Over the past year I have attended numerous meetings, with thousands of nurses, discussing the Doctor of Nursing Practice (DNP) and Clinical Nurse Leader (CNL) initiatives in the United States of America (USA) (AACN 2004a, 2004b). The DNP is a practice-focused doctoral program that prepares graduate nurses for the highest level of practice. The CNL assumes accountability for healthcare outcomes for a specific group of clients within a unit or setting through application of research-based information to design, implement, and evaluate client plans of care. The two initiatives are significant developments, with parallels occurring in other parts of the world. But what is the rationale of expending so much effort on new advanced practice programs when we have not yet reached consensus on what should constitute the first-level entry into professional practice?

In some countries, such as Australia, all newly Registered Nurses (RNs) now hold a Bachelor of Nursing degree, and the realization of an all-graduate nursing profession has been achieved or is the declared goal in many parts of the world. In the USA, however – despite having pioneered graduate education for nurses many decades ago – only a third of our RNs hold baccalaureate degrees and the majority of our public receive their nursing care from associate degree and diploma-qualified nurses. And yet, from our own research, we know that nurses prepared through baccalaureate and higher degrees attain better patient outcomes in terms of a ‘substantial survival advantage’: in other words, a decreased risk of patient death and a decreased ‘failure to rescue’ rate (Aiken et al. 2003). The more highly educated RNs also have lower rates of medication errors and procedural violations (Delgado 2002) and stronger critical thinking and leadership abilities (Goode et al. 2001).

Safe and effective care is also recognized increasingly as the product of good multidisciplinary teamwork. Central to this is effective communication between physicians and nurses (Arford 2005) and this, of course, must be based on mutual respect and implicit trust in each others’ contribution and integrity. We need to ask ourselves some uncomfortable questions. Do physicians, who take many years to achieve their medical degrees, really trust and respect nurses who have only 2 or 3 years of post-high school education? Is it reasonable to expect physicians to regard nurses as equal partners in the healthcare team when there are such wide variations in the educational level of RNs?

A number of groups in the USA have publicly supported baccalaureate-level preparation for registration, with the National Advisory Council on Nursing Education and Practice now recommending that at least two-thirds of the nursing workforce should have at least a baccalaureate degree in nursing by 2010. The American Association of Nurse Executives issued a statement in 2005 advocating that the future entry-level educational preparation for all nurses should be at the baccalaureate level.

But although we have research that links higher education with lower risks for patients, and despite numerous groups now calling for the baccalaureate as the minimum education for nursing, we are still far from seeing this as a reality even in the USA. The crux of the problem, as Diers (1985) pointed out some years ago, is that we have overemphasized the political concern of having the baccalaureate as the minimum educational preparation for nursing when, instead, we should have been focusing on the policy issue of what knowledge, experience, skills, and qualifications are needed by nurses today in order that the American public receives safe, high quality and effective health care. So, let's join together, not only nationally but also internationally too, in order to focus on this all-important policy issue for the citizens we serve. Quite literally, as we now know from research, their lives depend on better-educated nurses.


  1. Top of page
  2. References
  • AACN (2004a) AACN Position Statement on the Practice Doctorate in Nursing. American Association of Colleges of Nursing, Washington DC, USA.
  • AACN (2004b) Dialogue with the Board: AACN Clinical Nurse Leader Project. American Association of Colleges of Nursing, Washington DC, USA.
  • Aiken L., Clarke S., Chung R., Sloane D. & Silber, J. (2003) Educational levels of hospital nurses and surgical patient mortality. Journal of American Medical Association, 290, 16171623.
  • Arford P.H. (2005) Nurse–physician communication: an organizational accountability. Journal of Nursing Economics, 55(2), 7277.
  • Delgado C. (2002) Competent and safe practice: a profile of disciplined registered nurses. Nurse Educator 27(4), 159161.
  • Diers D. (1985) Policy and politics. In Political Action Handbook for Nurses (MasonD. & TalbottS. eds), Addison–Wesley Publishing Company , Menlo Park, CA, pp. 5359.
  • Goode C.J., Pinkerton S., McCausland M.P., Southard P., Graham R. & Krsek, C. (2001) Documenting chief nursing officers’ preference for BSN-prepared nurses. Journal of Nursing Administration, 31(2), 5559.