Introduction

When addressed to nurses, the question of educational preparation for entry into professional nursing practice is likely to provoke sighs of frustration. The frustration is not limited to educators in the various types of educational programs leading to licensure; it is pervasive in all settings and at all levels of nursing practice.

Why, almost forty years after the American Nurses Association published its position calling for the baccalaureate degree as the minimum preparation for nursing practice, has the nursing profession failed to come to agreement on a questions so critical to the future of nursing and its role in health care?

Why, almost forty years after the American Nurses Association published its position calling for the baccalaureate degree as the minimum preparation for nursing practice, has the nursing profession failed to come to agreement on a questions so critical to the future of nursing and its role in health care?

An examination of the entry into practice debate from an educational perspective reveals some interesting similarities in the social and political pressures felt by nursing in 1965 and the challenges that exist today. These similarities, in relation to the path taken by nursing education during the past thirty-seven years, will be considered in an effort to identify strategies for the future. Some recommendations for moving forward in developing a better educated profession will be offered.

The Spirit of 1965

In 1965, the American Nurses Association (ANA) declared one of its chief concerns to be "what nursing is today and what it will be tomorrow". What followed this introduction was the first position paper on nursing education to be published by the ANA. The "position paper", which was to become one of the most frequently cited documents in nursing history, was later published in full in the American Journal of Nursing (1965).

It was the passage of the Comprehensive Nurse Training Act in 1964 that prompted the ANA Committee on Education to study nursing education, practice, and scope of responsibilities (Jacobs, MiMattio, Bishop, & Fields, 1998). The study recognized the increasing complexity of health care and raised concerns about the hospital-based diploma programs. Specifically, the ANA noted changes in the practice of nursing, that included "major theoretical formulations, scientific discoveries, technological innovations, and the development of radical new treatments" (ANA, 1965, p. 107).

Subsequently the ANA Board of Directors adopted the Committee on Education's statement, which became the 1965 "position paper", and which contained the recommendation that the "minimum preparation for beginning professional nursing practice at the present time should be baccalaureate degree education in nursing" (ANA, 1965, p. 107). In the "position paper", three levels of nursing education were described: baccalaureate education for beginning nursing practice, associate degree education for beginning technical nursing practice, and vocational education for assistants in the health service occupations (ANA, 1965).

Nursing leaders believed that the future of nursing depended on moving nursing education into higher education and their first objective was the phasing out of the hospital-based diploma program. It was envisioned that these programs would merge with either baccalaureate or associate degree programs. Physicians, hospital administrators and diploma nurse educators and graduates opposed this move; and although some schools did close or merge with higher educational institutions, many continued to admit students. The push to eliminate the hospital-based programs, however, coincided with the phenomenal growth of the associate degree nursing (ADN) programs; and subsequently diploma program enrollments began to decline. The associate degree programs represented an opportunity for nursing to break away from the apprenticeship model of education and exert greater control over the educational experiences of nursing students. A combination of external factors including a shortage of nurses, increased federal financial assistance to nursing education, and growing social concerns about equal access to health care and education provided impetus for this movement (Haase, 1990).

The almost instant popularity of the associate degree programs was unexpected. These programs were so successful that, in the 1960's, they were expanding so rapidly that at times "a new ADN program was opening somewhere in the country every week" (Haase, 1990, p. 86). The ADN programs attracted innovative nurse educators who were willing to challenge traditions, experiment with new teaching strategies and take risks as they worked out a new two-year curriculum as preparation for nursing practice. At the same time the ANA was advocating for nursing education reform, the associate degree in nursing was emerging as an idea whose time had come. Mildred Montag, whose doctoral dissertation provided the plan for the first associate degree programs, had used the term "technical" to describe the level of education in these programs; and this terminology was consistent with that used in the ANA recommendations. Nevertheless, by the time the ANA "position paper" was published, the use of the word "technical" to describe the associate degree nurse sparked heated debate (Haase, 1990).

The ANA position in 1965 was later supported by a resolution in 1978 by the ANA House of Delegates in which was set forth the requirement that by 1985 the minimum preparation for entry into professional practice would be the baccalaureate degree.

These were still hopeful times when it was expected that by 1995, all states would have put in place the educational and legal elements necessary to mandate baccalaureate education for nursing.

