Associate degree nursing education remains a vital, compelling choice for students interested in entering the nursing profession. With its rich heritage and contemporary efficacy, associate degree nursing continues to positively impact the registered nursing population in the United States.

For fifty years, associate degree nursing programs have been a subject of curiosity, controversy, and conviction. Their growth from seven pilot schools to more than 800 programs nationwide, represents a phenomenal picture of success. Graduates of associate degree nursing programs represent almost 60% of the entry level graduates each year. As reported in The Registered Nurse Population, March 2000, Findings from the National Sample Survey of Registered Nurses (Spratley, Johnson, Sochalski, Fritz, & Spencer, 2001), of the nearly 2.7 million registered nurses in the United States, 34% report the associate degree as their highest education degree. More than 40% of the RN population received their basic nursing education in an associate degree program (Spratley et al., 2001).

The concept of preparing associate degree nursing graduates was developed during a time in our country that has marked similarities to today.

The concept of preparing associate degree nursing graduates was developed during a time in our country that has marked similarities to today.

World War II was just ending, and despite earlier predictions, not all nurses who had been in military or civilian practice were remaining in practice. A nursing shortage was present and evolving, affected by both a decreased supply and an increased demand. Haase (1990) reported two major concerns that were repeatedly questioned, specifically, "why weren't more students choosing nursing as a career?", and "why weren't more licensed nurses continuing in active service after the first few years following graduation?" (p.11). The increased demand was influenced greatly by three developments: advances in medical sciences, improved medical facilities, and increased numbers of health care insurance participants (Haase, 1990).

Several forces served as catalysts for the development of associate degree nursing education programs: interest and growth of junior colleges, federal involvement in funding and spending, consumer concern and support, and professional responsibility and accountability. As early as 1945, The American Association of Junior Colleges (AAJC), which is now recognized as the American Association of Community Colleges (AACC), during a meeting with the U. S. Office of Education, discussed the possibility of including nursing in junior college curricula (Haase, 1990). The involvement and support of AAJC/AACC continued through the early years of the development of associate degree nursing education and continue to date. Much of the evolvement and growth of associate degree nursing has matched the evolvement and growth of junior and community colleges.

The federal government impacted nursing education in numerous ways. Funding for nursing directly affected the number of nursing graduates. The Bolton Act of 1943 funded the costs of nursing education, and provided a living stipend. During these funding periods, annual graduation rates increased conspicuously. Unfortunately, this funding source ended in 1948. Without federal funding, the number of nursing graduates fell significantly. During this time, several attempts to legislate federal monies for nursing were defeated. Legislators, nurses, physicians, and health care administrators could not overcome reported concerns about how monies would be appropriated and spent. However, the federal government was spending an increasing percentage of the gross national product on health care (Haase, 1990).

Several consumer groups and foundations had a profound impact on associate degree nursing. Even the monies used to launch the pilot project for implementing associate degree nursing programs were given by an anonymous group of women. The Carnegie Foundation funded the research of Dr. Esther Lucile Brown, who published the study, Nursing for the Future, better known as the Brown Report. Although this report did not directly promote associate degree nursing programs, it did suggest that nursing take place in the nation's colleges and universities, instead of in hospital-based programs (Haase, 1990).

The W. K. Kellogg Foundation has been instrumental in several projects affecting the development and success of associate degree nursing education. Monies have been given to fund graduate programs to prepare associate degree nursing educators, continuing education for associate degree educators, consultant services, and various pilot projects (Haase, 1990). Some of the projects Kellogg has implemented over the past fifty years have included foci on teacher education, demonstration sites, education and service partnerships, and geriatric nursing curricula.

The shortage of nurses, the interest in moving nursing education to colleges and universities, and the desire to find more efficient ways to educate nurses were common concerns of nursing educators and administrators.

The shortage of nurses, the interest in moving nursing education to colleges and universities, and the desire to find more efficient ways to educate nurses were common concerns of nursing educators and administrators.

