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ADN and BSN Nursing Pathways: What are the Differences?

In unlicensed professions, employers set degree expectations, often following norms set by industry leaders. Sometimes this is the case with licensed professions as well. Bachelor’s level BSNs and associate level ADNs both practice as RNs. The level of licensing is the same, and roles do overlap, but nursing leaders are adamant: ADN and BSN roles are not the same.

Nursing leaders are adamant: ADN and BSN roles are not the same.

The BSN is increasing relative to the ADN, in part due to a strong call for action by the Institute of Medicine. The ADN is not fading out, though: not yet, not everywhere. The level of feasibility of beginning with an ADN depends on a number of factors: Will the nurse be practicing in long-term or acute care? At an urban hospital or a rural hospital? And in what part of the nation?

Differences in Role Preparation

All professional nursing programs, ADN and BSN, prepare nurses to provide care that meets generally accepted standards, whether procedures are performed personally or delegated to nursing assistants or certificate-level nurses. BSN programs place a greater emphasis on topics like research and informatics. They include clinical rotations in community and public health settings. A BSN typically does not get more clinical experience carrying out assessments and procedures in an acute care setting. Students will likely exit no more adept at wielding needles and tubes, but be better prepared for hospital employment nonetheless.

Many hospital positions are BSN preferred or BSN only. Research indicates that acute care outcomes are better when a greater percentage of the staff hold the BSN – even to the point of having lower mortality rates. It is important to note that facilities are made up of teams with diverse skills and backgrounds, and statistics are organizational. As American Sentinel University notes in The Sentinel Watch, issues like hospital-associated infections that influence mortality rate are largely systemic (https://www.americansentinel.edu/blog/2014/06/04/how-does-your-nursing-degree-affect-patient-mortality-rates). However, organizations are better able to make systemic change when they have more nurses with higher levels of education.

An individual nurse may be performing techniques in the manner they were taught – but does each step and each placement reflect current concepts of best practice? Small differences in procedure make a statistical difference in outcome, but it’s not obvious at the individual level. In the world of nursing, research isn’t something that goes on in ivory towers or is limited to PhDs. It’s part of the workday world of many nurses who work at academic healthcare institutions and magnet hospitals. Registered nurses from academic medical centers and magnet hospitals are examining data, identifying outcomes that are lower than they could be, and identifying solutions. Some hospitals produce an annual report specifically focused on nursing; these reports can give one a sense of what nurses do above and beyond providing care at the bedside (even when the primary role is bedside nurse).

Premier institutions -- academic healthcare organizations, magnet hospitals -- tend to want BSNs. Organizations that seek magnet status examine nurse sensitive indicators such as central line infections where it is widely accepted that the quality of nursing care affects outcome. The conclusion of the American Nurses Credentialing Center, the organization that awards magnet status, is in line with that of other healthcare leaders: Having a high proportion of BSNs matters.

The level of education is, on average, lower at rural hospitals. These represent their own specialty and need high caliber employees, though the skill set can be different.

Ideally, in the healthcare world of the future, less care will be required in acute settings. More emphasis will be placed on prevention and management of chronic conditions. Higher levels of education are also required many positions in public health; this is a direct reflection of the BSN curriculum. However, some states report significant proportions of community and public health nurses with degrees below the BSN level.

Long-term care employs many with education below the BSN level.

Increases in Opportunity

Some health systems reward the BSN directly through clinical ladder programs. The degree can of course indirectly affect salary level as well. A MedStar salary survey finds that averages are a little higher for nurses with the BSN: about $6,000 (https://www.medscape.com/features/slideshow/public/nurse-salary-report-2015#page=9). Montana, a state with a self-described tight market and little unemployment among nurses, reported a $2,000 difference (http://healthinfo.montana.edu/workforce-development/NursingReport2016.pdf). The big leap was at the master’s level.

Still, investing in the BSN is more about opportunity than salary. The nursing shortage was delayed for some years because of a recession. Many new graduates reported difficulties finding a first job. This was more likely to happen with ADNs than BSNs.

Many premier acute care facilities offer residencies or transition to practice programs for new grads. This can provide the opportunity to begin one’s career in a specialized hospital unit (pediatrics, oncology). Many facilities, though, limit their candidate pools to BSNs.

In tight markets, an ADN is more likely to be snapped up. The employer may well be a hospital or large medical system. ADNs who work for major employers may even have employee assistance in progressing to the higher level. Nursing organizations strongly support Academic Progression in Nursing (APIN).

Formal Role Distinctions

Some states make distinctions between degree level in code. The distinction, though, may be at the level of the level of educational preparation. Texas, for example, has differentiated competencies for students who graduate from different types of RN program (https://www.bon.texas.gov/pdfs/differentiated_essential_competencies-2010.pdf).

Washington State Administrative code stipulates what all RN students must be taught and what students of BSN and entry-level master’s programs must be taught (http://apps.leg.wa.gov/WAC/default.aspx?cite=246-840-541). Safe practice is of course fundamental, So is clinical experience with chronically and acutely ill populations across the lifespan. All RNs, moreover, are given the skills for health promotion and discharge planning. BSN programs include care coordination, team coordination, and quality assurance; this is in addition to community/ public health and research principles.

There is widespread recognition of Registered Nurse First Assistant, a relatively high level surgical role, as being bachelor’s level.

State by State Differences in Employment

In 2015, the Georgetown University Center on Education and the Workforce released a report, Nursing: Supply and Demand through 2020, that included state-by-state employment projections by level of educational attainment (https://cew.georgetown.edu/cew-reports/nursingprojections/). Some less populous states (Alaska, Delaware, North Dakota) were projected to have a very high ADN to BSN ratio. In DC, ADN positions were expected to be negligible; a relatively small percentage would be diploma.

Sometimes there were significant differences between bordering states. Georgia was predicted to be skewed toward the BSN. In Alabama, the ADN was expected to predominate, though only slightly.

Things do of course happen to change even very educated predictions. A majority of states have nurse workforce centers (https://nursingworkforcecenters.org/location-map/). Many states collect educational information at the time of re-licensure. Some include workforce information about regions within the state. Sometimes these reports also reference neighboring states.

New York has been in the news recently for passing ‘BSN in 10’ legislation. One can still enter the field with an ADN but they can’t stay at that level forever.

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