Missouri Summit for Educational Advancement
For Registered Nurses: BSN in Ten
White Paper
Proposal
In order to meet the current and future health care needs of the citizens of Missouri, the following is
proposed:
Legislation will be enacted that will require all newly licensed registered nurses to attain a
baccalaureate degree in nursing within ten years of initial licensure (BSN in Ten) in order to
maintain eligibility for unrestricted practice1 as a registered professional nurse in the state of
Missouri. Those individuals currently licensed in the state will be exempt [grandparented in]
from having to meet the requirements of this legislation. Those who are currently enrolled in
associate degree and diploma programs at the time of the enactment of this proposal will be
exempt [grandparented in] from having to meet the requirements of this legislation2
Support from this proposal is sought from the associate, diploma, and baccalaureate degree nursing
programs as well as nursing and healthcare organizations in Missouri. The BSN in Ten proposal
recognizes the importance of associate degree and diploma nursing education as affordable, accessible
entry points for many into nursing. The competencies of these graduates are reflected in high NCLEX
pass rates and consistently high employer satisfaction. However, as well-prepared as these graduates
are, the educational focus is for practice in acute bedside care. Research suggests that advanced
education has a direct impact on patient outcomes as well as on the individual skill and competence of
the nurse. BSN preparation is better suited to meet the health care needs of Missouri citizens as it
provides more than basic knowledge of patient care; it promotes a foundation that will enhance nurses’
ability to be effective change agents and to adapt to evolving models of care. Competencies in
leadership, health policy, evidence-based practice, quality improvement, and systems thinking will be
the expectation of future employers. Thus, the recommendation that 80% of the nursing workforce
achieve the BSN by 2020 was viewed as bold but achievable by the IOM Committee. Vital to the health
of Missouri citizens, Missouri nurses must adopt a framework of continuous lifelong learning that
includes basic education, academic progression, and continuing competencies (IOM, 2010).
At the present time, there are 35 associate degree, one diploma, and 23 baccalaureate degree programs
in nursing in the state of Missouri. While this proposal does not specifically address LPN education, it
does recognize that the LPN—BSN pathway provides an additional opportunity to achieve the
baccalaureate degree. Benner (2009) noted that those who choose LPN education represent a very
diverse population. Support for these individuals to achieve the BSN would further enhance the diversity
of the profession.
History. In 1965, the American Nurses Association (ANA) wrote a position paper supporting
baccalaureate preparation as the minimum education for nurses entering practice. This position was
later affirmed by a 1978 ANA House of Delegates, but was never legislated. The current proposal is
1
“Practice” needs to be defined.
2
A consequence of those not meeting the requirements of the legislation needs to be determined.
1
different from previous ANA proposals in that it allows initial entry into the practice with various
educational backgrounds. While the pros and cons of requiring minimum baccalaureate education in
nursing have long been debated, it appears that certain forces have convened that make this the right
time for Missouri to pursue this requirement:
 Other states are also engaged in similar discussions (e.g., Kansas, Oklahoma, New Jersey, New
York);
 Although a nursing shortage looms, due to the state of the economy and nurses remaining or
returning to the workforce, there is currently only a 4.1 % (MHA) vacancy rate for RN positions
in Missouri which means employers can be more particular about the educational background
of new hires;
 Funding for nursing education has been supported during the current initiative for health care
reform.
Professional Support. Several organizations, studies, and reports have recently supported the
enhancement of nursing education. In its 2001report to the US Department of Health and Human
Services, the National Advisory Council on Nurse Education and Practice (NACNEP) recommended that
66% of the nursing workforce hold a baccalaureate or higher degree in nursing by this current year 2010.
Approximately 14% of the 3.1 million registered nurses are masters prepared; less than 1% holds the
doctorate. Sixty-six percent of the nation’s graduates are prepared at the associate degree level (Aiken
et al., 2009). In 2008, the ANA House of Delegates resolved that the ANA advocate for and promote
legislative action that enhances nursing education. Within that context, the ANA also supports the
requirement of attainment of the baccalaureate degree in nursing within 10 years of initial licensure.
ANA’s suggested legislative approach seeks to build on the competencies nurses acquire during their
associate degree or diploma in nursing education by expanding their knowledge base in the liberal arts
and sciences. In addition they must develop competence in managing complex conditions, systems
thinking, quality improvement, coordination of care with multiple healthcare providers, and possess an
understanding of health care policy. Also in 2008, the American Organization of Nurse Executives
(AONE) issued a position paper which supported the need for nurses to advance their education in order
to meet the needs of an increasingly complex health care environment.
