Abstract: In the United States (U.S.), the nursing profession has evolved with efforts in advancing the professional role of the registered nurse (RN). Recent studies provide evidence supporting that RNs must pursue a baccalaureate degree (BSN) or higher for consideration in the workforce. The minimum education requirement suggests that BSN-prepared nurses are better qualified to enhance patient safety and lower patient mortality and failure-to-rescue (failure to prevent deterioration) rates. This renewed focus indicates that a nursing shortage does not exist; however, many hospitals may not consider non-BSN graduates for employment. High patient-to-nurse ratios not only negatively impact patient outcomes but result in higher burnout rates and decreased job satisfaction. Recent studies suggest there is no clear differentiation between the associate degree (ADN) and BSN-RN practice at the patient’s bedside. ADN-RNs are qualified to perform the same skills as the BSN-RN at the bedside, while the BSN-RN is trained to perform managerial tasks outside of the patient’s room. The purpose of this paper is to address the lack of differentiation between ADN and BSN nursing programs and recommend a solution to the current high patient-to-nurse ratios.
The Magnet Recognition Program is an evidence-based intervention to achieve better patient outcomes while providing a better work environment (Kerfoot & Douglas, 2013). Magnet hospitals are considered to be the highest ranked organizations in the healthcare field due to successful retention rates of qualified nurses and reputable work environments. The Magnet culture has gained recognition with an increase of about 8% of hospitals nationwide. Magnet hospitals hold the benchmark standard in national hospital rankings by following the evidence-based practice and are associated with more specialty-certified nurses, nurses with higher education levels, favorable working environments, and lower patient-to-nurse ratios. These factors result in lower patient mortality rates (McHugh et al., 2013). Many hospitals across the US aim for Magnet status by following the standard staffing requirements based on research. The requirements state nurses should obtain BSN degrees or higher for consideration of employment. Despite arguments suggesting that RNs must earn a BSN degree or higher, no clear evidence indicates a marked difference in skillsets between ADN- and BSN-prepared nurses at the bedside.
The “original” Magnet hospitals were formed in the 1980s and held a reputation of having excellent work environments resulting in lower burnout rates, and higher job satisfaction. In the 1990s, the American Nurses Credentialing Center’s (ANCC) Magnet Recognition Program was formalized to identify hospitals that followed the original standard. Lower fall rates and lower mortality rates among Medicare patients, deficient birth weight infants, and postoperative surgical patients are reported in Magnet hospitals. However, Magnet research does not specify the effects of nurse staffing levels for bedside nurses. Research is designed to analyze the organizational structure of the work environment and its impact on patient outcomes. While many RNs across the US experience burnout and job dissatisfaction due to unfavorable work environments, such as those caused by high patient-to-nurse ratios, numerous studies note an association between high workloads and low staffing, resulting in “high patient mortality and failure-to-rescue rates” (Buerhaus et al., 2005). In 2002, California was the first state to mandate patient-to-nurse ratios to improve patient care and surveillance. Hospitals adhering to the Magnet recognition program standards achieve successful retention rates of qualified nurses and provide favorable work environments (McHugh et al., 2013).
In the 1980s and 1990s, the proportion of women under 30 years of age who chose registered nursing as a profession declined from 30% to 12%, while the average age of RNs increased from 37.4 to 41.9 years (Auerbach et al., 2011). A shift toward entry into nursing at a later stage in life was trending. Unless the downward trend was corrected, a large number of RNs were set to retire, and a looming nursing shortage would occur. Shortfalls of about 400,000 RNs were expected by the year 2020. Recruitment initiatives were set by organizations nationwide to make nursing a more attractive career choice. An increase in two-year associate degree programs occurred and new methods were implemented in baccalaureate programs that attracted more applicants, particularly women in their late 20s and early 30s (Auerbach et al., 2011). For example, the number of accelerated baccalaureate degree programs offering a BSN increased from 84 to 231. Additionally, the number of federal funds, such as loan repayment programs and monies for baccalaureate- and master’s- level nursing education, increased to $240 million in 2010 from $80 million in 2001. Employers offered tuition benefits, sign-on bonuses, flexible work schedules, and increased salaries. Additionally, employers implemented mentorships for new graduates, nurse recognition events, financial incentives for quality improvements, and career development programs.