In January 1952, a project was initiated that introduced two-year associate degree nursing programs. This project, know as the Cooperative Research Project in Junior and Community College Education for Nursing, was based at Teachers College, Columbia University. The project director was Dr. Mildred Montag, whose dissertation, Education for Nursing Technicians, promoted a research-based plan to create and test a model for the new nursing degree. The two main purposes for the project were defining the new worker and designing the education program for the new worker (Haase, 1990, p. 26-27).

The curriculum design reflected approximately half general education courses and half nursing courses. The concept of nursing was patient-centered, not disease centered. Nursing courses were based on broader structures, e.g., adult nursing, maternal and child nursing, etc. Fundamental concepts were taught early in the programs, which were later built on, with complex concepts taught in the second year (Haase, 1990, p. 36).

Clinical experiences reflected great differences, too. Community facilities were added to hospital-based experiences. Clinical sites included "day nurseries, nursing homes, specialized hospitals, health clinics, family planning agencies, public schools, physicians' offices, and self-help groups" (Haase, 1990, p. 37). Interestingly, these clinical sites mirror those of many community college programs today, who have developed "new" curricula.

The student populations in the pilot programs differed from student populations in traditional nursing programs. The programs attracted older students, many of whom were married, widowed, or separated. Traditional hospital-based programs had not allowed older or married students. A higher number of male students were also represented in the pilot associate degree nursing programs (Haase, 1990, p. 38). Many of the population dynamics from this period continue to date.

Evaluation of the initial pilot schools reflected the following conclusions, as reported by Dr. Montag and cited by Haase (1990, p. 40).

• graduates were able to pass the licensing examinations;
• graduates were able to carry out the functions of the staff nurse;
• the programs attracted students;
• the program did become an integral part of the community college;
• the college was able to finance the nursing program just as it did other programs.

The success of the early programs became a stimulus for growth. Within 25 years, the number of associate degree nursing programs grew from seven to nearly 700. And today, fifty years after their introduction, there are more than 800 associate degree nursing programs in the nation.

Controversy has marked the associate degree nursing education since its inception. An exhaustive review of the controversies will not be included, but highlights of controversial issues will be examined.

In 1960, the American Nurses Association (ANA) first introduced promotion of the baccalaureate program to become the basic educational foundation for professional nursing. This authenticated earlier support from ANA and other groups for moving nursing education to colleges and universities. However, this took a further step by promoting the baccalaureate graduate as the professional nurse. Quickly, dissension occurred among educators from all program types; associate degree, diploma, and baccalaureate. That controversy, regarding the title of professional nurse, persists today (Haase, 1990).

Controversy in nursing was not limited to entry level issues. Nursing organizations had gone through mergers, divisions, and disagreements over organizational roles. However, in 1965, both the ANA and the National League for Nursing (NLN) took stands on the future of nursing education. The ANA document, known as "the Position Paper" described the baccalaureate degree as the minimum preparation for beginning professional practice for the present time. The NLN document, Resolution 5, was more cautious, but called for examination of the differentiated functions of the different entry programs (Haase, 1990). These position statements again proved to be controversial and divisive. The themes from these two documents highlight two of the most frequent themes of contention: professional nursing versus technical nursing, and differentiated nursing practice.

In 1982, the National League for Nursing (NLN) approved the document Position Statement on Nursing Roles-Scope and Preparation, which stated that "professional nursing practice requires the minimum of a baccalaureate degree with a major in nursing. Preparation for technical nursing practice requires an associate degree or a diploma in nursing" (Kaiser, 1983, p. 18). Many members of the NLN education councils for associate degree nursing and diploma nursing did not support the position statement.

In the NLN publication, The Associate Degree Nurse: Technical or Professional?, (Kaiser, 1983) three papers were included that were presented during a forum at the American Association of Community and Junior College (AACJC) annual meeting in 1983. The forum was established to respond to the 1982 NLN position statement. Dr. Mildred Montag discussed the historical use of the term technical nurse. Dr. Montag described how the choice of technical nurse was influenced by the nursing functions that the new nurse would be taught, and the fact that community and junior colleges were preparing other technical workers (Kaiser, 1983).