The designation of two levels of nursing practice, professional and technical, was reaffirmed. In 1982, the ANA House of Delegates again resolved to move forward in attaining recognition of the baccalaureate degree as the minimum educational qualification for professional nursing practice. At this time, the ANA resolution was supported by a number of professional and specialty organizations and by the Idaho Board of Nursing (Blaney, 1986). These were still hopeful times when it was expected that by 1995, all states would have put in place the educational and legal elements necessary to mandate baccalaureate education for nursing. Nursing in the United States would begin the 21^st century with one educational path to licensure. The supporters of the ANA position, however, were unable to generate the momentum needed to overcome the fear and resistance of its own constituents.

The View in 2002

Again recognition of the complexities of health care and the rapid expansion of knowledge is increasing the pressure to raise the level of basic nursing education. While the ANA is no longer leading the effort to require the baccalaureate degree for entry into professional nursing practice, other professional nursing organizations, such as the American Association of Colleges of Nursing (AACN) and the Association of California Nurse Leaders (ACNL) have recently published position statements recognizing the baccalaureate degree as the minimal preparation required for professional nursing practice (AACN, 1996; ACNL, 2000). Supporting the need to increase the numbers of baccalaureate educated nurses are the findings of commissions charged with defining the nursing workforce needs of the future (Division of Nursing, 1996; Pew Health Professions Commission, 1998). The National Advisory Council on Nurse Education and Practice calls for adoption of a policy to achieve a basic registered nurse workforce with at least two-thirds holding baccalaureate or higher degrees by the year 2010 (Division of Nursing, 1996).

Just one state, North Dakota, has been successful in changing the nurse practice act so that only baccalaureate programs are approved to provide education for licensure as a Registered Nurse. By 1997, ten years after establishing the BSN as a requirement for all new Registered Nurses, North Dakota had succeeded in raising the proportion of nurses with baccalaureate or higher degrees to 54%. This was accomplished despite population demographics frequently considered barriers to baccalaureate education. Wertz and Rambur (1997), note that North Dakota is a rural state where the majority of students are place bound, working parents, financially needy, and first generation college students. George and Young (1990) analyzed the pattern and success of baccalaureate entry proposals across the nation and concluded that the critical determinant of action to promote BSN entry, either in the state nurses' associations or in public policy arenas, was the ratio of BSN to ADN programs. In states where the number of ADN programs was double or more that of BSN programs, no action was likely.

While the ANA's predictions for rapid change and increasing complexity in health care have been realized, nursing has lagged behind other professions in raising educational standards.

Nurses remain the least educated among professional health care providers.

Nurses remain the least educated among professional health care providers. Christman (1998) notes that at the point of care delivery, where most impressions of nurses are formed, the majority of nurses encountered by patients, physicians, psychologists, and other care providers, do not have college degrees. The educational gap between nursing and other health professions continues to grow. Disciplines such as occupational therapy and physical therapy that, in the 1950s, allowed certification without a college degree, now require a master's education. Other professions that have raised educational standards since 1965 include pharmacy and audiology. In contrast to nursing, the assistant/technical personnel in many health care occupations are prepared at the associate degree level. In a climate in which strong cooperative relationships and interdisciplinary teamwork are becoming increasingly important in delivering health care, educational differences matter. A baccalaureate education or higher is needed if nurses are to maintain equal status with other health care professionals and to participate as full partners on interdisciplinary teams (Barter & McFarland, 2001).

Nursing education in other countries has also begun to move to the baccalaureate level. In 1982, the Canadian Nurses' Association adopted the goal to establish the baccalaureate degree as the requirement for entry into practice. This has sparked the development of a number of collaborative educational ventures in which hospital programs have joined with universities and colleges (Grenier & Dewis, 1995). In the 1990s, nursing education in Australia and New Zealand became located entirely in baccalaureate programs. In the United Kingdom, nursing education is in the process of moving into higher education (Lusk, Russell, & Rodgers, 2001).

Reconciling the Past with the Present

The position of associate degree programs in preparing the nursing workforce today can be compared to that of diploma programs in 1965. In 1965, 78% of nurses were educated in hospital-based programs. In 2000, only 29.6% of nurses received their basic education in a diploma program, while 40.3% were educated at the associate degree level. Although the proportion of baccalaureate graduates has risen steadily, approximately 15 % in 1965 and 29.3% in 2000, the numbers are far from the two-thirds called for by the National Advisory Council (ANA, 1965, Division of Nursing, 2001).

