When a member of the general public hears the word “nurse”, they have a picture in their mind of what that term means. But when it comes to the differences between licensed practical nurses (LPNs), registered nurses with an associate degree (RNs), and bachelors-prepared nurses (BSNs), many people — even some nurses and healthcare professionals — scratch their heads and feel confused. Further confusion may result from the fact that both nurses with an associate degree and bachelors degree are referred to as registered nurses; and when you add that LPNs are known as licensed vocational nurses (LVNs) in Texas and California, the waters get even muddier.
Why So Many Kinds of Nurses?
The history of nursing designations is far beyond the scope of this article. Nonetheless, let’s at least take a moment to discuss this stratification of nurses that we see out there in the workplace.
According to some sources, vocational training was seen as a way to make up for shortages in skilled labor in the late 19th century. Other sources cite Florence Nightingale’s work in the Crimean War as the main catalyst for practical nursing to emerge as a way to create a skilled nursing labor force to care for the infirm.
In 1873, three nursing programs opened their doors, namely the New York Training School at Bellevue Hospital, the Connecticut Training School at the State Hospital (later renamed New Haven Hospital) and the Boston Training School at Massachusetts General Hospital. Based on the ideas promoted by Nightingale, these schools initialized the professional training of American nurses.
The American Civil War, the establishment of the Red Cross in 1881, the creation of the American Nurses Association, the National League of Nursing Education (now known as the National League for Nursing), and myriad other factors and influences also weighed in on the need for trained nurses. Amendments to the Smith-Hughes Act of 1917 provided funding from the federal government for nurse vocational training, which was a boon to schools seeking to graduate more of these highly useful workers. And with the onset of World War II, the need for more than 20,000 skilled nurses exploded both at home and in the various theaters of conflict.
During the mid-20th century, arguments ensued over what tasks and skills nurses should and shouldn’t be able to perform, and what kind of education was needed. Thus, practical/vocational nurses became one of several tracks for nursing education and professional career development; baccalaureate programs emerged, as did associate degree programs at the newly popular community colleges popping up around the country. Essentially, from this plethora of educational pathways was born the LPN, RN, and BSN designations.
The Practical Nurse (LPN/LVN)
Essentially, LPNs/LVNs are vocationally-trained nurses who provide skill-based care to patients in a variety of settings. Practical nurses attend a vocational program for approximately 12 months. While these students take courses in basic biology and pharmacology, they do not engage in the study of the humanities (e.g.: psychology, sociology, behavioral science), as well as mathematics and advanced sciences such as microbiology required to receive an academic degree (associate or bachelors) in an institution of higher education such as a college or university.
In the 21st century, practical/vocational nurses tend to be more employable in settings such as nursing homes; long term care and assisted living facilities; physician offices; clinics; and home care. It is becoming less common to find LPNs in acute care hospitals, surgical centers, and similar higher-acuity settings.
While there are indeed fewer opportunities for LPN specialization than for RNs and BSNs, LPNs can seek specialty certification in several areas, including IV therapy, long-term care, and pharmacology.
Although their earning power is significantly less than that of nurses with higher degrees, LPNs are highly skilled clinicians with an essential place in the American healthcare system, fulfilling crucial roles providing care for those in need.
The Associate Degree Nurse (ADN/RN)
A nurse who enters an associate degree program in nursing will usually attend one of many community colleges in the United States. ADN programs generally present the student with a number of prerequisite courses to complete prior to application and entry, including but not limited to anatomy and physiology, English, chemistry, mathematics (generally algebra), microbiology, general and developmental psychology, sociology, and other courses in the humanities.
The associate degree program itself may encompass up to two years (not including prerequisites), and take a deep dive into nursing science, history, and theory — areas not addressed in vocational nursing programs — as well as other aspects of the expected knowledge base of the professional nurse. ADN graduates are prepared to supervise and delegate to LPNs, CNAs, nurses’ aides, and other staff members, as well as have an ability to read and evaluate nursing research and other scholarly information.
Until the 2010 publication of the Institute of Medicine’s report titled The Future of Nursing: Leading Change, Advancing Health, nurses with an associate’s degree enjoyed relatively unfettered access to high-paying positions within most acute care facilities around the United States. However, with the IOM’s research-based determination that patient mortality and other negative outcomes decreased proportional to the percentage of baccalaureate-prepared nurses working with patients in acute care settings, many hospitals began to require nurses to hold a BSN in order to be employable in such settings. For many associate-prepared nurses with long-standing professional careers and skilled experience, the prospect of returning to school to earn a BSN was a grave disappointment and financial burden, although many chose to do so in order to remain competitive.
While some acute care facilities still employ ADNs, the number who do has dwindled and many positions now require a BSN in order for a candidate to be considered. Nonetheless, thousands of nurses continue to graduate from associate degree programs and find positions in myriad non-acute settings where their skills, knowledge, and expertise are welcome, and they can always return to school for a BSN when the need arises.
The Bachelor’s of Science in Nursing (BSN)
The Bachelor’s of Science in nursing moves the nurse into the academic realm of the four-year university (although some community colleges now offer BSN programs in coordination with universities). When studying for a BSN, new topic areas and courses not fully addressed in ADN programs are introduced, and the nurse gains a more well-rounded education in terms of expanding beyond that offered by vocational and associate degree educational pathways.
Courses and core concepts brought forward in BSN programs may include:
- Community, population, and global health
- Nursing research
- Policy, finance, and healthcare regulation
- Statistics (often as a prerequisite)
- Healthcare ethics
Those individuals with a previous bachelor’s degree in a non-related subject can utilize a so-called “second bachelors” BSN program as their onramp into the profession. Students without a previous degree can also enroll in a four-year university and pursue nursing as their major. As mentioned above, those nurses with an ADN can pursue a “RN to BSN bridge program” that allows them to work as nurses while going to school and earning a BSN. And some vocational nurses may be interested in “LPN to BSN” bridge programs that elevate successful graduates from vocational to baccalaureate-prepared nurse.
Bringing it All Back Home
However we measure it, nurses of all stripes are essential workers within the American healthcare system. Each designation of nurses holds meaning and value, and we would be bereft without the millions of nurses who care for us across the lifespan. While more education does generally bestow greater opportunity and earning potential, we cannot overlook or denigrate the important skilled labor performed by vocational nurses, who are crucial clinicians in their own right.
As the lifeblood and backbone of the healthcare system, all nurses — no matter their level of education — deserve respect, healthy working conditions, competitive pay, and opportunities for advancement throughout highly meaningful and purposeful careers.