The first nursing shortage occurred from 1990 to 1992 and was the result of a national average of an 11% increase in hospital registered nurse (RN) vacancy rates. The brief shortage only lasted two years, and observers predicted an oversupply of nurses shortly. In 1998, hospitals experienced the second shortage of the decade. It began in intensive care units (ICU) and expanded to medical and surgical units by 2002. By 2001, the national average hospital RN vacancy rate increased to 13%, and nearly 1/5 of hospitals reported having an increase of 20% in vacancy rates. According to an American Hospital Association survey (2001), 126,000 full-time RN positions were vacant in 2001. The federal government reported that demand exceeded the supply of RN nurses by 110,000 in 2002. National surveys said that nurses felt “burned out” and “dissatisfied” with the workplace environment (Aiken et al., 2001). For nearly eight years, the nursing shortage became the longest lasting in 50 years. Analysis of the United States labor market showed positive economic trends in RN wage increases. An additional 185,000 RNs were hired by 2003, including RNs over the age of 50, RNs under the age of 35, and foreign-born RNs (Buerhaus et al., 2005). Problems associated with the nursing shortage have a substantial impact on the quality of work life, quality of patient care, and the amount of time spent with patients (Buerhaus et al., 2005). It also affects the early detection of complications, and the ability of nurses to maintain patient safety.
Predictions by Buerhaus et al. (2009) suggested a shortage of RNs by 2018 that would grow to about 260,000 by 2025. This projection is due to the large baby-boomer RNs nearing retirement and being replaced by a smaller workforce of RNs to follow. The nursing profession made new efforts to further the level of education of RNs in more recent years. Research by Aiken at al. (2002; 2003; 2013), which covered a 12-year period, suggests that RNs who deliver patient care should obtain a BSN degree. The studies showed improved patient outcomes as evidenced by decreased patient mortality rates relating to an increased number of BSN-prepared RNs. As a result, state legislatures, the Institute of Medicine (IOM) Future of Nursing Report, and the American Nurses Credentialing Center (ANCC) Magnet Recognition Program made an effort to increase the percentage of BSN-RNs in the industry. Despite these efforts to increase the number of BSN-prepared nurses, various educational pathways continue to thrive, allowing graduates eligibility for licensure.
The “BSN in 10” is an example of a New York State legislative proposal in support of ADN-RNs to advance their education within ten years; however, it lacks differentiation in the practice role (Matthias, 2015). This approach disregards evidence demonstrating the importance of the RNs education level impacting patient outcomes. The IOM recommends an increase of BSN-RNs to 80% by 2020; however, this recommendation fails to differentiate the practice roles of BSN-RNs — it suggests an eventual reduction of diploma and ADN programs. The American Association of Colleges of Nurses (2014) (AACN) stated, “while the IOM 80 by ’20 supports an RN workforce that favors BSN nurses, it fails to discuss mechanisms for continuing to employ differently prepared RNs, especially as a potential nursing workforce shortage looms in the health care system in the US” (p. 111). According to the 2013 National Workforce Survey of Registered Nurses, 18% of RN nurses hold a diploma, 39% practice with an associate degree, and 34% obtained a baccalaureate degree. These results represent an unrealistic expectation of potentially reducing the availability of ADN programs as an entry-level option.
Understanding how to utilize prepared RNs from different backgrounds by recognizing the original intent of the different educational pathways is needed. Matthias (2015) described three historical examples to address the original purpose of graduates from various educational channels. Researchers examined early diploma (1873), BSN (1916), and ADN (1952) programs in a case study research conducted by Matthias (2011). The program or school used in each case study were Bellevue Hospital Training School for Nurses (diploma), the University of Cincinnati School for Nursing and Health (BSN) and Orange County Community College (ADN). Despite the development of each pathway to specify nurse practice roles based on educational preparation, a lack of distinction existed between graduates (Matthias, 2015).