Recent publications such as the National League for Nursing's " A Vision for Nursing Education" (1993), and the ANA's "Nursing's Agenda for Health Care Reform" (1991), outline health care trends and describe the competencies all nurses will need, but avoid linking these to educational levels. The NLN (1993), maintains that all nurses, regardless of educational background or area of practice, should be prepared to work in a community based, community-focused care system. Graduates from all programs should be prepared to intervene at the macro level, to exert greater authority, accountability, and responsibility, and to depend less on institutional authority and policy. These additional competencies needed by nurses are clearly professional rather than technical in nature, yet there is no differentiation among educational programs (Hess, 1996). Consequently, there has been a proliferation of content in ADN programs that has expanded the number of units far beyond those required for associate degrees in other areas. It is not unusual for ADN programs to require 75 or more semester units that can take three years or longer to complete. Most ADN program goals now include the preparation of practice for all settings, community health content and experiences have been added, and programs describe themselves as community-based (AACC Position Statement on AD Nursing, 1999). It is now generally inaccurate to describe associated degree nursing programs as "two-year programs". It is interesting to note that curriculum expansion became a problem for diploma programs in the 1930s when, despite opposition from hospital administrators, nursing educators began to add courses in psychology, mental health nursing, public health nursing, and natural sciences. (Kalish & Kalish, 1986).

Just as the hospital-based diploma programs are historically intertwined with the evolution of modern hospitals, associate degree nursing education has been important in the growth of community colleges. Fagin and Lynaugh (1992) note that as both flourished, nursing became caught in the divergent roles of the community college. Rather than a program leading to transfer to four-year colleges and universities, associate degree nursing became primarily a vocational program with a terminal degree. Most community colleges award nurses an associate in applied science degree which places them in the same category as technicians and assistants in relation to other health professions. Those arguing for associate degree education as the entry level into nursing also assert that nursing is a profession, yet they have not brought forward a sound model for a two-year professional education that has been emulated by any other profession. Rather than advance solid educational rationale for their programs, associate degree nursing educators have essentially maintained that the results "speak for themselves."

In 1965, it was becoming clear that nursing education was outgrowing the confinements of the hospital training system. Today it seems appropriate to ask whether nursing education has evolved beyond the community college setting. Hess (1996) questions whether the current ADN education is fair to the student and graduate. She maintains that a nursing student has the right to receive the appropriate credential for the amount of learning required in an educational program. She notes the ethical issues that arise when practice demands necessitate that, in certain subject areas, ADN and BSN students learn similar content in nearly equal depth, yet the BSN student receives upper division credit while the ADN student earns lower division credit. Despite the widespread availability of RN-BSN degree completion programs, only about 14% of ADN graduates continue on into baccalaureate programs (Division of Nursing, 1996).

As there were strong defenders of hospital-based education in 1965, there are many with vested interest in maintaining the associate degree as an entry level option.

Community college presidents gain prestige from having a professional program with excellent job prospects and high salary relative to other programs at their institution.

Nursing is a premier program for community colleges. In 1996-97, health professions and related sciences were second only to liberal/general studies and humanities in the number of associate degrees awarded in community colleges. In 1997, registered nursing was sixth in terms of average starting salary among "hot programs" offered by community colleges (Phillippe & Patton, 2000). Community college presidents gain prestige from having a professional program with excellent job prospects and high salary relative to other programs at their institution.

What have we learned?

The ANA proposal for the baccalaureate degree for entry into practice is still relevant, but there seems little to be gained by continually revisiting old arguments. Fagin and Lynaugh (1992) have called the baccalaureate degree in nursing "legitimate and coherent" noting that it recognizes the occupational as well as the professional realities of nursing. It provides for the production of safe, competent workers who, along with other professionals, are positioned to move into university graduate programs. In looking back at the course of nursing education since the 1965 "position paper" was published, some useful insights emerge which can help to set direction for the future. These will be described briefly.

The current nursing shortage should not be used as an excuse for postponing action to raise educational standards. To argue that no change can occur in a time of shortage is to succumb to the status quo. A nursing shortage existed at the time of the 1965 ANA proposal and has continued during most of the time since. The proliferation of associate degree programs did not prevent shortages from occurring as initially predicted. Today shortages are expected to be the greatest for those nurses with baccalaureate and higher education and those with advanced competencies. (Pew Health Professions Commission, 1998).