The Institute of Medicine (IOM) report, The Future of Nursing: Leading Change, Advancing Health
(2010), cites four key messages around which the document is developed. One of those messages
“Nurses should achieve higher levels of education and training through an improved education system
that promotes seamless academic progression” is foundational to the proposal for the BSN in Ten.
Based on the implementation of the Affordable Care Act (ACA), there will be an increasing need for
nurses in public health and community settings to manage chronic illness and to coordinate care among
agencies and clinicians. Nurses will require the ability to work with patients across the lifespan--in
particular the growing geriatric population. Patient needs have become more complex which require an
extraordinary level of competence in clinical reasoning. Care in the evolving healthcare setting requires
the ability to utilize sophisticated technology in conjunction with complex information management
systems that require skills in analysis and synthesis. Such skills are gained through exposure to the
liberal arts and higher education. Significantly higher levels of preparation in evidence-based practice
and research skills were reported by new BSN graduates (Kovner et al., 2010).
Professional Influence. Advanced education will better enable nurses to practice as full partners of a
multidisciplinary team. Other healthcare professions have increased educational entry requirements
including physical therapists requiring a masters’ degree in 2002 with doctoral degree required by 2020;
2
social workers require a masters’ degree; the Pharm.D has replaced the bachelor of pharmacy degree
for pharmacists. Failure to require pursuit of a baccalaureate degree may imply to the public that
nursing is a technical career and may discourage highly competent individuals from pursuing the career.
Faculty Shortage. The need for BSN prepared nurses has been heightened by the current shortage of
nursing faculty. For eight consecutive years, nursing programs have turned away thousands of qualified
applicants; the primary reason is lack of qualified faculty (AACN, 2010). Curley and Kovner (Jonas Center
for Nursing Excellence, 2010) note in their estimate of the impact of the faculty shortage that “each
nurse educator position left unfilled could affect the care of as many as 3.6 million patients.
Nationwide there are nearly 900 vacancies among schools with baccalaureate programs.” Cleary et al.,
(2009) note that nurses who enter the profession with an associate’s degree are less likely than those
who enter with a BSN to advance to the graduate level over the course of their careers. Aiken et al.
(2009) research indicates that nurses whose initial degree is the ADN are just as likely as BSN prepared
nurses to seek another degree; however approximately 80% of the time ADN graduates do not move
beyond the BSN. Thus, Aiken’s findings suggest that nursing programs will never have enough faculty as
it is a “mathematical improbability”. Bevill et al., (2007) conducted an analysis of nurses in North
Carolina and found similar results. Both AACN and National League for Nursing (NLN) data demonstrate
the current faculty shortage; the National Sample Survey (2004) data reflect an insufficient number of
nurses advancing their education. Data show that only 6.4% of those educated at the associate degree
level and 11.7% of those educated at the diploma level obtained graduate degrees in nursing. Twentytwo percent of those prepared initially in baccalaureate programs obtained a graduate or doctoral
degree. Based on these data, strategies need to be implemented across all educational levels to
facilitate educational advancement (e.g., ADN to MSN advancement).
Barriers. Certain barriers prevent educational advancement. These barriers include: redundancy of
educational content as students move from one level of education to another; means of delivery and
access to technology through a lack of broad-band access in rural areas; limited, if any, pay differentials
for advanced education; financial support; family responsibilities in a currently female-dominated
profession; travel requirements—especially from rural areas; mandatory overtime in the workplace; and
limited support from peers and managers.
Summary. If this trend continues nationwide, the profession will be ill-prepared to provide care for
patients, to function in a reformed health care system, to advance nursing science, to enter faculty roles,
or to manage clients in a variety of advanced practice settings. In its landmark consensus policy
statement on the educational advancement of registered nurses, the Tri-Council3 encouraged “all
nurses, regardless of entry point into the profession, to continue their education in programs that grant
baccalaureate, masters, and doctoral degrees. Without a more well-educated nursing workforce, the
nation’s health will be further at risk” (Tri-Council, May 2010). The policy statement outlined
developments leading to the consensus and action steps to achieve their goals. This position paper
further supports the need for advanced education in light of the increasing complexity of care, lack of
qualified faculty and projected shortage of nurses.
3
The Tri-Council includes the following organizations: American Association of Colleges of Nursing (AACN);
American Nurses Association (ANA); American Organization of Nurse Executives (AONE); National League for
Nursing (NLN).
