ONA Position on BSN within 10 Years of Licensure

BSN Within 10 Years of Licensure
Developed: 11/2016
Approved by Board: 08/2017
Reaffirmed by ONA BOD: 6/2020

OHIO NURSES ASSOCIATION RECOMMENDATIONS AND ACTIONS
Registered nurses (RN) should complete the BSN within 10 years of initial licensure.

“As adopted by the House of Delegates 2015”
Toward that end, the Ohio Nurses Association (ONA) commits to educate, encourage,
and support nurses in advancing their academic education and professional development by
collaborating with other stakeholders, publicizing opportunities for advancing nurses’
education, and actively promoting funding for nurses’ education. Further, the ONA will
continue to monitor whether legislation is necessary to achieve the Institute of Medicine
(IOM)’s goal of an 80% BSN educated nursing workforce. The ONA commends employers
whose policies support advancing their nurse workforces’ education.

BACKGROUND
The ONA’s (2016) vision and mission is to advocate for and advance professional nursing
in Ohio through evolving evidence-based practice, influencing legislators, promoting education,
improving economic and general welfare, and advocating for quality health care in a cost
effective and economically stimulating manner. This position statement examines how these
goals come together to support the BSN in 10 proposal.

EVIDENCE REGARDING SAFETY AND PATIENT OUTCOMES
A higher percentage of nurses educated at or above the level of Bachelor of Science
(BSN) is associated with better patient outcomes. The Institute for Healthcare Improvement
(IHI) estimated 40,000 instances of harm occurred every day in United States’ hospitals, totaling
15 million occurrences per year (Safe Care Campaign, 2007-2016). An IHI patient safety study
estimated that annually more than 400,000 American deaths are associated with preventable
harm done to patients in hospital settings (Institute for Healthcare Improvement [IHI], 2015).
Since 2003 numerous research studies have correlated improved patient outcomes with
increased percentages of BSN or graduate degree educated nurses among staff (Aiken, Clarke,
Sloane, Lake, & Chaney, 2008; Curtin, 2003; Easterbrooks, Midodzi, Cummings, & Giovannetti,
2005; IOM, 1999; Tourangeau et al., 2007). These outcome improvements include shorter
lengths of stay, fewer complications, fewer medication errors, and decreased patient mortality
rates. Supporting these findings, a 2016 systematic review and meta-analysis determined that
a 10% increase in the proportion of a hospital’s nurses holding a bachelor’s degree or above
was associated with a 6% reduction in odds of patient mortality and a 5% reduction in odds of
death from a hospital-acquired complication (Laio, Sun, Yu, & Li, 2016). A 2014 study
demonstrated a 10.9% reduction in odds of mortality in Healthcare Facilities (HCF) in which at
least 20% of the nursing staff had a BSN or higher degree (American Association of Colleges of
Nursing [AACN], 2015). Research evidence demonstrates a correlation between higher
percentages of BSN or graduate degreed nurses and meeting the objective of safe and effective
healthcare.

EVIDENCE REGARDING ECONOMIC FACTORS
It is economically strategic for HCFs to hire greater numbers of BSNs. Between 2007 and
2009, patient safety events in hospitals cost the federal Medicare system $7.3 billon (DunhamTaylor & Pinczuk, 2015). Starting in 2009, the Centers for Medicare and Medicaid Service (CMS;
n.d.) reimbursement eligibility became linked to patient outcomes. The CMS (n.d.) now
prohibits reimbursement for provider-preventable conditions, that is, those conditions which
could have been prevented through effective healthcare (Department of Health and Human
Services, 2011). Additionally, starting in 2012, the CMS (2014) began adjusting its
reimbursement dependent upon HCF’s patient-satisfaction scores (PSS). Many, if not most, of
the PSS are sensitive to the quality and quantity of nursing care received (Curtin, 2008;
Easterbrooks et al., 2005; Tourangeau et al., 2007). Improving patients’ outcomes (as
demonstrated above) and satisfaction by staffing with greater percentages of BSN and graduate
school educated nurses proves cost effective. Confirmation of this is found in a 2011 study
indicating increasing a HCF’s level of BSN educated nurses (BSNs) to 80% and assuring patients
receive a high percentage of care from BSNs throughout their stay, projected quality care and
costs benefits supporting a strong business case (Yakusheva, Lindrooth, & Weiss, 2014).
Further, there is evidence hiring BSN’s help HCFs preserve their market share within the
community. The American Nurses Credentialing Center (ANCC)’s Magnet Hospital Recognition
Program (“Magnet”), has been recognized by The Leapfrog Group (2011; an organization
mobilizing employer purchasing power) as a criterion for ranking top hospitals. Initial Magnet
credentialing requires 75% of HCF’s nurse managers to have BSN or higher degrees, with this
percentage increasing to 100% upon re-credentialing (Hawkins & Shell, 2012). Thus there is
evidence demonstrating the financial advantage for HCFs to hire greater percentages of BSN
educated nurses.