The diploma pathway was established in 1873 and influenced by the Nightingale model at the Bellevue Hospital Training School for Nurses in New York, New York. In the early 1900s, the BSN program was designed to provide an entry-level pathway for practice in community health. The Cincinnati General Hospital School of Nursing and Health established a dual diploma/BSN program for student nurses in 1916. The program provided liberal studies within an undergraduate program, qualifying students to assume a role as a public health nurse upon entry into practice. These guidelines set professional recognition for graduates who were trained in schools meeting minimum educational guidelines, allowing distinction between the trained and untrained nurses in the field (Matthias, 2015). Regardless of the advanced curriculum designed within the dual diploma/BSN programs, graduates received the same licensure as nurses trained in hospital-based diploma schools (Matthias, 2015). The ADN pathway was established in 1952 to distinguish technical and professional roles in the nursing profession. Mildred Montag, a faculty member at Columbia University’s Teachers College, proposed an ADN program in community colleges. She created a model identifying the difference between the ADN- and BSN-RNs. She defined a nurse holding a baccalaureate degree as a professional nurse, and the nurse with an associate degree would be limited to routine circumstances requiring skilled techniques and sound judgment at the bedside. Experimental programs were implemented, resulting in a successful expansion of ADN programs while diploma programs steadily decreased (Matthias, 2015). Montag’s model of differentiation was never implemented, and hospitals determined the roles of the nurse based on licensure. Until recently, hospitals did not consider educational experience; therefore, the roles of diploma, ADN, and BSN nurses lacked practice differentiation.
ADN programs promote diversity while allowing the opportunity to enter the workforce for individuals who are unable to enroll in a baccalaureate program, which could be due to enrollment capacity, distance, or tuition costs (Matthias, 2015). The number of RNs enrolling in RN-to-BSN programs increases every year. In 2012, 100,000 RNs enrolled in RN-to-BSN programs compared to 35,000 in 2004 (Matthias & Godwin, 2016). These numbers indicate that nurses with a diploma or an associate degree hold the potential to become future BSN-RNs. The need to differentiate practice roles based on education should be considered while making an effort to increase the number of BSN-RNs in the workforce, which would allow the current educational pathways to strengthen the nursing workforce, and prepare RNs with a clearly defined practice role based on education. The National League for Nursing (NLN) (2010) stated, “the level of competence for nursing judgment varies between the ADN/diploma RN and the BSN RN in that the former ‘integrate[s] nursing science in the provision of safe, quality care’ and the latter ‘synthesize[s] nursing science and knowledge from other disciplines in the provision of safe, quality care’” (p. 112). Clinical ladder programs have been developed to retain bedside nurses, improve quality care, and identify the different levels of competency among nurses. A clinical ladder program encourages non-BSN RNs to further their education while providing bedside care and provides institutions with guidance in hiring and staffing RNs while clearly defining practice roles (Matthias, 2015). Differentiation does not limit the scope of practice, nor does it require removing direct care responsibilities. Instead, the focus is on different competencies acquired through varying levels of education. Clinical ladder programs can refine the AACN essentials and NLN competencies while differentiating practice roles as the availability of BSN-RNs expands in the workforce.
While history has shown waves of shortages, the current problem is not one of too few nurses. A recent surge of available nurses has occurred due to increased enrollment in nursing education programs and career incentives such as tuition benefits and sign-on bonuses (Buerhaus et al., 2005). With the influx of nursing graduates every year, why are hospitals short staffed in critical care and medical-surgical units? Perhaps there is a growing but false distinction between the skillsets of ADN and BSN nurses. Many nurse educators attempt to reduce the barriers that prevent associate degree nurses from progressing into a baccalaureate program. A significant obstacle is a failure to identify the difference between an ADN and a BSN education. Accreditation measures individual programs against an established set of outcome standards with which programs must comply. Currently, two academic accreditation organizations exist in the US: the Accreditation Commission for Education in Nursing (ACEN) and the Collegiate Commission on Nursing Education (CCNE). The ACEN accredits schools from various educational pathways, and the CCNE’s goal is to approve baccalaureate, graduate, and residency programs. Nurse educators need a better understanding of what is taught in each type of program and what standards are expected in each to identify the differences between ADN and BSN education. The AACN identifies three primary roles of the BSN-RN: “provider of care, manager of care, and members of the profession” (Landry et al., 2012). Nurses practice advocacy for their patients and focus on providing education in the plan of care. As managers of care, they work autonomously and collaborate with interdisciplinary healthcare professions. Nurses employ strong clinical reasoning and knowledge to perform assessment skills and communicate with patients and team members.
