E
Undergraduate Nursing Education

According to the findings of the 2008 National Sample Survey of registered nurses (RNs), just over 3 million licensed RNs live in the United States; nearly 85 percent of these women and men are actively working in the nursing profession. Nearly 450,000 RNs are estimated to have received their first U.S. license between 2004 and 2008 (HRSA, 2010). The current nursing workforce includes a high proportion of nurses working in the later years of their careers, soon to retire, and a high proportion of nurses at the onset of their careers. Midcareer nurses, the group most needed to fill the roles of those leaving the workforce, are the lowest in number. Therefore, the knowledge, experience, and mentoring that senior nurses can provide could potentially be lost (Bleich et al., 2009). Table E-1 shows the demographic and educational distribution of the current nursing workforce.

Nursing is unique among the health care professions in the United States in that it offers multiple educational pathways leading to an entry-level license to practice. For the past four decades, nursing students have been able to pursue three different educational paths: the diploma in nursing, the associate’s degree in nursing (ADN), and the bachelor’s of science in nursing (BSN). More recently, an accelerated, second-degree bachelor’s program for students who possess a baccalaureate degree in another field has become a popular option.

DIPLOMA IN NURSING

For many years, the most common choice of nursing students was the diploma program at a hospital-based school. Generally lasting 3 years and providing limited liberal arts content, diploma programs trace their origin to the work of Florence Nightingale and her colleagues in the 19th century. In many ways,



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E Undergraduate Nursing Education According to the findings of the 2008 National Sample Survey of registered nurses (RNs), just over 3 million licensed RNs live in the United States; nearly 85 percent of these women and men are actively working in the nursing profes- sion. Nearly 450,000 RNs are estimated to have received their first U.S. license between 2004 and 2008 (HRSA, 2010). The current nursing workforce includes a high proportion of nurses working in the later years of their careers, soon to retire, and a high proportion of nurses at the onset of their careers. Midcareer nurses, the group most needed to fill the roles of those leaving the workforce, are the low- est in number. Therefore, the knowledge, experience, and mentoring that senior nurses can provide could potentially be lost (Bleich et al., 2009). Table E-1 shows the demographic and educational distribution of the current nursing workforce. Nursing is unique among the health care professions in the United States in that it offers multiple educational pathways leading to an entry-level license to practice. For the past four decades, nursing students have been able to pursue three different educational paths: the diploma in nursing, the associate’s degree in nursing (ADN), and the bachelor’s of science in nursing (BSN). More recently, an accelerated, second-degree bachelor’s program for students who possess a baccalaureate degree in another field has become a popular option. DIPLOMA IN NURSING For many years, the most common choice of nursing students was the di- ploma program at a hospital-based school. Generally lasting 3 years and provid- ing limited liberal arts content, diploma programs trace their origin to the work of Florence Nightingale and her colleagues in the 19th century. In many ways, 3

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30 THE FUTURE OF NURSING TABLE E-1 Demographic and Educational Characteristics of Registered Nurses, by Age Under Age 50 Age 50 or Older Total Estimated total population 1,694,088 1,369,074 3,063,162 Race/ethnicity White, non-Hispanic 80.0 87.2 83.2 Nonwhite or Hispanic 20.0 12.8 16.8 Gender Male 7.7 5.3 6.6 Female 92.3 94.7 93.4 Initial nursing education Diploma 9.0 34.5 20.4 Associate’s 48.5 41.6 45.4 Bachelor’s or higher 42.5 23.9 34.2 Highest nursing or nursing-related education Diploma 6.6 23.0 13.9 Associate’s 40.0 31.2 36.1 Bachelor’s 43.1 28.9 36.8 Graduate 10.3 16.8 13.2 SOURCE: HRSA, 2010. diploma programs are similar to apprenticeship programs for physicians in the 1800s before the widespread development of medical schools (Gebbie, 2009). As nursing gained a stronger theoretical foundation and other types of nursing programs increased in number, the number of diploma programs declined remark- ably throughout the 20th century except in a few states, such as New Jersey, Ohio, and Pennsylvania. One advantage of the diploma program is that there are guaranteed clinical spaces for those accepted into the program, something ADN and BSN programs cannot offer. The number of all working nurses who began their nursing education in diploma schools fell from 63.7 percent in 1980 to 20.4 percent in 2008; the number of new diploma graduates dropped to 3.1 percent of all graduates in the 2005−2008 graduation cohort (HRSA, 2010). ASSOCIATE’S DEGREE IN NURSING At present, the most common way to become an RN is to pursue an ADN at a community college. The proportion of nurses in the United States whose initial education was an ADN increased from 42.9 percent in 2004 to 45.4 percent in 2008 (HRSA, 2010). ADN programs in nursing were launched in the mid−20th century in response to the nursing shortage that followed World War II (Lynaugh, 2008; Lynaugh and Brush, 1996). Generally speaking, the ADN remains less