3
Health care organizations throughout the US are now requiring the BSN for entry level positions (IOM,
2010). Those hospitals who have been recognized by the American Nurses Credentialing Center (ANCC)
Magnet Recognition Program or are on the Magnet Journey seek to employ BSN-prepared graduates
(Aiken, 2010). Effective January 1, 2011, the Magnet Recognition Program requires that 75% of nurse
managers must have at least a baccalaureate in nursing. A higher degree in nursing (a master's or
doctorate in nursing), will meet the requirement even if the baccalaureate degree is not in nursing.
Goode et al. (2001) noted that depending upon the type of hospital, the goal for the proportion of BSNprepared nurses ranges from 50% to 90%. Cronenwett’s (2010) survey of hiring practices in acute care
settings revealed that absent a nursing shortage, new graduates who were BSN-prepared were
preferred. This may be related, in part, to several studies that support a significant relationship
between the educational level of nurses and patient outcomes in the acute care setting, including
mortality rates (Aiken, et al. , 2003; Delgado, 2002; Estabrooks et al., 2005; Friese, et al., 2008;
Tourangeau, et al., 2007; Van den Heede et al., 2009).
In community and public health settings, the BSN has historically been the minimum requirement based
on the knowledge and competencies required in those settings (ACHNE, 2009). The US Army Nurse
Corps has required the BSN for nurses on active duty since 1976 followed by the enactment of similar
requirements for the Navy and Air Force. The chief of the Army Nurse Corps stated that “this basic
educational preparation of Army Nurses gave us the credibility, creativity, and flexibility to maximize
nurses’ contributions to patient care” (January 2004 letter from Brigadier General William Bester as
cited in the ONA report). The Veterans Health Administration requires the BSN for those who wish to
advance beyond entry level appointment.
While there may be a temporary halt in the shortage of nurses at the bedside, the recent release of a
statement by the Tri-Council for Nursing in July 2010 cautioned that programs not slow the production
of nurses given the projected demand for nursing services in light of the new health care reform. Peter
Buerhaus, in the same paper, called for stakeholders to “resist the short-term urge to curtail the
production of registered nurses”. Buerhaus et al. (2009) also reported that the shortfall is expected to
grow to 260,000 by 2025.
Support Strategies
In addition to input provided by education and practice settings, legislators, professional organizations,
and healthcare organizations related to current and future state of the discipline, the following support
strategies will be needed to facilitate the achievement of the goals of this proposal:
 Implementation of a common state-wide articulation plan to promote seamless articulation that
will provide maximum transfer of academic credits
 Development of new models of articulation (e.g., Oregon Consortium)
 Review of curricula to eliminate redundancies
 Increase in capacity at colleges offering the BSN degree to ensure that all qualified nurses have a
place in accredited schools
 Design of processes that will enhance the comfort level of adult learners in the current
technology environment
 Increase in faculty salaries
 Provision of transparent and easily accessible financial aid information
 Development of systems of flexibility and support in the workplace so nurses can work
while obtaining advanced education, e.g., on-site programs; flexible scheduling for nurses
4






returning to school; salary/benefits during coursework to facilitate completion in timely manner;
a provision to prohibit mandatory overtime as one of the barriers nurses face while pursuing
their education; employer recognition for completion
Evaluation of pay differentials for BSN (newly licensed and upon completion of RN-BSN)
Provision of tuition assistance for nurses pursuing the BSN degree through a
combination of federal, state, and employer funding
Provision of scholarships and loan forgiveness programs for nursing faculty
Implementation of high-speed broadband infrastructure that will allow facilitate rural
participation
Regular collection of minimum data set to assess healthcare workforce needs by demographics,
numbers, skill mix, and geographic distribution, including projected nursing workforce needs
Development of partnerships to enact legislation to support educational advancement with
such organizations as:
o Missouri Association of Colleges of Nursing (MACN)
o Missouri Associate Degrees of Nursing (MOADN)
o Missouri Community Colleges Association (MCCA)
o Missouri Council of Practical Nursing Education (MCPNE)
o Missouri Hospital Association (MHA)
o Missouri League for Nursing (MLN)
o Missouri Nurses Association (MONA)
o Missouri Organization of Nurse Leaders (MONL)
o Missouri State Association of Licensed Practical Nurses(MOSLPN)
o Missouri State Board of Nursing ( MSBN)
Conclusions
The proposed legislation seeks to be responsive to meeting the increasingly complex health care needs
of the citizens of Missouri. It is not intended to eliminate current associate degree or diploma education
that may be more accessible and financially feasible as an entry point into the profession. Rather its
purpose is to build upon the strengths of those future graduates in order to prepare them for the
complex challenges of patient care in a variety of settings in an evolving health care system and to
assume roles in advanced practice and as nurse educators and nurse scientists. Vital to the health of
Missouri citizens, Missouri nurses must adopt a framework of continuous lifelong learning that includes
basic education, academic progression, and continuing competencies (IOM, 2010).
