Upon reading the article "Must have bachelor's degree: Hospitals' new requirement for nurses" concerning a report published by The Wall Street Journal, I wanted to provide perspective from experts with first-hand experience in the industry addressing points within and not included in the Wall Street Journal report.
Back in the mid-1980s, I applied for a job at a leading hospital currently on Becker's Hospital Review's list of top 100 hospitals in the country. Their hiring policy mandated a Bachelor of Science in Nursing, therefore I was not a candidate — even though I had been a practicing registered nurse for years and a charge nurse when I was 20 years old. So I proceeded to join a nursing agency, being called in to work at this same hospital because there was a shortage for BSN clinicians.
An order was issued to start a maintenance IV drip on one of my patients. After getting the equipment together, I was instructed that I was not allowed to do IVs because I was not qualified and had to wait for a member of the IV team. I responded that I had a license being fully trained to do intravenous insertions since I was 18, and that I had been doing IVs for years, including successful first time insertions working fresh out of school on a nephrology unit with some of the hardest "sticks" with poor veins.
I was told that only the IV team was allowed to do and nurses were not certified.
This hospital discovered it was not possible to maintain a qualified workforce with their hiring policies, driving up costs filling BSN vacancies using agency nurses who were just as qualified and licensed with associate and diploma degrees. And the job mandates were only increasing care costs, using IV teams instead of using primary bedside nurses who should have had the basic skill sets.
The issue demonstrated by the IV team example has increased today as many BSN licensed nurses do not possess some basic clinical skills with critical thinking, requiring specialty groups such as rapid response, sepsis and triage teams, etc. A recruiter for a Magnet hospital — one of the top 10 hospital systems in the nation — stated the majority of BSN candidates she has been interviewing lack the skill knowledge and basic critical thinking skills of a diploma nurse.
When asked for examples, she said her interview questions of BSNs include: "Where is the endotrachial tube placement on a patient?" Several have pointed to their esophagus drawing their fingers to their stomachs. "If a patient comes in with positive orthostatics, what does that mean?" They have had no idea. "If a patient becomes hypovolemic…a patient has chest pain…etc. What do you do?" For each question, she received the response, "I will consult the physician."
So what happens if the physician is not available, not up to speed on the patient you have been caring for, or the physician is busy with an emergency on another patient? As the nurse accountable for that patient, what steps are you going to take to save their life while waiting for the physician?
This past year, I spoke with a recent BSN graduate beginning her first nursing job. Three points I wanted to convey to her:
- Always fear the words from your patient, "I feel funny." The patient is not in pain, their labs are probably off and they are most likely about to crash on you. Assess them and look at labs fast.
- A great physician told me when I first started as a nurse, "Never lose the fear when pushing medication in an IV. Always remember, your patient's life is in your hands every time you push that plunger." Complacency can cause injury or death.
- Always do a head-to-toe assessment of patients. I relayed a few use case examples when this practice uncovered major issues in seemingly stable patients.
Her responses to me included, "What do you mean by a head-to-toe assessment?" And, "I don't want to ask questions if I don't know because I don't want to look stupid."
I spoke with another BSN student studying arterial blood gases who was having difficulty with the various interpretations. When I mentioned to her to go back to the basic acid-base balance equation to think through the body's compensatory mechanism, she stated she had never heard of that equation before.
One of my main initiatives in the industry is the promotion and establishment of patient champions (advocates). I am specifically shifting the use of the word "advocate" to "champion" because many within the industry have morphed the term "advocate" to mean advocating for reimbursement or access as opposed to being a champion for: ensuring proper medical care coordination and care across continuums; making certain nurses are following proper procedures, assessment and delivery of quality care measures; and assuring patients are informed about their care, knowing the right questions to ask to understand their own healthcare.
One case example as a patient champion includes an 80 year old man* with increasing memory loss, increasing malaise, constipation with some diarrhea, nausea and then projectile vomiting, who had to be taken to a leading health system emergency room. Upon being admitted to the floor with hyponatremia and atelectasis presented on the chest X-ray, two women entered the room without introducing themselves.
As the patient champion, I had to ask, "Who are you, and why are you asking questions?" One woman announced she was the nurse with a nursing student shadowing her. The nurse proceeded to ask the patient with memory issues redundant questions already in the EMR from the emergency room, then told the elderly patient in distress with memory issues to notify her when his IV needed to be changed. They proceeded to leave the room without the nurse performing level of consciousness assessment, nor did she listen to the patient's lungs or bowel sounds — no physical admission assessment was performed except the vital signs taken by the certified nursing assistant.
There are numerous examples regarding lack of evidenced-based, comprehensive clinical preparation among BSN trained nurses that I have heard from various educators, consultants (trained "old school" nurses who completed refresher courses) and recruiters from across the country. Two simple examples include BSN nurses who do not know how to calculate basic macro or micro IV drip rates. Personally, if someone needs to hang a maintenance, second or third IV drip, I would want a bedside nurse to know basic math skills for running a drip in the absence of available pumps. Or as stated by a recruiter, BSN nurses who with only one year of clinical experience believe they are qualified to work anywhere, in any unit, after obtaining their degree online with very little hours of interdisciplinary clinical experience.
In the WSJ article, I read the comments attributed to Diana Mason, president of the American Academy of Nursing and a nursing professor at Hunter College in New York. She is concerned that "nurses with four-year degrees could block what has been seen as a reliable way into the middle class…That's a beautiful aspect of nursing's career ladder, is that it enables people to move from maybe a family growing up in poverty, to solidly middle class." I was taken aback that the focus would be put on an economic status and not on quality training for delivering care excellence.
Over the years I have spoken with young people going into nursing whose comments demonstrate my point. Upon asking several in multiple states, "Why are you going into nursing?" responses I received varied: "Oh, I can make good money quickly." And, "Because I washed out of my previous career, there is a shortage so it is easy to get into programs and then find a job." They were focused on economic status without the calling to want to help people, and provided me with blank looks when I stated they needed to be there for the needs of the patients and not their own.
Diploma and associate nurses require extensive, simultaneous clinical care with class time for the ability to perform quality, full patient loads in order to graduate, so they can perform immediately when hired as a nurse. The question needs to be asked, "Is this training considered inferior to current BSN degrees, which can be completed online, without extensive clinical experience, often including business, general education / liberal arts or computer training?"
As shown in the above examples, the critical thinking and skills training compared to the BSN can be superior. If all nurses — regardless of diploma, associate or BSN — were acting as the patient advocate for the delivery of excellent patient care and training focused on producing highly skilled, critical thinking nurses, patient champions would not be needed.
*For purposes of de-identification, facility names have been omitted and the patient demographics have been changed in use case examples.
Rose Rohloff is a 30+ year healthcare veteran with a background of nursing, business and information systems with success creating industry leading business intelligence solutions for meaningful analysis. Her focus is the removal of information silos within health systems, and the expansion of the care continuum to a health maintenance continuum. Rose Rohloff can be contacted at rosemrohloff@outlook.com.