Finances as they affect individual nurses are as follows. Financial benefits to the
individual nurse include greater income, and expanded and more stable job opportunities
(Hader, 2011). The ONA does, however, acknowledge that although 75% of healthcare
institutions pay tuition reimbursement, education costs can be a barrier to higher education,
and there are instances wherein higher education is not associated with pay increases (Hader,
2011). Additionally, while BSNs do typically earn a higher wage than nurses with less education,
the cost of the education is not necessarily offset by the acquired income gains (Hader, 2011).

As more highly educated employees contribute to their organizations’ economic value,
organizational incentives for nurses to obtain a BSN are needed.

EVIDENCE REGARDING HIGHER EDUCATION PREPARING NURSES FOR LEADERSHIP
Although the nursing profession is unique in being the most populous healthcare
profession, the most trusted profession, and one that stands at the juxtaposition between
healthcare policy and healthcare delivery, yet this group of expert frontline clinicians lacks an
authoritative voice and is not perceived as a leader in healthcare development and delivery
(Khoury, Blizzard, Wright Moore, & Hassmiller, 2011; Kreitzer & Koithan, 2014; “Nurses top
ranking,” 2015; Patton, Zalon, & Ludwig, 2015; Prybil, Levey, Killian, Fardo, & Chait, 2012).
Healthcare providers have recognized the appropriateness of, and have called for, nurses to
take a leadership role in shaping and providing healthcare. In order for nurses to accept and
excel in this role, they must have the necessary training and education. Competencies gained in
baccalaureate and graduate degree programs, but absent from associate degree programs, will
meet this need. Those competencies include health policy and health care financing,
community and public health, leadership, quality improvement, systems thinking, critical
thinking, and technology and information management systems (Accreditation Commission for
Education in Nursing [ACEN], n.d.; American Association of Colleges of Nursing [AACN], 2008).
While benefiting the front-line clinicians and managers, this additional education also poises
nurses to become needed primary care providers, researchers, and faculty members (IOM,
2014).

State, national, and international healthcare and nursing organizations promote nurses
attaining higher levels of education. Those organizations include the IOM (which
recommended 80% of nurses earn their BSN by 2020), the Tri-Council for Nursing (American
Nurses Association, American Organization of Nurse Executives, National League for Nursing,
and the AACN; calling for all registered nurses to advance their education
(http://www.aacn.nche.edu/Education-Resources/TricouncilEdStatement.pdf), the Ohio
Student Nurse Association (endorsing BSN in 10), and the American Organization of Nurse
Executives (AONE; 2012) which endorses nurses advance to BSN and MSN degrees stating, “A
well educated nurse is better prepared for changes in technology, advanced treatments and
protocols and, most important, can offer better and safer patient care”. The Carnegie
Foundation for the Advancement of Teaching study (see Benner, Sutphen, Leonard and Day,
2010), the World Health Organization (2009) in association with Sigma Theta Tau, all
recommend the BSN be required for RN licensure. The United States’ Army Nurse Corp (2011),
the Navy (n.d.), and the Airforce (2014) all require a BSN as military nurses are commissioned as
officers for leadership roles. The competencies gained in BSN or graduate degrees are widely
acknowledged as appropriate for today’s professional nurse.

In Summary, the ONA acknowledges this is a multifaceted issue and there remain
unresolved issues and concerns. However, due to the compelling evidence, and with the
recognition that nurses and the ONA have an interest and responsibility for Ohioans’ public
safety, health, and welfare, the ONA is making this formal position statement.

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