Educational standards influence perceptions about nursing as a career choice. In its 1965 position paper, the ANA noted that "the increasing availability of college to more and more young people, and the ever-widening opportunities for women in the traditionally masculine business and professional fields have an impact on recruitment by nursing.

Failure to require a baccalaureate degree for professional practice has made nursing a less appealing option for college-bound freshmen.

We must assess realistically the portents of the changing picture in higher education for the recruitment of qualified young people for nursing" (ANA, 1965, p. 110). Failure to require a baccalaureate degree for professional practice has made nursing a less appealing option for college-bound freshmen. The impressions of nursing expressed in interviews with school children indicate that a career requiring only two years of education is viewed somewhat negatively. Ninth and tenth grade students thought of nursing as technical, "more like shop", than professional (JWT Specialized Communications, 2000).

It is no longer feasible to try to differentiate practice along current educational points of entry. The distinctions between professional and technical nursing roles have not been translated into differentiated practice expectations in the work setting. Although a number of models for differentiating nursing roles have been proposed, they have been difficult to implement in health care areas where identical licensure implies that "a nurse is a nurse is a nurse." Attempts to identify variables that can distinguish educational preparation in practice settings have yielded few that can be easily measured. North Dakota, as the only state to date to establish the baccalaureate degree as the educational requirement for registered nurses, did not differentiate practice along the technical versus professional lines suggested in the 1965 ANA position paper. In North Dakota, the associate degree has become the educational requirement for licensed practical nurses rather than for beginning technical nursing practice as proposed by the ANA.

Any successful plan for changing nursing education must be inclusive. One of the frequently mentioned strengths of the associate degree programs is the history of providing affordable access to the nursing profession for underserved populations. Many still believe that community colleges are the only option for those from disadvantaged, minority, and rural populations. Some have argued that establishing the baccalaureate degree as the minimum requirement for entry into practice has racist implications because it presents an additional barrier to people of color who have not had equal access to higher education and could potentially be excluded from the benefits and status of professional nursing (Mason, Backer, & Georges, 1991). Countering this argument are those who note the racist, classist, and gender implications in the contention that older, minority and nontraditional students are dependent on the associate degree programs for access to professional nursing. With appropriate guidance and adequate financial aid, students from traditionally disadvantaged groups can and do attain true professional mobility through baccalaureate education (Fagin & Lynaugh, 1992).

Agreement about BSN requirement for entry into practice should disenfranchise no one. Qualified nursing faculty are a vital resource. The majority of associate degree nursing educators have masters degrees and many have doctorates and are thus qualified to teach in baccalaureate programs. With projections that the current faculty shortage will worsen, it is inconceivable that experienced and capable teachers will be unemployed if the educational requirement for entry into practice is raised to the baccalaureate level. Faculty in associate degree and baccalaureate programs have generally taught in isolation from one another, however, educational philosophies aside, they have much in common. They have attended the same graduate schools, spent hours developing curricula and writing learning objectives, agonized over failing students, and written voluminous self-studies. When the demand arises, they can learn to teach together. Grenier and Dewis (1995) describe the successful assimilation of faculty from a university and a hospital school of nursing in the development of a joint baccalaureate program in Canada.

Employers will not make the decision about entry into practice for nursing. It is unrealistic to wait for employers to provide incentives in the form of differential pay scales or other recognitions of educational differences. The reality is that the majority of the nursing workforce are associate degree and diploma graduates and nursing administrators are fearful that creating special incentives for baccalaureate graduates will impair their ability to fill nursing positions. It is important to note, however, that the practice sector is beginning to speak up about educational requirements. Employers have expressed a preference for BSN prepared nurses in order to meet the demands of patient care. A BSN degree is required for a commission in the armed forces, for employment in the Public Health Service, and for certification as a Public Health Nurse in California. The Veterans Administration system has recently changed qualifications for appointment to require a baccalaureate for RNs (Veterans Health Administration, 1997).

Moving forward

Resources need to be redirected to support baccalaureate entry and end licensure at the associate degree and diploma levels.

Emphasis should be placed on the development of true articulation programs in which baccalaureate nursing education begins in community colleges and ends in four year degree granting institutions.