5
Bibliography
AACN. 2009a. Student enrollment expands at U.S. Nursing colleges and universities for the 9th year
despite financial challenges and capacity restraints.
http://www.aacn.nche.edu/Media/NewsReleases/2009/StudentEnrollment.html (accessed March
13, 2010).
AACN. 2010a. Education policy: New policy statement from the Tri-Council for Nursing on the
educational advancement of registered nurses. http://www.aacn.nche.edu/Education/ (accessed
September 7, 2010).
AACN. 2010b. The impact of education on nursing practice.
http://www.aacn.nche.edu/media/factsheets/impactednp.htm (accessed September 7, 2010).
ACHNE (Association of Community Health Nursing Educators). 2009. Essentials of baccalaureate
nursing education for entry level community/public health nursing. Wheat Ridge, CO: ACHNE.
Aiken, L. H. 2010. Nursing education policy priorities. Paper commissioned by the Committee on the
RWJF Initiative on the Future of Nursing, at the IOM (see Appendix I on CD-ROM).
Aiken, L. H., Clarke, S. P., Cheung, R. B., Sloane, D. M., and Silber J. H. 2003. Educational levels of
hospital nurses and surgical patient mortality. JAMA 290(12):1617-1623.
Aiken, L. H., Cheung, R. B., and Olds, D. M. 2009. Education policy initiatives to address the nurse
shortage in the United States. Health Affairs 28(4):w646-w656.
American Nurses Association. (2001, January 31). Strategies to reverse the new nursing shortage (Press
release. Retrieved from:
nursingworld.org/FunctionalMenueCategories/MediaResourcespressReleases/2001/ANAPressRelease.a
spx
American Organization of Nurse Executives (2008). Position Statement. Retrieved January 11, 2011
from: http://www.aone.org/aone/resource/practiceandeducation.html
Benner, P., Sutphen, M., Leonard, V., and Day, L. 2009. Educating nurses: A call for radical
transformation. San Francisco, CA: Jossey-Bass
Bevill, J. W., Cleary, B. L., Lacey, L. M., and Nooney, J. G. 2007. Educational mobility of RNs in
North Carolina: Who will teach tomorrow's nurses? A report on the first study to longitudinally
examine educational mobility among nurses. American Journal of Nursing 107(5):60-70; quiz 71.
Buerhaus, P., Auerbach, D., and Steiger, D. O. 2009. The recent surge in nurse employment: Causes and
implications. Health Affairs 28 (4):w657-w668.
Cleary, B. L., McBride, A. B., McClure, M. L., and Reinhard, S. C. 2009. Expanding the capacity of
nursing education. Health Affairs 28(4):w634-w645.
6
Cronenwett, L. R. 2010. The future of nursing education. Paper commissioned by the Committee on the
RWJF Initiative on the Future of Nursing, at the IOM.
Curley, D. and Kovner, C. 2010. First estimate of nursing faculty shortage portends widespread patient
crisis. Jonas Center for Nursing Excellence press release. December 2010.
Delgado, C. 2002. Competent and safe practice. Nurse Educator 27: 159-161.
Estabrooks, C. A., Midodzi, W. K. Cummings, G. G., Ricker, K. L., and Giovannetti, P. 2005. The impact
of hospital nursing characteristics on 30-day mortality. Nursing Research 54(2):74-84.
Friese, C. R., Lake, E. T., Aiken, L. H., Silber, J. H. , and Sochalski, J. 2008. Hospital nurse practice
environments and outcomes for surgical oncology patients Health Services Research 43(4):1145-1163.
Goode, C. J., Pinkerton, S., McCausland, M. P., Southard, P., Graham, R.,. and Krsek, C. 2001.
Documenting chief nursing officers’ preference for BSN-prepared nurses. Journal of Nursing
Administration 31(2):55-59.
HRSA. 2006. The registered nurse population: Findings from the National Sample Survey of Registered
Nurses, March 2004. Rockville, MD: HRSA.
IOM (Institute of Medicine). 2010. The future of nursing: Leading change, advancing health. Washington,
DC: The National Academies Press.
Kovner, C. T., Brewer, C. S., Yingrengreung, S., and Fairchild. S. 2010. New nurses' views of quality
improvement education. Joint Commission Journal on Quality and Patient Safety 36(1):29-35.