The Kansas State Board of Nursing Annual Report (2012) identify the AACN Baccalaureate Essentials outcomes in accredited ADN programs in Kansas through research using qualitative and quantitative data. A conference for ADN instructors was held at the University of Kansas. A survey containing the nine AACN Essentials and corresponding outcomes was distributed to each participant before the seminar. Questions asked if the outcomes were met, partially met, or not met in the associate degree program. Open-ended statements by the participants provided qualitative data about AACN outcomes. The results revealed that all 17 nationally accredited associate degree programs in Kansas were represented (Kumm et al., 2014). Analysts of the Kansas State Board of Nursing considered above 80% as indicating an outcome was met, below 70% reporting an outcome was not met, and any value in between indicating that remaining outcomes were partially achieved. Results showed that 42 outcomes were satisfied, and 12 outcomes were not met, and ADN programs partially met 16 outcomes. Information management, patient care technology, professionalism, and BSN-RN practice were among the majority of the AACN’s Baccalaureate Essentials outcomes that were reached. Additional outcomes met included technology centering on care at the bedside, the electronic health record (EHR), and gathering assessment data to provide quality care. Kumm et al. (2014) stated, “professional outcomes not met related to the history of nursing, contemporary issues, ethical dilemmas, and lifelong learning” (p. 219).
ADN education programs train graduates to perform comprehensive assessments and exercise patient-centered care while demonstrating patent teaching. Kumm et al. (2014) confirmed that “educators stated topics such as community healthcare, evidence-based practice (EBP), genetics, quality improvement, finance, and policy would be better taught in baccalaureate programs” (p. 220). Analysis of data revealed that it is necessary for associate degree graduates to be active bedside nurses with intuitive practices of safe patient care. Knowing the ADN curriculum can facilitate BSN educators to construct outcome-based RN-to-BSN programs that avoid redundancy. Liberal arts education, essential organizational and system leadership, scholarship for EBP, healthcare policy, finance, and regulatory environments, interprofessional communication for improving patient health outcomes, and clinical prevention and population health are suited for an RN-to-BSN program. Findings support the theoretical framework provided by the AACN, which explains the three roles of the BSN-RN. ADN nurse educators concluded that 42 of the 109 baccalaureate outcomes were met in the accredited ADN programs in their state and that 67 of the baccalaureate outcomes are needed to construct RN-to-BSN curricula (Kumm et al., 2014).
Several qualitative studies (Adorno, 2010; Anbari, 2015; Delaney & Piscopo, 2007; Einhellig, 2012; Morris & Faulk, 2007; Rush et al., 2005) involving semi-structured individual interviews with ADN-to-BSN graduates were conducted with the research question: “what components of their coursework do ADN-to-BSN graduates perceive as having contributed to their ability to keep patients safe” (Anbari & Vogelsmeier, 2018, p. 301). A sample of eight ADN-to-BSN graduates was obtained with the criteria being that nurses had adult acute or critical care responsibilities to make sure the workplaces were similar. Only RNs with two to six years of work experience were included in the study to control the amount of practice with patient safety. Benner’s (2001) theory suggests that RNs in practice two to five years should have similar skills, regardless of education. All eight participants attended an online RN-to-BSN program, while four had programs that required completion of clinical hours in a hospital setting (Anbari & Vogelsmeier, 2018). The clinical rotations centered on management, leadership, and community care. Graduates who completed an ADN-to-BSN degree regard their higher level of education as worthwhile and that it improved their practice. However, participants were unclear about how a baccalaureate degree affected their capacity to maintain patient safety.
When participants were asked how their BSN coursework determined their capability to maintain patient safety, several stated that the additional coursework developed stronger critical thinking skills. They also mentioned their approach to care had changed, and that they had a better comprehension of nursing management and leadership. However, they lacked specific examples of how the coursework enhanced their ability to maintain patient safety. One participant stated, “my BSN and my experience did not change any nursing practice or safety or medication administration. I mean, I did not give one med[ication] I do not think during my BSN completion. So it was, it was paperwork and a BlackBoard discussion and a homeless shelter clinical” (Anbari & Vogelsmeier, 2018, p. 301). RN-to-BSN graduates continued to explain their experience with patient safety came with the practice rather than a higher level of education. One participant explained that her ADN education provided the opportunity to work as an RN and gain the experience needed to keep patients safe. All participants perceive their baccalaureate degree as an accomplishment, and a way to advance in their career. Findings confirmed the outcome of another study that was conducted by Matthias and Kim-Godwin (2016), who reported no significant difference in nursing practice and maintaining patient safety with a BSN education in RN-to-BSN graduates. Possibly RN-to-BSN programs do not improve patient outcomes. However, if a difference in outcomes exists, it is unclear. For example, one participant described an understanding of legal and insurance issues. However, no direct relationship shared expanded knowledge of patient safety. Aside from job security, the advantages of a BSN education must be identified to emphasize how an advanced degree relates to better patient outcomes.
