In her Annapolis, Maryland-based career counseling service, Valerie Restifo, RN, MA, MS, explains why many of her RN clients are reluctant to return to the student role: "Some sticking points are writing papers and sitting in class with ‘kids’. Their original nursing school experience was so intense that they were glad to pass their boards and be done. Years ago, they promised themselves that they would never go back to school." Yet bypassing the BSN may no longer be an affordable luxury, as RN employment has become a buyer’s market.

Carole Anderson, RN, PhD, FAAN, president, American Association of Colleges of Nursing (AACN), says, "The hospital industry, the major employer of nurses, is downsizing. We can no longer promise that a two-year post-high-school education will serve you for a 40-year career."

In fact, the majority of nurses in the United States are associate degree (AD) or diploma nurses. "Every year, two-thirds of nurses graduating in this country come from AD programs," says Carol Haaf, RN, president of the Illinois-based National Organization for Associate Degree Nursing. However, the AACN points out that the percentage of BSNs is rising, from 22 percent in 1980 to 32 percent in 1994.¹

Be prepared for differentiated practice

AACN president Anderson says, "We can no longer say that because we are all registered, we should have the same responsibilities. Given the complexity of the healthcare system, we need to implement a differentiated practice model. In these models, the associate degree- prepared nurse is expected to function well in a role with a lot of routine, predictability, and structure." Anderson does not deny that AD nurses can take care of complex patients, but maintains, "It’s not the level of complexity, but the level of predictability along the care path. If a patient develops complications deviating from what we anticipate, then a different level of provider is needed." Are such distinctions elitist? "In every discipline, education has been the mechanism for advancement," says Anderson.

Recently retired as director of nursing at Illinois Valley Community College, AD advocate Haaf says, "AD programs are upfront with their students, that they are not being educated for roles such as director of nursing or unit supervisor. Yet, with experience, some AD nurses do flow into management roles. But as a rule, if a position in administration, education, or research is your goal, you will need more than an AD or even a BSN." AD nurses do have their own niche, says Haaf: "Most AD programs reside in community colleges, whose philosophies are to respond to community needs. In long-term care and home health, AD nurses deliver direct patient care. Do they make decisions? Are there managerial aspects to their roles? Of course."

The concept of differentiated practice is gaining acceptance. Recommendations from the much-discussed Third Report of the PEW Health Professions Commission include "focusing associate preparation on the entry-level hospital setting and nursing home practice, baccalaureate on the hospital-based care management and community-based practice."² Rita Gallagher, RNC, PhD, senior policy fellow with the American Nurses Association (ANA), agrees: "Differentiated practice is appropriate."

Theory is quickly becoming reality. "Our hospital is rolling out a differentiated practice model," says Terry Bennett, RN, technical recruitment specialist, Johns Hopkins Hospital, Baltimore, Maryland. "Associate and diploma nurses will not do as much care planning and will not have primary responsibility for patient assessment. They will be assessing patients but reporting to primary or associate nurses for overall coordination of patient care."

In some ways, the future hospital milieu may be more appropriate for AD nurses. According to Leners and colleagues in the May/June 1996 issue of Nursing Outlook, "Because hospitals will prefer technical workers who are competent, but economical in terms of salary, the bulk of the future hospital workforce may indeed be licensed practical nurses and those with an associate’s degree. Professional nurses with baccalaureate and higher degrees will probably function as administrators, specialists, case managers, researchers, and educators."³

With all indicators pointing to a reduced AD nurse role, why do nursing students continue to pursue the AD? "For some, the AD is the attainment of a goal, for others, it’s the stepping stone to the next degree," says Haaf. "AD programs provide an opportunity for an affordable education, located in the student’s community. We have a lot of nontraditional students. Some are more mature in age, and some are making midcareer changes and earning second degrees."

"We shouldn’t disenfranchise people who are meeting the needs of society," says Haaf. "I don’t believe that anyone has proven that we’re not meeting a need. The research has not been done." Veteran nurse Merritt says, "The degree does not make the nurse. All nurses who have graduated from an accredited school of nursing sit down together at the same table and take the same test to become registered nurses."

Seek alternative routes to success

For AD nurses determined to tough out a job search in today’s tight market, Restifo says, "Find a friendly employer. In initial research, find out if there are nurses with similar backgrounds in the facility. Look at continuing education workshops, seminars, conferences, and home study." AD nurses looking for work may need to change specialties, she says.

Nurse recruiters cite certification as an asset in potential employees, but AD nurses need to move quickly. Says Carolyn Lewis, RN, PhD, director of the American Nurses Credentialing Center, an ANA subsidiary, "In 1998 we will be implementing a baccalaureate requirement in order to take generalist certification exams, a decision made in 1992."