Missouri Hospital Association (MHA) 2010 Annual Workforce Report. Retrieved January 27, 2011 from:
http:web.mahnet.com2010AnnualWorkforceReport.pdf.
National Advisory Council on Nurse Education and Practice. (2001). Nursing: A strategic asset for the
health of the nation, first report to the Secretary of Health and Human Services and the Congress.
Bethesda, MD: HRSA.
Oklahoma Nurses Association (2009). Educational advancement of Registered Nurses—BSN in Ten.
ONA Task Force Report.
Tourangeau, A. E., Doran, D. M., McGillis Hall, L., O'Brien Pallas, L., Pringle, D,. Tu, J. V., and
Cranley, L. A. 2007. Impact of hospital nursing care on 30-day mortality for acute medical patients.
Journal of Advanced Nursing 57(1):32-44.
Tri-Council for Nursing Issues New Consensus Policy Statement on the Educational
Advancement of Registered Nurses (May 14, 2010). Washington, D.C.
Van den Heede, K., Lesaffre, E. , Diya, L., Vleugels, A. , Clarke, S. P., Aiken, L. H., and Sermeus, W. 2009.
The relationship between inpatient cardiac surgery mortality and nurse numbers and educational
level: Analysis of administrative data. International Journal of Nursing Studies 46(6):796-803.
7
Summit Participants
On October 27, December 6 or Both
And their Affiliation
Participants
Affiliation
Diane Lutes
MOSLPN
Dave Strong
MOSLPN
Thom Switzer
MOSLPN
Senda Guertzgen
MOADN
Karen Mayes
MOADN
Pat Porterfield
MOADN
Lori Bonnot
MLN
Susan Devaney
MLN
Pam Galbraith
MLN
Lana Martin
MLN
Rebecca Miller
MLN
Debra Funk
MSBN
Bibi Schultz
MSBN
Nancy DeBasio
MACN
Susan Fetsch
MACN
Kathryn Hope
MACN
Heidi Cooper
Graduate Student
Representing Self
Beth Hindmon
MCPNE
Rhonda Hutton-Gann
MCPNE
Winnie Youger
MCPNE
Maura Browning
MHA
Sharon Burnett
MHA
8
Joan Brundick
LTC
Shirley Farrah
LTC
Martha Baker
MONA – NETF
Sarah Bradshaw
MONA – NETF
Nelda Godfrey
MONA - NETF
Cheri Hunt
MONA – NETF
Jill Kliethermes
MONA – NETF
Lynne Ott
MONA - NETF
Celia Reed
MONA – NETF
Jo Riggs
MONA – NETF
Glenda Dahlstrom
MONA – speaker
9
Proposed Timeline
Activity
Notes
Date
White Paper Draft
Include Timeline for remaining work; Task
force includes Nancy DeBasio, Susan
Fetsch, Katie Hope, Cheri Hunt
Gather input and seek approval from
constituency group by conference call;
Identify remaining questions
Review white paper, provide input
January 12, 2011
Request Financial Support for Stakeholder
Summit (concept paper will be available)
Summit members will be able to report on
white paper response from their
constituency groups
Task force includes Becky Miller, Rhonda
Hutton, and Karen Mayes
Gather input from constituency group by
E-mail
Review/Discuss White Paper;
Identify potential funding sources
March 2, 2011
Review White Paper
Missouri Associate Degree in
Nursing (MOADN) Meeting
Missouri Nursing Coalition
Meeting
Report input from
constituencies
Model Curriculum Draft
Review Model Curriculum
Stakeholder Summit
Add Stakeholder Input to White
Paper
Deadline for Legislative
Language
Sponsor Identification
Face to face meeting with summit group
Will legislative language only include the
issue of education/licensure or might it
include a fiscal note and/or workforce
center?
For legislation
January 18, 2011
February 4, 2011
April 15, 2011
(tentative)
April 15, 2011
(tentative)
Date TBD
June 14 or 15, 2011 in
association with the
Missouri Educators
Conference
September 2011
November 1, 2011
December 1, 2011
Other:
 MSBN Board Meeting Schedule for 2011: 1st week of March; June 1,2,3; September 7, 8, 9;
December 7, 8, 9
 MACN meets April 1, 2011
 MOADN meets February 4, 2011
Initial draft by Nancy DeBasio and Susan Fetsch 1-11-11
Reviewed and revised by Summit participants on conference call 1-18-11
Approved by Summit participants via E-mail consensus 2-1-11
10