Three educational routes lead to the same registered nurse license and the same examination: a hospital diploma, a two year associate degree, and a four year bachelor's degree. No other licensed profession in the United States admits candidates at three different educational levels to identical practice authority.
The profession has been arguing about this since 1965, when the American Nurses Association proposed that the bachelor's degree become the minimum preparation for professional nursing. The argument is usually called the entry into practice debate, and it has never been settled by regulation.
The one state that tried
North Dakota is the only state that ever wrote the requirement into law. From 1987 it required a bachelor's degree for registered nurse licensure and an associate degree for practical nurse licensure.
No other state followed. Neighboring states kept admitting associate degree graduates to the same license, North Dakota's own rural hospitals struggled to recruit against them, and the legislature repealed the requirement in 2003 after sixteen years. It remains the only real world test of mandating the degree, and the reason usually given for the repeal, that it worsened a rural nursing shortage, is why the idea has not been seriously attempted since. See nursing in North Dakota.
New York's compromise
New York found a way around the objection. A law signed in 2017 and applying to nurses licensed from 2019 requires a registered nurse to complete a bachelor's degree in nursing within ten years of initial licensure. It is generally called BSN in 10.
The design is the point. An associate degree graduate can still be licensed, can still work, and can start earning immediately, and the degree requirement lands later, usually part time and often with employer tuition support. The entry gate stays open and the profession still gets the degree. New York is the only state with a law of this kind. See nursing in New York.
What the labor market did instead
Regulation stalled and hiring practice moved anyway.
The Institute of Medicine's 2010 report on the future of nursing recommended that 80 percent of registered nurses hold a bachelor's degree by 2020. The target was missed, but it became the number hospitals were measured against, and Magnet recognition, which many large systems pursue, pushed in the same direction by setting expectations for the education of nursing leadership and the workforce.
The result is that federal occupational data now lists the bachelor's degree as the typical entry level education for registered nurses even though no state requires it. Many academic medical centers hire only bachelor's prepared nurses, or hire associate degree graduates on condition they complete the degree within a set period. RN to BSN completion programs, mostly online and often employer subsidized, exist to serve that requirement and are now a substantial part of nursing education.
Hospital diploma programs, which trained most American nurses into the 1960s, have nearly disappeared. Associate degree programs remain, concentrated in community colleges, and they are the main route into nursing for students who cannot leave work or move to attend university. That is the strongest argument against mandating the degree: the associate route is what makes nursing accessible to rural, older and lower income students, and closing it narrows who becomes a nurse.
There is also a supply constraint that no amount of policy solves on its own. Nursing schools turn away qualified applicants every year for lack of instructors, because a doctorally prepared nurse can earn substantially more in clinical practice than in teaching. See the nurse faculty shortage.
What the research says
The evidence most often cited is the 2014 study across nine European countries which found that a higher proportion of bachelor's prepared nurses was associated with lower surgical mortality, alongside the separate effect of staffing levels.
It is observational, like the rest of this literature, and hospitals that employ more graduates differ from those that do not in ways that are hard to adjust away. It is nonetheless the most careful work available, and it is why the argument is not purely about professional status. See nurse staffing and patient outcomes.
Related
- Levels of nursing
- The NCLEX
- The nurse faculty shortage
- Magnet recognition
- Nurse staffing and patient outcomes
Sources
- Occupational Outlook Handbook: Registered Nurses. U.S. Bureau of Labor Statistics, on typical entry level education. Accessed September 8, 2026.
- The Future of Nursing: Leading Change, Advancing Health. Institute of Medicine, 2010, for the 80 percent recommendation. Accessed September 8, 2026.
- Nurse staffing and education and hospital mortality in nine European countries. Aiken LH, Sloane DM, Bruyneel L, et al., The Lancet 2014;383(9931):1824. Accessed September 8, 2026.
- New York State Education Department, Office of the Professions, registered professional nursing. On the baccalaureate completion requirement. Accessed September 8, 2026.
- North Dakota Board of Nursing. Accessed September 8, 2026.