Representing AACJC, Dr. Theodore Tilton expressed the premise that although the original design might have been for associate degree graduates to have different roles, the fact was they were being licensed as registered nurses in all states. Dr. Tilton emphasized the contributions that associate degree nursing had made in thirty years: the vast numbers of graduates, the large number of programs, the influence of change on the nursing population, with greater numbers of older students, with a higher representation of minority groups and males. For certain, the majority of Dr. Tilton's comments were in opposition to the 1982 NLN position statement (Kaiser, 1983).

The third paper presented comments from an associate degree nursing educator, Celia L Hartley. Ms. Hartley supported the 1982 NLN position statement noting that: NLN represented all four types of basic nursing education; the position statement did not propose change in licensure; NLN supported educational mobility; and NLN had supported projects to define competencies of all graduates. Acknowledging associate degree educators' lack of acceptance of the term "technical," Ms. Hartley expressed the discomfort between the contrast of technical to professional. Speaking to the word "professional," Ms. Hartley said, "it is unfortunate that nursing has chosen the word to label the graduates of four-year programs and their skills. We don't hear medicine, law, or dentistry talk about professional doctors or professional attorneys" (Kaiser, 1983, p. 14).

With the stronger position statement from the National League for Nursing and funding from ANA to implement the ANA position statement, many associate degree educators became disenfranchised with the two leading nursing organizations. In 1986, the National Organization for the Advancement of Associate Degree Nursing was established. This organization later became known as the National Organization for Associate Degree Nursing (N-OADN). N-OADN is the only national professional nursing organization whose goals and strategic plan are focused on associate degree nursing education and maintaining licensure for graduates from associate degree nursing programs:

N-OADN's Position Statement in Support of Associate Degree Nursing as Preparation for the Entry-Level Registered Nurse (National Organization for Associate Degree Nursing [N- OADN], 1998) reports:

Associate Degree Nursing (ADN) education provides a dynamic pathway for entry into registered nursing (RN) practice. It offers accessible, affordable, quality instruction to a diverse population. Initiated as a research project in response to societal needs, ADN education is continually evolving to reflect local community needs and current health care trends. ADN graduates are prepared to function in multiple health care settings, including community practice sites.

Graduates of ADN programs possess a core of nursing knowledge common to all nursing education routes. They have continuously demonstrated their competency for safe practice through National Council Licensure Examination for Registered Nurses (NCLEX-RN®) pass rates. These nurses provide a stable workforce within the community. The majority of ADN graduates are adult learners who are already established as an integral part of the community in which they live. They exhibit a commitment to lifelong learning through continuing education offerings, certification credentialing, and continued formal education.

Nurses prepared at the ADN level are caring, competent, and committed health care providers who fill a vital need in local communities. Accordingly, the National Organization for Associate Degree Nursing supports ADN preparation as the entry level into registered nursing (N-OADN, 1998, p.1).

Differentiated nursing practice is another concept that has been interpreted differently by various nursing groups. Most constituencies believe there are varying roles required for nursing practice. Points of difference usually involve the importance formal education holds on the ability of the nurse to assume different nursing roles. Some differentiated nursing practice models include formal education, lifelong experiences, work experience, and specialty certification as mechanisms for maintaining or assuming new roles. Many state and national models have been identified, but none of them have been implemented at a national level.

In 1995, A Model for Differentiated Nursing Practice was published (American Association of Colleges of Nursing [AACN], 1995). The American Association of Colleges of Nursing and the American Organization of Nurse Executives began the work that resulted in this publication, which later included associate degree nursing education and community and long-term care delivery organizations in the task force work. In a letter acknowledging the Associate Degree Nursing Perspective, Dr. Carol Singer, the president of N-OADN at the time of the task force work stated:

N-OADN has previously acknowledged the need for and continues to support health care reform in the United States but recognizes the new and different challenges it will bring to nurses as well as changes in their practice roles. To meet the demands of health care reform, we believe that it is critically important that approaches be used that recognize that each nurse has value and purpose, and as such will play an important role in it. In addition, the basic premises of this project, built upon the essence of nursing as a series of integrated values, enhances its potential acceptance as a model far different from the traditional, incremental, competency-based models of the past (AACN, 1995, p. v.).