Although the National League for Nursing (NLN) and the American Association of Colleges of Nursing (AACN) have documented essential standards differentiating ADN- and BSN-prepared RNs, a universal understanding has not been identified. The increased demand for BSN-prepared nurses urged a supply of ADN-prepared nurses to advance their level of education. Many nurses have returned to school to obtain or maintain employment, and the number of nurses who enrolled in RN-BSN programs in 2012 increased to almost 100,000 compared to the 35,000 who returned to school in 2004. An understanding of the students’ perceptions of ADN- and BSN-prepared nursing practices may help determine the differences in competencies between both levels of education, which may also help educators facilitate a more effective transition to BSN nursing practice and help students identify the differences expected once they achieve a BSN degree. A qualitative study was used to assess the perceptions of ADN- and BSN-prepared nurses (Matthias & Kim-Godwin, 2016). The study consisted of 171 newly admitted students who were enrolled in an online RN-to-BSN program at a southeastern university. During the second week of class, the following questions were asked: “(1) How would you differentiate practice within your work setting between the ADN and BSN nurses? Describe your differentiation model with an example, (2) How does your differentiation model reflect your professional expectations for returning to school with regard to growth, change, and opportunity?” (Matthias & Kim-Godwin, 2016, p. 209). The following themes were reported upon analysis: “‘A nurse is a nurse’ at the bedside, beyond the bedside, BSN wanted, digging deeper, and appraisal” (Matthias & Kim-Godwin, 2016, pg. 209). All participants reported similarities in the skills and advocacy of ADN- and BSN-prepared nurses at the bedside. No indication emerged of any significant difference between hands-on skills, safe care, assessment, or scope of practice. Participants agreed that the baccalaureate curriculum identified by the NLN and AACN was necessary beyond the bedside. Four critical roles of the BSN-RN were recognized: “leader, change agent, comprehensive approach, and evidence-based practice” (Matthias & Kim-Godwin, 2016, pg. 209).
More significant opportunities for leadership roles result with a BSN-degree, and one participant stated, “a BSN education helps train the nurse to be a leader in the field and act as a leader in the work environment” (Matthias & Kim-Godwin, 2016, p. 209). In terms of a comprehensive approach, students perceived a BSN-degree as a way to enhance the method of community health. The change in hiring practices represents an external force urging students to return to school. According to participants, obtaining a BSN degree was essential to conform to hospital requirements. Many acknowledged the limitations in career advancement without it. Some internal motivation stems from a desire to enhance their identity and advance in their career with a higher level of education. Many students returned to school intending to obtain leadership and management positions for future positions as nurse educators. A significant number of participants could not identify the differences between ADN- and BSN-prepared nurses until reading the NLN and AACN documents provided in the study. Although research suggests that baccalaureate-prepared nurses are needed at the bedside to improve patient safety, the findings of this study indicate that the participants could not recognize any difference in bedside care by a nurse with an ADN degree (Matthias & Kim-Godwin, 2016).
In 1999, the National Council of State Board of Nursing assessed the RN job description. The findings represented a 98% relationship between BSN- and ADN-RNs, including routine nursing care activities, teaching, and managing care. The human capital theory implies that if a BSN degree improves clinical proficiency at the bedside, then employers should compensate for the growing marginal product with increased wages. However, hospitals recognized the advantage of a BSN-RN to provide patient safety was regarded as a public benefit rather than giving financial incentive (Spetz & Bates, 2013). The nurses’ perception for completing a higher level of education is due to a growing body of research, presenting a correlation between RN education levels and patient outcomes. Also, insurance reforms have issued penalties and rewards for patient care outcomes, leading hospitals to acknowledge that financial rewards are possible with BSN-prepared RNs. Spetz and Bates (2013) stated, “if so, then employers should reward baccalaureate-educated nurses with higher wages and pursue strategies to increase the education level of their employees” (p. 1861).
