PHILADELPHIA – While John Jerzak, a newly licensed registered nurse, was looking for a job this spring, he stumbled into a controversy that has been simmering for decades among nurses.

The 55-year-old former airline worker thought a predicted shortage of nurses would ensure him a secure, well-paid job. But he discovered that growing numbers of Philadelphia hospitals do not think his brand of R.N. — one you can earn at a community college — is good enough. They want only nurses with bachelor’s degrees in nursing, even though they have exactly the same license.

Incensed, the feisty Jerzak has been turning up the heat, lobbying against what he perceives as discrimination with nursing and political leaders.

“The mere fact that we’re being denied a chance to compete for a job based on merit is maddeningly difficult to accept,” he said.

People can take three paths to becoming registered nurses. All end in passing a licensing exam that tests basic skills.

They can get a four-year nursing degree, or bachelor of science in nursing. They can get an associate’s degree, which takes two to three years. Or they can go to a diploma school for about three years.

Starting pay is about the same, though nurses need higher degrees for promotions.

Community colleges train more than half of the country’s new nurses.

Legislation has been introduced in New Jersey and New York that would require nurses to get a bachelor’s degree within 10 years of licensing. Pennsylvania nursing leaders are discussing how to help nurses move up the educational ladder more easily.

While increasing numbers of hospitals in cities rich with nurse-training programs have been loading up on nurses with bachelor’s degrees, many rural hospitals do not have that option.

“In rural America, this is not the issue at all,” said Elaine Tagliareni, a former Community College of Philadelphia nursing professor, who now is chief program officer for the National League for Nursing. Her organization supports having multiple entry points into nursing.

Until the 1950s, the vast majority of nurses were trained in diploma schools, although there were college programs. Then, a doctoral student suggested piloting two-year programs in junior colleges that would produce “technical” nurses. Four-year graduates would be “professional” nurses. Two-year programs soon proliferated, but the licensing never changed.

The American Nurses Association has been arguing since 1965 that the entry level for nursing should be four years of college.

“One of the greatest mistakes we’ve made as a profession is that we’ve allowed all these different ways into the profession and still only have one licensing examination,” said Andrea Hollingsworth, dean of Gwynedd-Mercy College’s nursing program. “It’s been a divisive issue for 40 years.”

Studies at the University of Pennsylvania showing that nurses with higher degrees produce better patient outcomes have fueled demand for bachelor’s degrees.

“The evidence base is growing, and a number of hospitals are acting on it,” said Linda Aiken, director of the Center for Health Outcomes Research at Penn’s nursing school. One of her studies, for example, showed that every 10-percentage-point increase in the proportion of nurses with a bachelor’s degree in a hospital is associated with a 5 percent decline in patient mortality.

Why is a mystery. Aiken said it might be because nurses with bachelor’s degrees have better critical thinking or social skills. Or it could be that college graduates are better able to negotiate with other hospital workers.

Hospital nursing leaders say they can be choosy now because of the economy. There are fewer openings because experienced nurses are staying in the workforce instead of retiring, and others are increasing their hours. Plus, demand for some hospital services has fallen, and nurse-training programs have expanded.

Those who prefer nurses with bachelor’s degrees say that nurses today work with increasingly complex machines and patients. Hospitals are moving toward evidence-based medicine — translating scientific studies quickly into new procedures at the bedside — and that sort of thinking is not emphasized in the more technically oriented associate-degree programs.

Victoria Rich, chief nursing executive for the University of Pennsylvania Medical Center, said the bachelor’s-degree requirement has led to a more sophisticated nursing corps. She is impressed by the “intelligence of these nurses at a complex level, at a critical-thinking level.”

She also thinks nurses need more education to get respect from other medical professionals, all of whom have at least a bachelor’s degree. “It’s hard to define yourself as a profession,” she said, “when you can get the same salary after two years or four years.”

So far, she is attracting more than enough nurses. “We are 92 percent baccalaureate-prepared now, and I have waiting lists of 300 to 400 nurses that want to work here.”

Nancy Valentine, chief nursing officer for Main Line Health, said her system last year had 600 applications from nurses with bachelor’s degrees for 70 positions for new graduates. “You cannot believe some of these people,” she said. “They are absolute stars.”

Fifty-one percent of her nurses now have bachelor’s degrees, and the system is subsidizing tuition for about 300 more who are working on bachelor’s degrees.

Jerzak is particularly galled by Main Line Health’s rules, because he did some of his clinical training in one of its hospitals. In the past, student nurses often had an inside track for jobs at hospitals where they trained.

Lana deRuyter, dean of allied health and nursing at Delaware County Community College, where Jerzak got his degree, understands his frustration. Like Jerzak, 30 percent to 40 percent of her students already have bachelor’s degrees. The associate’s degree is the cheapest, fastest way for them to enter nursing.

“I think we graduate an extremely qualified and safe nursing practitioner,” she said. The new Main Line Health policy has “disenfranchised our graduates. Our graduates were the largest number of graduates they hired in the past.”

Nursing leaders say nurses with associate’s degrees can get jobs outside hospitals or in more rural areas. It likely will be easier for all nurses to find work when the economy improves and the health care overhaul takes hold.

Stephanie Conners, chief nursing officer at Hahnemann University Hospital, said she had looked for the right attitude and thinking skills in new R.N.s, not particular degrees.

“What makes a great nurse is just not the initials by your name,” she said.

Jerzak thinks patients would agree. His nursing classes focused on how to take care of patients, and that is all he wants to do.

“I don’t want to be a nurse manager. I don’t want to do research,” he said. “I want to be at the bedside.”

He thinks that, at the bedside, the extra knowledge he might get in a bachelor’s-degree program — or, for that matter, from the four-year degree he already has — will not matter nearly as much as whether he can, say, painlessly thread a catheter through a man’s urethra.

At that moment, his patient’s chief concern, he said, “is not going to be my baccalaureate exposure to Faulkner. Does he want to talk about Martin Heidegger? I can do it. I have a B.A. in philosophy.”Those who prefer nurses with bachelor’s degrees say that nurses today work with increasingly complex machines . Hospitals are moving toward evidence-based medicine — translating scientific studies quickly into new procedures at the bedside — and that sort of thinking is not emphasized in the more technically oriented associate-degree programs.


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