Two years later, N-OADN (1997) published a resolution on differentiated nursing practice that acknowledged the contribution of experience, competence, and life long learning in defining the roles and functions of registered nursing practice. The resolution acknowledged N-OADN's support of the registered nurse's involvement in developing competencies of roles in varied practice environments, and support of practice models that value registered nurses and their practice. The resolution also challenged N-OADN to serve as an advocate for registered nurses, so that the nurses would have the opportunity to assume roles appropriate to their capabilities and experience (National Organization for Associate Degree Nursing [N-OADN], 1997).

With such diverse opinions about entry level registered nursing practice and practice models, it is not surprising that the various nursing organizations today continue to find obstacles when defining the future of registered nursing practice. Many previous efforts have been unsuccessful because decisions were made without significant representation of all program types. Speaking of associate degree nursing, Kaiser commented, "Decisions about nursing must heed the voice of this large and significant group, who are making an important contribution to health care" (Kaiser, 1983, p. iv.). At the state, regional, and national level, integration of associate degree nursing educators and nurses in practice into groups who are designing a vision for nursing practice is essential.

Demographics related to associate degree nursing education and practice demonstrate the impact that associate degree nursing continues to make on the U. S. registered nursing population and provide information for defining future implications. The most recent national statistics show that fewer women are choosing nursing, and the number of men has not significantly changed. Minority representation is better, but does not nearly represent the U.S. population. There are fewer graduates with lower pass rates. The nursing population is aging. The effect associate degree nursing has on each of these factors will be examined.

As mentioned in the introductory comments, of the nearly 2.7 million registered nurses in practice, 40.3% of registered nurses reported completing an associate degree program and 34% of registered nurses reported their highest education degree as associate degree. Registered Nurses who obtained their basic education in diploma programs and baccalaureate programs are 30% and 29% respectively. Graduates from associate degree nursing programs also provide a source for baccalaureate and masters programs: 15.5% of registered nurses initially prepared in an associate degree nursing program reported completing additional nursing or nursing related degrees (Spratley et al., 2001, pp. 6-7).

Graduates of associate degree nursing programs represent almost 60% of the RN candidate pool. (National Council of State Boards of Nursing [NCSBN], 2000). During the past five years, the NCLEX-RN Candidate pool for associate degree graduates has decreased by 26%. This is the same decrease in percentage as for all candidates. From 1995 to 2000, the number of graduates of all program types was reduced from 96,610 to 71,475, and the number of graduates of associate degree programs from 59,908 to 42,665. Similarly, and mirroring the national pattern, graduates of associate degree programs have seen an 8% decline in first time pass rates over the past five years, moving from 91% to 83.8% (NCSBN, 1995, 2000).

Associate Degree Nursing reflects a higher representation of minorities. Graduates of associate nursing programs are represented by 21.3% individuals from minority groups, and 10.7 % are male. This corresponds with 12.3% minorities and 5.4% males in the total registered nursing population (Spratley et al, 2001). Table 1 demonstrates the breakdown of minority groups for associate degree nursing graduates compared to the total RN population.

The average age of registered nurses employed in nursing is 43.3. The average age at graduation of associate degree nursing graduates is 33.2, almost three years higher than all basic education programs. The age for Baccalaureate and Diploma graduates is 27.5 and 30.8, respectively. Over the past twenty years, nurses who are less than forty years of age have changed from representing almost half of the nursing population in 1980 to representing less than a third of the nursing population in 2000 (Spratley et al, 2001).

Associate degree nursing education continues to present a compelling option for individuals interested in the nursing profession.

If there is any self-criticism of associate degree nursing, it would involve the lack of consistent efforts to publish information about associate degree nursing education and practice.