Poor work environments and high workloads result in excessive burnout rates and job dissatisfaction for nurses in the healthcare setting. These conditions result in a costly turnover and adverse patient outcomes. Attractive wages are incentives for job seeker when considering employment in the workforce. Increasing salary to solve retention issues and promote incentive for new potential employees is a short-term intervention. However, the wage is not the only factor to consider. Work environments tend to be a more favorable factor to consider when seeking employment. Healthcare workers associate better work environments with lower burnout, increased job satisfaction, and more reasons to stay at their job (McHugh, 2014).
Considering that higher wages compensate for poor working environments may be accurate. A secondary cross-sectional analysis from a survey conducted by Aiken et al. (2011) included RNs in California, Florida, New Jersey, and Pennsylvania in 2006-2007. The survey included information regarding the work environment and nurse staffing ratios. Magnet hospitals were used as a measure to exemplify a pleasant work environment with better outcomes. Magnet hospitals were used to compare the work environment to non-Magnet status hospitals.
Information on hourly wage was collected from nurses in patient care, administrative roles, and other healthcare positions from hospitals participating in Medicare. Overtime pay, vacation, holiday, sick days, lunch breaks, severance, paid time off, and bonuses were included as total paid wages. The survey focused on staff nurses in acute care hospitals only. The Emotional Exhaustion subscale of the Maslach Burnout Inventory was used to measure burnout rates (Kelly et al., 2011; McHugh et al., 2011). Nurses were considered to be “burned out” if their score was 27 or above (Kelly et al., 2011). The work environment was assessed using the Practice Environment Scale of the Nursing Work Index (PES-NWI). Hospital work environments were classified as either “good,” “poor,” or “mixed.” Hospital characteristics were divided by structural components, teaching status, size according to the number of beds - small (less than 100 beds), medium (101-250 beds), or large (more than 251 beds), and technology, such as advanced-technology hospitals where open heart surgery and/or organ transplants are performed. After collecting data, the results showed about half of the 534 hospitals analyzed were non-teaching hospitals, more than 90% of the hospitals were medium or large sized, and approximately 10% were compliant with Magnet standards (McHugh, 2014).
The average patient-to-nurse ratio in the sample was roughly 5:1, and the RNs average wage was $37.20 an hour. Little difference existed in salary between Magnet ($36.29/hr) and non-Magnet ($37.30/hr) hospitals. Hospitals with proper nurse staffing had higher hourly wages ($43.67/hour) compared to inadequate nurse staffing ($32.23/hr), teaching hospitals ($37.70/hr), hospitals with advanced technology ($38.22/hr), and large hospitals ($$38.33/hr). California hospitals had the highest average hourly wage ($45.27/hour) compared to hospitals in Pennsylvania with the lowest average hourly wage ($29.72/hour). Finally, the average hourly wage was higher in hospitals with functional working environments ($40.49/hour) compared to the poor ($33.82/hour). Of the 26,005 nurses who participated in the survey, 24.8% reported dissatisfaction with their job, 33.6% experienced burnout, and 13.7% considered leaving their current position (McHugh, 2014).
In regards to the highest level of education, 41.0% of nurses attained a BSN degree or higher. Successful work environments are the result of job satisfaction and lower burnout rates. Although wage is an essential factor when expanding the workforce, wages do not indicate better outcomes. McHugh et al. (2011) noted that “nurses, particularly those in direct patient care roles in hospitals and nursing home, have reported dissatisfaction with wages, as well as non-wage benefits such as health care, tuition reimbursement, and retirement benefits” (p. 8). A nurse’s skill level should be considered when negotiating wage rates, and competitive wages combined with attractive benefits are likely to encourage retention within the organization. McHugh and Ma (2014) acknowledged the studies conducted by Aiken et al. (2011) and noted that wages are an essential tool; however, they are not a critical factor when considering employment.
