Should the entry into nursing practice be the baccalaureate degree?

AORN Journal,  March, 2008  by David L. Taylor, III

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The health care industry is changing rapidly. Because of advances in medicine, technology, and lifesaving techniques, patients now have a better chance of surviving traumatic injury, life-threatening disease processes, and delicate surgical procedures than ever before. As a result, patients are living longer than ever expected, and health care providers need the ability to think critically and provide health care services at levels never before imagined.

Nursing is no exception. To ensure that the nursing profession does not fall behind during these rapid changes, nurses must look at the level from which they practice. To meet the increasing complexity of patient needs, the nursing profession must increase nurses' educational requirements by requiring the baccalaureate degree as the entry into practice.

In 1965, the American Nurses Association (ANA) took a bold stance by publishing a position paper calling for a baccalaureate degree to be the minimum level of education for entry into practice. (1) By taking this initiative, the ANA was attempting to move nursing education away from the hospital-based, diploma programs of the day into colleges and universities, thus changing the education of nurses from an apprenticeship to a science-based practice. Why, then, more than 40 years later, are nurses still debating this issue?

BACKGROUND OF THE ISSUE

Many good intentions went into the development of the 1965 position paper; however, three main factors worked against the ANA's position being fully realized. First, government funding influenced how and where students were educated. Second, the development and proliferation of community colleges and two-year nursing degree programs stalled the requirement for a baccalaureate degree. Finally, nurses' inability to see themselves as more than just caregivers has been a continuing stumbling block.

GOVERNMENT FUNDING, To examine the effect of government funding, one must look back to 1943 when the Bolton Act funded the costs for nursing school and provided nursing students with a stipend for living expenses. (2) Although it is not clearly established in the literature, the funding for this act may have been a direct result of a shortage of nurses after World War II, when in spite of previous predictions, not all nurses who had been in military or civilian practice remained in practice afterward. (2) Between 1943 and 1948, graduation rates increased significantly. When the funding source ended in 1948, however, the number of graduating nurses fell significantly. The nursing shortage continued to grow, affected by a decreasing supply and an ever-increasing demand. (2) Without available funding, few nursing students were likely to seek more education than was necessary to practice in the field.

TWO-YEAR DEGREE PROGRAMS. In 1945, a meeting was held between the US Office of Education and the American Association of Junior Colleges, now known as the American Association of Community Colleges, to discuss the possibility of including nursing in junior college curricula and developing an associate degree program for nursing at the community college level, a plan that would come to fruition in 1952. (2) Around the same time, Dr Esther Lucile Brown's study, Nursing for the Future, advocated for nursing education to take place in the nation's colleges rather than in hospitals. (2) The W. K. Kellogg Foundation also directly influenced the development and success of associate degree nursing programs by providing funds for graduate-level education to prepare associate degree nursing educators. (2) Associate degree nursing (ADN) programs expanded rapidly through the 1960s. (3)

NURSES' PERCEPTIONS. At this time, the evolution of nursing had been at a standstill for more than 100 years. Nurses worked under the supervision of physicians and exercised little autonomy. It was difficult for nurses to see themselves as professionals rather than just caregivers. Formal education aligned with on-the-job training was a new concept for nurses who had "worked in the trenches." One can only imagine the excitement and anxiety of the times.

Four decades have passed since the ANA's position paper was published, and it is apparent that more should have been done to guide those seeking a career in nursing. The ANA and nursing leaders should have defined educational standards with clear objectives that would help to develop the profession. The proliferation of community and junior college programs in the 1950s and the desire to move nursing out of the hospital into institutions of higher learning seemed a perfect fit; however, it also was an ideal time to educate the hospital system about the rebirth of the profession and the impact that the first class of college-educated graduates was going to make on nursing.

RELATIONSHIP OF THE ISSUE TO PRESENT DAY NURSING

According to the Occupational Outlook Handbook published by the US Department of Labor, Bureau of Labor Statistics, nursing is the largest health care profession, with 2.5 million nursing jobs, and is projected to generate 587,000 more jobs between 2006 and 2016. (4) Yet despite having strength in numbers, nurses are the least educated of all the interdisciplinary health care team members with whom they collaborate. These teams consist of physicians, pharmacists, speech pathologists, and physical and occupational therapists, all of whom recognize the importance of and need for higher education to deliver appropriate patient care. (5)