Lowered self-esteem may perpetuate a vicious cycle for out-of-work AD nurses says Restifo: "They buy into the idea that as nurses without a degree, they are lacking. They give up fighting against this bias." Yet she advocates not immediately ruling out jobs that include BSN required in the qualifications. "Go ahead and apply, as long as you have the other qualifications listed. Highlight your expertise."

For the mature nurse with years of experience, Restifo suggests submitting a functional resume. This form, which places more emphasis on accomplishments and less on dates, is not presented in chronological order, rather, similar types of experience are grouped together. Those who use the chronological resume should go back no more than 10 to 15 years, then summarize the remaining work history, Restifo says. She has tips for the mature interviewee: "Don’t mention your age. Concentrate on projecting an energetic, alert image in your appearance and behavior. Convey that you can deal with change. Be prepared to show willingness to upgrade skills, such as computer literacy, and ask if training is available. Finally, present your maturity as a strength." Before interviewing, "decide on your bottom-line salary. You might have to go backwards a little, to make less until you can prove yourself."

She recalls one client, out of work for several years, who "didn’t even apply for positions reading BSN preferred. There was too much competition from younger BSNs, who were less experienced and willing to accept lower salaries." With this client, Restifo "focused on building networking skills. Her first step was to reacquaint herself with colleagues. We made a list of well-connected people that she knew. One advantage of working for years in a number of different facilities is that you know many people. She first called those with whom she was most familiar and then got in touch with contacts whom she didn’t know as well. On one of her first calls to a ‘referral,’ she got an offer into a training program for a community-based facility. She is now transferring her critical-care skills into a whole new setting."

For nurses in similar situations, Bennett, who is president of the Maryland Association for Health Care Recruitment (MAHCR), says, "Explore opportunities outside of the acute-care setting that use nursing expertise, for instance, growth areas such as the insurance business and quality assurance. These areas do not always require bachelor’s degrees. The boom is in home care, where skills and experience are most important. Know what’s out there so you feel less vulnerable. If you don’t like what’s out there, that may be motivation to go back to school."

Set realistic goals toward a BSN

When making the RN to BSN transition appears the only resort, take small, rather than large steps. "One course is to start with non-nursing electives that you’ll need for any degree, rather than with hard-core nursing courses that include clinicals," says Restifo. "Get your study skills back." Still intimidated at competing for grades? Restifo suggests starting with noncredit courses.

The ANA, says Gallagher, is "very much supportive of programs that assist people with ADN degrees or diplomas to get that [BSN] degree." Gallagher, who was in charge of the RN-BSN degree completion program at Oakland University School of Nursing, Michigan, says, "We allowed students to test out of basic content areas such as peds, psych, and med/surg. Those with community health expertise were permitted to submit a portfolio showing that expertise." Regarding those dreaded term papers: "Students can attend reading and writing workshops in most institutions and also use learning centers."

Research and networking are as important for those who are returning to school as to those who are avoiding school. Bennett says, "Find out the demographics of schools you’re considering. The average age range in degree programs is now in the mid-thirties. Take one class to get your feet wet, to test the waters. That kind of environment is motivating. You may find it’s not so scary, and you will find others who have overcome the same fears."

BSN completion does involve a considerable time investment. "On the average, going to school part-time, but at a fast pace, an RN-BSN program takes two-and-a-half to three years, and five years at a slower pace," Bennett says. "Talk to your own nurse-manager and recruiter. Recruiters can put you in touch with people who’ve already completed these programs."

According to Sister Nöel Loughlin, professor of nursing, the Marymount University School of Nursing’s "nongeneric" BSN program in Arlington, Virginia, "was designed to go on top of the ADN program, to flow from one to the other." Following sophomore year, students can choose to leave with their Associate of Applied Science in Nursing (AAS) degrees or continue on toward their BSNs. "You can walk in with your AD and earn 30 credits off the bat if you pass the clinical challenges," Sister Nöel says. There are a variety of scholarships for which full-time students can apply, as well as other forms of financial aid, such as loans.

"With only two years of study, ADNs pass the same boards for which BSNs have four years to prepare," says Sister Nöel. "So don’t think you’re not smart enough to succeed in a BSN program."

Remember that quality RNs will always find opportunity

Coexistence among levels of nurses is possible, says Haaf: "There is a place in the workforce for ADN, BSN, and practical nurses." ANA’s Anderson urges all nurses to work from a position of strength: "With all this change, we cannot take a victim role. We have to look at where there are opportunities. This is true at every level. Do your job well, make yourself valuable, focus on quality care, and you will be valued."

1. Division of Nursing. The Registered Nurse Population: Findings from the National Sample Survey of Registered Nurses. March 1992. US Department of Health and Human Services:6.

2. Third Report of the PEW Health Professions Commission- Critical Challenges: Revitalizing the Health Professions. 1995:34.

3. Leners D et al. 21st Century Nursing and Implications for Nursing School Admissions. Nursing Outlook.1996;(3)44:138.