Nursing Education: Removing clinical from RN-BSN programs

I have been debating as to whether I was going to write about this subject that has been on my mind for a while. I believe I will proverbial ‘step in it’ with this post, but I wanted to find out what others think.  This is not an ‘old guard’ post where I have an opinion because I want other nurses to have to complete exactly what I have had to.  I love nursing and the patients I serve, even when the days are rough and the patients too many.  To change as healthcare is changing, nursing education needs to beef up, not dumb down, curriculum…

Removing Clinical and Hours from RN-BSN Programs to Make them More Marketable

This post stems out of a conversation with a highly regarded person evaluating our RN-BSN program.  This person advised our program to drop all clinical to make it more ‘marketable’.  I was shocked…

I proudly work for an RN-BSN program that requires clinical.  We do this because our general experience in working with our amazing nursing students is that they have only had acute care experience (which is critical and a great starting place to build other knowledge on).  Let me emphasize that the majority of them are very bright and capable acute care nurses and I learn from them daily.  However, one of the goals of our program is to push the envelope in their thinking… exposing them primary care, public health, and areas where they have not practice previously.  In turn, we like for them to reflect on how these new areas, access, disparities, etc. affect the patients they see every day in their own acute care practice.

We also strive to expand their knowledge base, teaching them about how health affects not only individuals, but families, communities, and the like.  Many of our nurses (who are students) do not know how or even where to palpate for lymph nodes, test consolidation in lungs, or how to map out a liver boarder.  Will they use these skills daily in practice?… Perhaps not, but they do use them.  I had a student just last month, during health assessment class, pick up a pneumonia in an ICU patient that others had missed because he could test for consolidation.  I have had many students pick up on other critical findings, simply by expanding and completing full assessments that they learned in their RN-BSN program.  In the acute care setting in particular, it is rare for other providers to even asses a patient, they simply look at the nurse’s notes and tests to make decisions.  As inpatient care becomes more complex and patients continue to be more ill, why would we CUT health assessment clinical from RN-BSN programs?

Our nurses have also had little exposure to community health and administration/leadership areas.  Do associate or diploma degree students learn how to write up a community assessment, spend time in community health centers and health  departments,  learn vaccination schedules and mass vaccination protocols, learn about community resources, WIC clinics, STD counseling and testing, food purification systems, the importance of epidemiology, large scale school nursing management, and the like?  Further, in the administration and leadership course I teach I find that students have been little exposed to communication styles, interviewing, hiring, firing, and managing committee meetings, budgeting, finance, and service projects/leadership within their communities.  Can these things simply be learned from reading and writing assignments, or should they be observed, practiced, and implemented in a ‘practice’ setting?  (I  know it sounds like I am asking rhetorical questions here, but I honestly want to know.)

In addition, many of my students want to go on to graduate school.  Several graduate clinical programs require a separate health assessment course with clinical, as they should.  Several BSN prepared nurses come into our RN-BSN program each year simply to take health assessment with us for graduate school.  While I love having these students… this is ridiculous. Why should students have to take additional coursework beyond what they had in their BSN to get into school?  Why did their original BSN program fail them in this way?

Who would have thought that we would make a move to remove clinical from RN-BSN programs simply to get more people into them and through  them.  Again I ask, isn’t the point/argument of a BSN degree to be more educated and prepared?  Does cutting clinical help or hurt those students?  The most popular courses in our program, based on qualitative and quantitative data from the students, are our three courses with a required clinical portion based entirely on the students feedback and learning in clinical!

More than 80% of our students go on to either graduate education, move up in career clinically or into administration, or move out into the community to provide care within a year of graduation.  Why on earth would we leave them ill-prepared simply to make a program marketable?  Wouldn’t we be doing them a great disservice, or their patients?  Most all of our students work and manage families along with clinical requirements well, finding clinical to be a new outlet of exposure to worlds of practice and nursing that breathe new life and excitement into their personal nursing practice.  The biggest obstacle for them in planning clinical and school work is often their current employer, not home life demands.

The Problem

The problem, I think, is that there are no clearly defined differences from accrediting bodies or research in what should be required within BSN education.  AACN only accredits BSN level programs and higher, thus their clearly written standards, do not help RN-BSN programs much with what clinical and classroom portions need to be included.  Many programs argue that their RN-BSN students have had plenty of clinical in their places of work (mostly acute care) and do not need any more.  I would argue with this ill-laid premise.  They have had much clinical, but need more, nursing is a clinical practice after all.

The BSN educational standards laid out by the NLN-AC build upon the ASN standards for sure, but are merely expansions on those in conceptual terms of student abilities.  These same accrediting bodies have clearly laid out the need for nursing informatics and transcultural curriculum within BSN programs, and have laid out objectives for community health, population care, and administration and this is good. However, these guidelines do not require clinical for programs to meet accreditation standards. To my knowledge, there are no specific quantitative measures for RN-BSN students at program start and completion to see if students have gained knowledge in certain standardized areas, all testing for BSN students comparing national standards are geared toward pre-licensure measures of passing NCLEX.  Likewise, standardized pre-licensure testing programs for both ASN and BSN students are identical.

This academic problem of defining the difference between associate/diploma and BSN education continues to bleed into practice.  Until we clearly define a domain difference for our students, this problem will remain.  It affects our nurses both in acute care and community health/primary care, because we cannot clearly articulate the difference in their knowledge base, employers do not see an added need nor do they delegate more activities to nursing which need to be delegated to nursing.  Nurses both in acute care and beyond need to be released to more tasks that come under their scope of practice, like being able to order social work consults, diabetic education, foot care, etc., until we clearly define roles and educational foundations, nursing education will continue to be part of the problem for our bedside nurses regarding scope of practice.

I am enthusiastically all for all nurses returning to school!  Life-long education is critical for nurses no matter their setting of nursing practice or education.  I am fully aware of how difficult it is to schedule school with working, family, and life.  I have done it myself now in four different nursing degrees and I do not want in any way to belittle the difficulty in continuing education for any of my students.  Continuing one’s education is a difficult path, but one that benefits both nurse and patient.  To help emphasize the importance of life-long learning, nursing educators must clearly articulate what skills and knowledge are gained at every level of education and the accrediting bodies must hold programs accountable for this.

However we move forward, it must be deliberate, clear, and evidenced based… and for GOODNESS SAKE… don’t cut the clinical from your RN-BSN program simply to be more ‘marketable’.