defined as associate degree (AD) technical nurses and baccalaureate (BSN) professional nurses. Although a lofty goal, the Position Paper itself did little more than to divide the 3 groups that hold responsibility for attaining a BSN-educated profession: nurses in education, nurses in the workplace represented by chief nurses, and individual nurses and students.2

After 1965, nursing education did experience the migration from hospital diploma programs to community colleges and universities and the number of AD programs increased nationally. The drivers of this migration in education were hospitals that were experiencing the high cost of continuing nurse training programs when labor laws began to regulate the free work of students, and the profession itself that pushed for academic-based education.

The workplace demand changed over 50 years. More and sicker patients needed nursing care. Medicare became a primary funding source for health care, and the Medicare reimbursement scheme to hospitals changed from the original cost base to a prospective payment system and incentive structure.3 Chief nurses were challenged to implement cost-effective patient care delivery models. Workplace models migrated from teams composed of aides and LPNs (licensed practical nurses) with fewer RNs to a majority RN workforce, especially in acute care, to meet the more complex care needs of sicker patients. Thus, the pressure on education was to produce more RNs because the service side needed nurses to care for patients, regardless of their basic education. The RN demand was supported by more AD program graduates, especially in rural states.

We must ask ourselves if we do value the BSN in the workplace or do we value the license more than the degree? Is an AD RN with 5 to 10 years of experience more valuable to an employer than an inexperienced new graduate with a BSN degree? Are there any employment guarantees that a new BSN graduate would be hired over a new AD graduate in most settings because there is no difference in what they can do legally?

Yet, we do see some evidence of BSN support in terms of patient outcomes and programs such as Magnet Recognition that values the BSN.4 We continue to ask ourselves if there is a difference between the outcomes of care provided by AD and BSN nurses. Evidence exists about outcome differences in care provided by the BSN workforce.5,6 But even with that evidence, we have not, and perhaps cannot, commit to a BSN workforce yet because there are not sufficient BSN nurses to meet demand.

To maintain the supply of nurses, regulatory boards of nursing did not change licensing laws to conform to the Position Paper proposals, although some states made attempts.7 All RNs, whether they were educated in diploma, AD, or BSN programs, were licensed the same at their entry into practice, and in the workplace, all RNs were equal. That system continues today.

Education has basically done its part to promote the BSN workforce. Creative education pathways have been developed with RN to BSN offered in classrooms and online. Others include the LPN to BSN pathway and AD to MSN options that have all emerged to make it easier for nurses to complete a BSN degree. Dual-enrollment pathways between community colleges and universities allow for less expensive and faster academic progress. Articulation agreements have been negotiated so that credits are more easily transferred between programs and institutions and nationally vetted essential documents exist that help provide curriculum uniformity.8-10 Today, individual academic institutional barriers might need to be overcome, but the models are in place to support academic advancement to the BSN workforce.11

Nurses themselves often lack motivation for academic progression because they are satisfied with their jobs and their educational level allows them to have secure employment. Even if they are motivated to obtain a BSN degree, evaluating the return on their investment when considering their age and overcoming the barriers of cost, time, and geographic or technical access to BSN completion make academic progression less attractive and more challenging. Instead of a unified stand supporting necessary BSN education, many have taken the position that academic progression is an individual professional responsibility, making it a nice to have but not a need to have if you desire to be a staff RN.

The Institute of Medicine 2010 report on The Future of Nursing: Leading Change, Advancing Health and the impact of the Affordable Care Act has prompted Americans to look at how nursing can be a better utilized solution to improve health care nationally. Using RNs in new roles that have greater autonomy and impact on patient outcomes and overall health care requires a better educated workforce.12 The Center to Champion Nursing in America established the Future of Nursing-Campaign for Action in cooperation with the Robert Wood Johnson Foundation and AARP. They have funded multiple state-based nursing action coalitions with the goal of promoting academic progression in nursing and attaining an 80% BSN-educated nursing workforce by 2020.13

Our quest for more BSN nurses in the workforce is a challenge, but evidence shows we are increasing BSN numbers. Each of the 3 groups, educators, employers, and individual RNs who can impact this effort, has different roles to play. While educators introduce creative academic programs, employers must evaluate their hiring practices and the value they place on an education versus a license, and individual nurses must seek resources and invest the 1 to 2 years of study to achieve the BSN degree. The goal that was set in 1965 had an objective that nursing has maintained for 50 years. Although achieving that goal has been slower than anticipated and the goal had minor modifications over time, nursing can achieve the 80% BSN education goal if it continues its current collaborative efforts.

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