The goal of this research was to address the lack of differentiation between ADN and BSN nursing programs and to understand what constitutes a qualified nurse among Magnet status institutions. Why are some hospitals refusing highly skilled ADN-RNs? What patient care skills do BSN-RNs possess that ADN-RNs do not? It was discovered through research that there is no distinction between the skillsets of ADN-RNs and BSN-RNs at the bedside. Evidence states that high patient-to-nurse ratios lead to higher mortality and failure-to-rescue rates. Meanwhile, there is an influx of qualified ADN-RN graduates every year; however, there are fewer employment opportunities available. If more ADN-RNs are hired, patient-to-nurse ratios will be managed with greater success. Burnout rates will be minimized, and job satisfaction will improve. Patient care will enhance through focused supervision and more extended one-on-one interactions between the nurse and the patient. Most importantly, mortality and failure-to-rescue rates will potentially decrease, which is not to deny the BSN-RNs’ role in patient care. If hospitals hire more ADN-RNs, the BSN-RN can focus on managerial tasks with a collaborative approach and experience in public health, while the ADN-RN can perform the same skills at the bedside as the BSN-RN did previously. Budgets will also improve as employee turnover and length of patient stays decrease. To conclude this research, a shortage of qualified nurses in the workforce exists. The final question to be asked is when will leaders in healthcare recognize this and act appropriately?
Aiken, L. H., Cimiotti, J. P., Sloane, D. M., Smith, H. L., Flynn, L., Neff, D. F., (2011). Effects of nurse staffing and nurse education on patient deaths in hospitals with different nurse work environments. 1-7.
Aiken, L. H., Clarke, S. P., Sloane, D. M., Sochalski, J., Silber, J. H., (2002). Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. The Journal of the American Medical Association, 288 (16). 1987-1993.
Anbari, A. B., Vogelsmeier, A. (2018). Associates degree in nursing-to-bachelor of science in nursing graduates’ education and their perceived ability to keep patients safe. Journal of Nursing Education, 57 (5). 300-303.
Auerbach, D. I., Buerhaus, P. I., Staiger, D. O. (2011). Registered nurse supply grows faster than projected amid surge in new entrants ages 23-26. Health Affairs, 30 (12). 2286-2292.
Buerhaus, P. I., Auerbach, D. I., Staiger, D. O. (2009). The recent surge in nurse employment: causes and implications. Health Affairs. 657-668.
Buerhaus, P. I., Donelan, K., Ulrich, B. T., Norman, L., Dittus, R. (2005). Is the shortage of hospital registered nurses getting better or worse? Findings from two recent national surveys of RNs. Nursing Economics, 23 (2). 61-71, 96.
Buerhaus, P. I., Staiger, D. O., Auerbach, D. I. (2003). Is the current shortage of hospital nurses ending? Health Affairs, 22 (6). 191-198.
Kerfoot, K., Douglas, K. (2013). The impact of research on staffing: An interview with Linda Aiken - Part 1. Nursing Economics, 31 (5). 216-220; 253.
Kumm, S., Godfrey, N., Martin, D., Tucci, M., Muenks, M., Spaeth, T. (2014). Baccalaureate outcomes met by associate degree nursing programs. Nurse Educator, 39 (5). 216-220.
Matthias, A., D. (2015). Making the case for differentiation of registered nurse practice: Historical perspectives meet contemporary efforts. Journal of Nursing Education and Practice, 5 (4). 108-114.
Matthias, A. D., Kim-Godwin, Y. S. (2016). RN-BSN students’ perceptions of the differences in practice of the ADN- and BSN-prepared RN. Nurse Educator, 41 (4). 208-211.
McHugh, D. M., Kelly, L. A., Smith, H. L., Wu, E. S., Vanak, J. M., Aiken, L. H. (2013). Lower mortality in Magnet hospitals. Med Care, 51 (5). 1-14.
McHugh, D. M., Ma, C. (2014). Wage, work environment, and staffing: effects on nurse outcomes. Policy, Politics & Nursing Practice, 15 (0). 72-80.
Shekelle, P. G. (2013). Nurse-patient ratios as a patient safety strategy: a systematic review. Annals of Internal Medicine, 158 (5). 404-409.
Spetz, J., Bates, T. (2013). Is a baccalaureate in nursing worth it? The return to education, 2000-2008. Health Services and Research, 48 (6). 1859-1878.