The topic of "Entry into Practice" is one that has plagued nursing for decades. Throughout this period, position statements have been regularly forthcoming from various professional organizations, no doubt the most remembered being the ANA "First Position on Education for Nursing" of 1965. Each has aroused debate and controversy, more often within the discipline of registered nurses, but also to a lesser extent by other communities of interest including physicians, hospitals, professional and educational organizations and associations, and the general public. The themes of these various documents have been to move formal nursing education out of the service sector and into academic education, to suggest the nature of education needed for the future, and to address nursing's anticipated future. Overall, entry into practice has been one of the most contentious issues in all of nursing.
One might question why OJIN has chosen at this point in time to address the entry into practice issue. Many of the same questions raised with each position document published still remain. Are there now different answers to be found? What the reader will realize in examining the positions of authors Donley & Flaherty, Mahaffey, Nelson, and Joel is that the historical context of nearly half a century suggests varied perspectives in answer to the questions. It is not a matter of finding right and wrong answers but rather in understanding the differences in perspective and context.
Especially interesting to note is that during the period of time examined, there has indeed been considerable change in the actual entry into practice demographics. For example, in the early 60's, 75% of all nurses were educated in diploma schools of nursing, 16% in baccalaureate programs, and associate degree nursing was in its infancy. By the year 2000, diploma education had dramatically declined to just 6%, while BSN doubled to 30%, but ADN has risen to nearly 60% of all new graduates. Indeed, entry into practice has changed! It is also somewhat sobering to note that although the vast majority of today's new nurse graduates are being educated in academic programs, today's nurses are the least educated of all health professionals with two-thirds possessing less than a baccalaureate education. In contrast, most other health professionals (i.e., therapists, speech pathologists, pharmacists) are now requiring entry into practice at the graduate level. Each of the authors provide insightful explanations of the evolutionary factors contributing to the entry into practice issue in nursing. Themes of professional turmoil, health care economics, feminine oppression, external societal controls, political and governmental policy, and lack of valuing of education are found in the perceptive critiques and analyses of these authors.
In " Revisiting the American Nurses' Association First Position on Education for Nurses," Donley and Flaherty provide an insightful comparison and contrast between the education scene of the 1960's and the contemporary educational issues in nursing today. The authors offer not only an in depth review of the 1965 ANA Position Paper but clearly describe the parallel political forces and social issues occurring at the time. Interesting to note is their observation that "circumstances of 1965 are somewhat similar to those of today." Workplace issues, insufficient workforce supply, and lack of professional autonomy are noted to be parallel themes of the two periods.
Mahaffey in "The Relevance of Associate Degree Nursing Education: Past, Present, Future" presents the reader with a comprehensive overview of the remarkable evolution of ADN education. The dramatic impact of ADN education is realized just in sheer numbers from 7 pilot programs in the 50's to more than 800 programs today. Mahaffey, like Donley and Flaherty, notes parallel societal issues of the decade of the 60's and today, including issues of nurse shortage, decreased interest in nursing as a career, and use of creative educational strategies. An important contribution of ADN education is that it has traditionally appealed to the non-traditional student - older, minorities, and males represent nearly twice as many ADN students than those in other type programs. Despite the relevant significant impact ADN education has had on the entry into nursing issue, Mahaffey notes that "decisions were sometimes made without significant representation of all program types." She further pleads an essential need for inclusion of the voice of ADN educators, as well as nurses in practice, in the groups who are designing a vision for nursing.
In "Education for Professional Nursing Practice: Looking Backward into the Future" Nelson provides a retrospective review of educational developments in nursing since 1965. She too, as have the previous authors, identifies the similarities of societal and political pressures felt by nursing, both then and today. In contrast to Mahaffey's compelling argument as to the important contributions of ADN education, Nelson expresses concern that as in the past when, diploma programs served the needs of hospitals, so too today's associate degree nursing program has become primarily a vocational program with a terminal degree and serves as a lucrative offering for technical and community colleges. She then provides a series of compelling arguments in support of rationale for BSN entry into practice, and notes that several organizations have expressed preference for the BSN, including the American Organization of Nurse Executives and the Veterans Administration. She concludes that, "Doors to future educational changes should be kept open, but moving education to the BSN level is the first step."
The last article by Joel entitled "Education for Entry into Nursing Practice: Revisited for the 21st Century" suggests that nursing education has not been in control of its own destiny but rather, "nursing has been dominated by an external loss of control" and has been "swept along by a host of societal and educational circumstances." Joel reiterates for us the true characteristics of a profession - service oriented, learned, and autonomous. Of service, she notes that service orientation must be relevant to the times and carefully orchestrated to meet specific societal needs. To be learned requires not only a unique body of knowledge and skill and considerable educational investment and rigor but also "cognitive artfulness." Autonomy, she reminds us, has two perspectives: the autonomy of the field of work and autonomy of the individual. She concludes that "nursing has resisted the normal course of occupational development" and notes that nurses have traditionally derived their identity from their statutory title, RN, rather than from their academic preparation. The clear differences in clinical competency between the associate degree nurse and the graduate level advanced practice nurse have been unquestionably demonstrated. Joel suggests further pursuit of this differentiation of practice and presents the view that "nursing would always be a work in the process of becoming."
And so, as you, the reader, reflect on the issues of entry into practice not only from the perspectives of these authors, but from your own unique vantage point, I challenge you to share your thoughts, new insights, and reactions to these authors by either writing a letter to the Editor or by submitting a manuscript which will further elucidate the issue of entry into practice. We look forward to hearing from you.
