BSN in 10: How do ethics figure in?
EDITOR'S NOTE: Karen Schmidt, RN, is a freelance writer.
On Dec. 17, 2017, New York Gov. Andrew Cuomo signed a bill into law that requires nurses to earn a BSN within 10 years of initial licensure. Besides setting the BSN standard for RNs, the law creates a temporary nursing program evaluation commission to make recommendations on barriers to entry into nursing.
“When I started hearing more and more about the baccalaureate and master’s degree requirements for teachers in New York, I wondered if we might be able to use a similar model for nursing,” Zittel said, explaining she believes if teachers should be expected to be master’s prepared, nurses should at least be baccalaureate prepared. Research also impelled the NY board of nursing to push toward the BSN requirement, said Zittel, who called it an ethical duty. She said research published in 2003 by Linda Aiken and others in the Journal of the American Medical Association described educational levels of hospital nurses and surgical mortality. “A huge population of 232,000 patients demonstrated that for every 10% increase in the number of bachelor’s degree-prepared nurses, there was a 5% decrease in preventable deaths,” Zittel said. That data prompted the NY State Board of Nursing to decide something needed to be done to increase the number of nurses with baccalaureate degrees, she said.
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A baccalaureate nurse brings an ethical skill set of being able to assess a situation, do the research or know what needs to be done to seek the information they need, and then reach out to leaders and others who can give guidance.” — Cheryl Peterson, RN
Zittel said the board recognized their ethical duty to require baccalaureate preparation related to provisions in the Code of Ethics. The first one, she explained, is provision 3: Nurses’ primary commitment is to the patient and to protect that patient.
Additional research since 2003 has shown that hospitals with nursing staffs with a higher number of baccalaureate-prepared nurses have fewer deaths or poor outcomes, whether pneumonia, UTIs or patients being re-hospitalized within 30 days of discharge. Zittel cited studies in the Journal of Nursing Administration, the Journal of Nursing Scholarship, and Health Affairs as further evidence.

Peterson added that other provisions in the Code of Ethics also support the BSN requirement. Provision 7 concerns advancing the profession and speaks to nursing’s need to engage in greater knowledge development through research and scholarly inquiry, while Provision 5 obligates nurses to continue their personal and professional growth.

Still work to do Peterson emphasized a caveat related to ethics and nursing preparation. “We don’t have enough ethical education in many basic nursing programs, whether associate degree, diploma or baccalaureate,” she said, pointing out the ANA’s ethics advisory board is working on this matter, searching out answers for how to strengthen the ethical education for nurses in general.
In terms of salaries that reflect additional education for a BSN, Peterson said work remains to be done. “We need to continue to advocate for wages commensurate with our education and professional responsibilities.” “We need to continue to press for nursing education dollars geared not just for the initial nursing preparation, but also for the transition from RN to BSN.” She added that employers need to look at how they will support this transition.
BSN preparation goes deeper Peterson explained the new law formalizes what nurse leaders already understood. “We know from years of study around baccalaureate education that it has a stronger foundation and theoretical basis, leadership skills, nursing research and critical thinking,” she said.

A baccalaureate nurse brings an ethical skill set of being able to assess a situation, do the research or know what needs to be done to seek the information they need, and then reach out to leaders and others who can give guidance,” Peterson continued.
Zittel said the additional education provided in a baccalaureate program also gives more preparation for ethical decision-making and problem solving. She cited an example from her early nursing practice experience while she was en route to her own baccalaureate degree. Zittel was caring for a hospitalized, elderly Jewish male patient who needed his pacemaker replaced. Zittel said the man agreed to the procedure, stating “he wanted to live as long as God wanted him to.” “When it came time for us to get his written consent,” Zittel recalled, “he refused to sign it.” When questioned, the patient simply said it wasn’t a good time to sign it Having just taken a course in comparative religion as part of her degree acquisition, Zittel asked the patient, “Are you concerned that this is the Sabbath?” He acknowledged that this caused his reluctance since his faith tradition meant he was unable to sign a contract on that day of the week. Her knowledge about his faith and how it influenced his decisions allowed the staff to work around the time situation and get the consent to do the procedure, Zittel explained.


Nurse consultant Barbara Zittel, PhD, RN, worked on the creation of the bill starting in 2003 while she was the executive secretary of the NY State Board of Nursing. She remembers learning, while serving with the state education board, that NY state teachers were required to earn a master’s degree within five years of initial certification.
Connection to the code
The ethical implications make sense also to Cheryl Peterson, MSN, RN, vice president for nursing programs for the American Nurses Association. “From our perspective [at ANA], this is perfectly congruent with the nursing Code of Ethics.”

RNs discuss rationale behind the new legislation
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Contents
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Choose your words wisely
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