By Jennifer L. Boen

May 12, 2008 (McClatchy-Tribune Regional News delivered by Newstex) --
Beginning next year, Indiana University-Purdue University Fort Wayne will drop its two-year associate nursing degree and offer only a four-year baccalaureate degree.

Projections made in 2007 by the federal Health Resources and Services Administration (HRSA) indicate nursing schools must increase their number of graduates by 90 percent in order to meet the demand for nurses that will exist by 2020. Beginning nursing students at IPFW can now opt for a two-year associate of science in nursing (ASN) or a four-year bachelor of science in nursing (BSN).

A third option -- the two-plus-two -- allows students to complete the associate degree, take the state licensing exam and continue toward the baccalaureate degree while working as a registered nurse.

But, by the fall of 2009, students entering IPFW's nursing program will have only the four-year baccalaureate degree option.

"The baccalaureate is the professional degree that is typically offered at a four-year institution," said Carol Sternberger, chair of IPFW's Department of Nursing. The state's Commission for Higher Education has ruled that state-run universities move toward BSN-only and above nursing programs, leaving ASN programs to Ivy Tech Community colleges.

But elevating the profession by demanding more education is not the only driving force toward BSN programs.

Today's hospital patient is much sicker than the average patient 30 years ago. Additionally, nurses are challenged to become competent in technologies and knowledge of an ever-increasing number of medications, Sternberger said.

Judy Boerger, Parkview Health's chief nursing officer, said there is still a need for associate-degreed nurses, but agrees, "Typically any level of increasing responsibility will require a minimum of a bachelor's, and many management positions are master's level."

The University of Saint Francis, which offers both associate and bachelor's degree nursing programs, has no intention of eliminating the ASN program, at least not in the foreseeable future, said Amy Knepp, chair of the university's nursing department.

Also spurring four-year or higher nursing degrees, she said, is the increased focus on patient safety and outcomes, with Medicare tying reimbursement to outcomes. For example, cost of additional care needed because a wrong medication was given will no longer be reimbursed by Medicare, and private insurers are moving that way, too.

More education tied to better outcomes

Higher education for nurses aligns with research spearheaded by Linda Aiken at the University of Pennsylvania. She found hospitals that employed a larger proportion of nurses with bachelor's in nursing degrees or higher had lower death rates among surgical patients and lower rates of "failure-to-rescue." The latter means fewer deaths occurred among patients with serious complications.

For every 10 percent increase in the proportion of nurses who held higher degrees, mortality and failure-to-rescue correspondingly decreased by 5 percent. Aiken's research was reported in the Sept. 24, 2003, Journal of the American Medical Association.

BSN-degreed nurses comprise about 40 percent of hospitals' nursing workforces.

With the ongoing shortage of nurses, Aiken also looked at patient outcomes and nurse-staffing ratios, finding staffing ratios proved almost as significant as nurses' education levels in lowering mortality rates. For every patient added to a nurse's workload, patient mortality increased by 7 percent.

The least-educated nurse, the licensed practical nurse (LPN), may disappear. The LPN degree is earned in one year. Fort Wayne's hospitals are not employing new LPNs, said Jewel Diller, chair of Ivy Tech's Nursing Department, but they are working in doctors' offices and nursing homes.

Because of employment issues, Ivy Tech is purposefully lowering the number of entering LPN students, Diller said, although she points out the state Nursing Practice Act "is nebulous" in clarifying the scope of duties of LPNs compared to RNs.

Yet under Medicare regulations, "The LPN can't do a whole lot," Diller said, which is why hospitals are no longer employing them.

Both Saint Francis and Ivy Tech offer LPN-to-RN programs.

What makes difference?

What is it about the four-year baccalaureate program that makes for better-prepared nurses and improved patient outcomes? Is it more science courses? Increased hands-on clinical hours? Coursework in research methodology?

All of the above, said Sarah Beckman, assistant professor of nursing at IPFW. "There are higher-level expectations in critical thinking, in leadership and in understanding the broader perspective of practice," she said.

Both ASN and BSN nurses "become skilled and educated in the foundational elements, but clinical courses at the upper level are focused on leadership, community health nursing and advanced acute care."

Nursing is both art and science. "Some are very good at bringing the art. A bachelor's degree is very good at bringing the science," Boerger said.

Informational literacy, the ability to research diseases, treatments and medications and discern how the information applies to patients, and knowledge of evidence-based practices are crucial, Beckman said.

While in the past, obtaining a bachelor's or master's degree in nursing was emphasized for nurses wanting to go into management, Beckman emphasizes leadership skills are needed "to influence people to address common goals," which include everything from disease-prevention education to developing workplace-efficiency strategies.

"You don't have to be a manager over staff to be a leader," Beckman said.

IPFW's and Saint Francis' BSN enrollments have increased significantly in recent years. Sternberger said at IPFW, it was 3-to-1 BSN entrants compared with ASN in the semester just completed.

Saint Francis' Knepp said more than 90 percent of students entering the four-year program are doing so right after high school. ASN students are more likely to be nontraditional and choosing nursing as a second career while working part time and raising a family.

Nursing is a profession

Tyra Watson typifies the career path many of today's hospital nurses have taken in the past. She earned her associate degree in nursing from IPFW in 1992 and worked at Parkview Hospital for eight years.

"It was always my plan to get my bachelor's," she said, but working and raising a family delayed that, although she pared away toward the degree a little at a time. "It took me eight years."

Watson, who is now clinical manager of Parkview North's medical/surgical and pediatric units, said she did not realize at the outset of pursuing a BSN how much value the degree offered.

"When I went back to school, it was an enlightenment. It has helped me look at the patient holistically, not as the 'pneumonia case.' This is a profession, not a job," she said. "Getting the bachelor's degree opens up your perspective of what you do and your role in giving well-rounded care."

Change may take time

While the nursing profession advances with higher levels of education required, nurse educators and practicing nurses say the pay differential between associate- and bachelor-degreed nurses must be addressed. Parkview is looking at a system that would give new RNs with bachelor's degrees more points on a pay-scale system.

Becky Henry, St Joseph Hospital's chief nursing officer, said a pay differential between the two degrees does not exist at St. Joe.

"The career goals of the individual influence their degree attainment, as well as the ability to begin working after two years rather than four years. The American Nurses Association has been pursuing a BSN (bachelor of science in nursing) as an entry-level position for years," Henry said. "At this time, given the current and projected nursing shortage, it may be difficult to implement."

But Sternberger maintains more education is needed for beginning nurses to ensure they are adequately prepared to meet today's health care challenges.

"In Ireland, they changed to a mandatory baccalaureate at the height of their nursing shortage five years ago," she said, "and they have a worse nursing shortage than we have."

Newstex ID: KRTB-0071-25204344