Emphasis should be placed on the development of true articulation programs in which baccalaureate nursing education begins in community colleges and ends in four year degree granting institutions. The rapid growth in numbers of associate degree programs can be partially attributed to the amount of federal and state funding they have received and continue to receive. Funding should be redirected to support community college and university collaborations that provide for the direct transfer of liberal arts, science, and selected lower division nursing courses into baccalaureate programs. Baccalaureate and associated degree nursing educators should be encouraged to plan joint curricula. These programs would be based on the assumption that completion of the requirements for professional nursing and licensure would occur only at the baccalaureate level.

The need for the addition or expansion of RN-BSN degree completion programs should be assessed and these should be recognized as time limited.

The need for the addition or expansion of RN-BSN degree completion programs should be assessed and these should be recognized as time limited.

Doors to future educational changes should be kept open, but moving education to the BSN level is the first step. Noting the increasing complexity of health care, some nurse leaders are concerned that a baccalaureate degree is no longer sufficient preparation for practice. They advocate master's or even doctoral level education and abandonment of the Registered Nurse title in favor of an advanced practice role that is clearly distinguished from entry into practice at the associate degree level. While raising the educational bar even higher can possibly be justified in terms of the knowledge base needed for advancing professional practice, we need to pay attention to past lessons and view with caution any proposed solution that would further split the profession and separate nurses with college degrees from the ranks of bedside caregivers.

Conclusion

Nurses need to claim the power to raise educational standards for the profession. Jacobs, DiMattio, Bishop, and Fields (1998) suggest that nursing is experiencing the consequences of a "shifting the burden" approach in which fundamental problems go unsolved while a series of short term solutions are implemented. Short-term solutions will eventually undermine an organization's ability to arrive at fundamental solutions. The authors maintain that continued recognition of the associated degree in nursing as a terminal degree is a short-term solution to the entry into practice issue.

The power of the community college system to counter nursing's efforts to raise educational standards should not be underestimated. Nursing educators in associate degree programs should not mistake support by the American Association of Community Colleges (AACC) for their programs as support for nursing as a profession. In the AACC Position Statement on Associate Degree Nursing (1999), there is no mention of career progression or entry into higher degree programs for associate degree graduates. The AACC Position Statement focuses on defending the status quo rather than setting direction for the future.

In 1965, Helen Nahm, a member of the ANA Committee on Education described nurses as reluctant to "face the fact that the whole world has changed, that it will continue to change, and that the nurse of the past will not return" (Nahm, 1965, p.98). Nahm could not possibly have envisioned the extent and magnitude of the changes in health care that would shape nursing in the next 37 years. In 1965, critical care units were new, Medicare and Medicaid legislation had just passed, HMOs were futuristic plans for reducing health care costs, and no one had heard of AIDs. The nursing leaders who drafted the 1965 ANA position statement knew that nursing had to prepare for change and that setting higher educational standards was an important component in this preparation.

We've missed all the previous deadlines for resolving the entry into practice issue and allowed the 21^st century to begin without agreement about the educational preparation needed for professional nursing practice.

Nurses with varying educational preparation will continue to practice for many years to come, but decisions about the future education of nurses need to be made now.

Now, some organizations have set 2010 as the target year for requiring the baccalaureate in nursing as the educational preparation for entry into practice as a registered nurse (Barter & McFarland, 2001). It's time to finish what was started in 1965. Past failures suggest that it is unlikely that the entry into practice issue will be resolved initially through legislative changes. Nurses with varying educational preparation will continue to practice for many years to come, but decisions about the future education of nurses need to be made now. The qualities that enable nurses to succeed in the most difficult of circumstances: determination, persistence, dedication, and resourcefulness can move us forward or hold us back. If we can agree on the importance of developing a better educated profession and leave the old debates behind, we can create a brighter future for nursing.

Author

Martha A. Nelson, PhD, RN
E-mail: nelson@dominican.edu

Dr. Nelson, Dean of the School of Arts and Sciences at Dominican University of California, has been a nursing educator for 20 years. She began her own nursing education in a hospital diploma program and then returned to school as an RN to obtain a baccalaureate degree. After earning her master's degree in nursing, she taught in an associate degree nursing program for four years. Since then she completed a PhD in nursing and has been teaching in a baccalaureate program. Her previous publications have addressed women's health and community-oriented primary health care.

(9), 428-431.

---