Numerous characteristics of associate degree nursing programs attract prospective students: lower tuition rates, geographic locations, completion time, reputation of graduates, dynamic curricula, and effective faculties. Unfortunately, these qualities are promoted primarily by word of mouth. If there is any self-criticism of associate degree nursing, it would involve the lack of consistent efforts to publish information about associate degree nursing education and practice. Quite often, decisions are made about associate degree nursing, based on outdated or a lack of information. There are exemplar programs across the nation that can serve as benchmarks for excellence in such areas as retention, creative teaching, alternative clinical sources, curriculum process, and student satisfaction.

Comparison of Associate Degree Nursing Population Demographics to Total RN Population
	Associate Degree Nursing	Total RN Population
White	76.4%	86.6%
Black	10.0%	04.9%
Hispanic	06.3%	02.0%
Asian	03.9%	03.5%
American Indian	01.1%	00.5%
Women	89.3%	94.6%
Men	10.7%	05.4%
Note: Data from The Registered Nurse Population, March 2000, Findings from the National Sample Survey of Registered Nurses by Spratley, E., Johnson, A., Sochalski, J., Fritz, M., and Spencer, W. (2001), published by U.S. Department of Health and Human Services.

In N-OADN's Policy Statement on the Nursing Shortage (2001), the following statement summarizes the commitment of associate degree educators to impact the current shortage in nursing:

The current nursing shortage is most acute in hospitals; the initial setting for practice for the majority of registered nursing graduates. Therefore, associate degree nursing educators continue to be committed to provide educational programs that produce the nurses necessary to meet the demands of the nursing shortage.

Associate degree programs provide a sound foundation for the delivery of safe client care in the current complex health care delivery system. The programs are a reasonable investment of time and money for the student, allowing for licensure and employment in two years from the time of admission to the nursing program. Evidence of this can be seen by: the number of students who seek associate degrees in nursing; the strong passage rate on the NCLEX-RN exam by associate degree nursing graduates, which exceeds or equals that of other graduates; and the success of the associate degree graduates in nursing practice. (N-OADN, 2001).

Partnerships between education and practice should be expanded to develop creative extern, intern, and residency programs, for students, graduates, and nurses in practice. Lifelong learning to promote continued competence and enhanced knowledge should continue to be emphasized in associate degree nursing programs. Intensive efforts should be made to collaborate with other organizations to create and promote national models for education mobility to baccalaureate and master's programs.

Associate degree nursing educators should also continue to be involved in recruitment efforts. Several national initiatives have already made great strides in promoting the image of the registered nurse. The collaborations among all program types, as well as between education, practice, and the public, are producing the most effective recruitment endeavors. Implementing recruitment activities at the local level remains vital, including age groups from elementary schools to adults, with emphasis on minority populations.

The future of nursing has been the subject of many groups over the past fifty years. In recent years, these groups have attempted to be inclusive of the various education program types, and multiple practice groups. Unfortunately, through timing, degree of involvement, or number of participants, associate degree nursing has not enjoyed equal inclusion in many of these endeavors. Participation involves risks, but is essential if a group or organization is to have a voice in what the future of nursing will be. For associate degree nursing, it is our responsibility to articulate the educational outcomes of our programs, and the competencies of our graduates.

All efforts to define the future of nursing should center on the needs of the communities we serve.

Models of nursing practice that compliment the efficacy of associate degree nursing education must be identified or designed.

All efforts to define the future of nursing should center on the needs of the communities we serve. Models of nursing practice should reflect the ability of the nurse to meet those identified needs. Although there is no current consensus on the future of nursing, or future models of nursing practice, very few could disagree with the words of Dr. Mildred Montag,

The real concern of nursing, of nurse educators and nursing service administrators alike, is that practitioners of nursing be prepared and employed in a manner that promotes the nursing care of patients. This is not a new concern, or a concern of a few, but rather of nurses generally. We can no longer fail to prepare and use nurses honestly. Nursing's destiny is indeed the concern of nurses (Kaiser, 1983, p. 4).

Author

Elizabeth H. Mahaffey, RN, PhD

E-mail: ehmahaffey@hindscc.edu

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