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31 APPENDIX E expensive than a BSN because of the cost structure of the community college system and the shorter program duration. Once conceived as a 2-year program, the ADN is seen as taking less time than a BSN, but this situation has changed over the years (Orsolini-Hain, 2008). In most non−health care disciplines, the associate’s degree takes 2 years to complete. In nursing, however, surveys have found that it takes students 3–4 years to complete an ADN program because of the need to fulfill prerequisites and the lack of adequate faculty, which lead to long waiting lists for many programs and classes (Orsolini-Hain, 2008). The ADN cur- riculum often combines intense science and clinical coursework into a condensed time frame, posing additional challenges to completing the program in 2 years. BACHELOR’S OF SCIENCE IN NURSING The BSN is a 4-year degree, typically offered at a university; the first univer- sity-based schools of nursing were founded in the early 20th century (Lynaugh, 2008; Lynaugh and Brush, 1996). BSN programs emphasize liberal arts, ad- vanced sciences, and nursing coursework across a wide range of settings, along with leadership development and exposure to community and public health competencies. As of 2008, 34.2 percent of RNs throughout the United States had started with a BSN, up from 31.5 percent in 2004 (HRSA, 2010). Begin- ning in the latter part of the 20th century, an accelerated option for a BSN or MSN became available to applicants who had already completed a bachelor’s degree in a different field. Also known as fast-track or second-degree programs, these programs have added substantially to the growing number of baccalaureate graduates (AACN, 2010). Most BSN students complete their degrees in 4 years. Accelerated programs that offer the BSN to students who have already completed a bachelor’s degree are typically completed in 11–18 months, with intense coursework and profes- sional formation accelerated based on previous collegiate and life experience (AACN, 2010). For much of the 20th century, following the release of a significant 1965 position paper of the American Nurses Association, nursing leaders and educa- tors tried to standardize nursing education and make the BSN the minimum entry-level requirement for nursing practice. Four states were targeted for early implementation (Smith, 2010). Only one of them—North Dakota—fully followed through on that recommendation by establishing the BSN as the minimum degree in nursing in 1987 (Smith, 2010). In 2003, however, the state legislature, at the urging of hospitals and long-term-care stakeholders, passed a law that allowed nurses with an ADN to practice (Boldt, 2003). Nationwide, market forces and the needs of individual employers generally determine whether a BSN is required for entry into practice.

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32 THE FUTURE OF NURSING LICENSED PRACTICAL NURSES In addition to the RNs, who receive a diploma, associate, or baccalaureate degree in nursing, another undergraduate-level degree offered is the licensed practical/vocational degree in nursing. Licensed practical/vocational nurses (LPNs/LVNs) are especially important because of their contributions to care in long-term care facilities and nursing homes. Historically, LPN/LVN programs have fluctuated based on need. The first training program for licensed practical/vocational nurses (LPNs/LVNs) dates back to the late 19th century. These programs increased in number following the nursing shortage of World War I, and the passage of the Smith Hughes Act, and again following the nursing shortage of World War II, when LPNs/LVNs were in demand to assist RNs in civilian hospitals (lpntraining.org, 2010), which were short-staffed as a result of war efforts. LPNs/LVNs also found employment in long-term-care facilities and nursing homes. LPN/LVN receives a diploma after completion of a 12-month program. The LPN/LVN is not educated for independent decision making for complex care but obtains basic training in anatomy and physiology, nutrition, and nursing tech- niques. With additional study, these nurses can perform supplemental nursing tasks that are useful to patients and nursing home residents and can contribute to clinical documentation and team performance. Some LPNs/LVNs also supervise nursing attendants and direct care workers in long-term care settings. CONCLUSION The fact that each educational pathway (i.e., diploma, ADN, and BSN) leads to the same licensure exam (the NCLEX-RN; see Chapter 4) makes it difficult to argue that a graduate with a BSN is more competent to perform entry-level tasks than one who has a diploma or an ADN. Statistics from the National Council of State Boards of Nursing show little difference in the pass rates of BSN, ADN, and diploma graduates, which is to be expected because the exam tests the minimum standards for safe practice. In 2009, 89.49 percent of 52,241 BSN candidates passed the NCLEX-RN exam, compared with 87.61 percent of 78,665 ADN candidates and 90.75 percent of 3,677 diploma candidates (NCSBN, 2010). REFERENCES AACN (American Association of Colleges of Nursing). 2010. Accelerated baccalaureate and master’s degrees in nursing: Fact sheet. http://www.aacn.nche.edu/Media/FactSheets/AcceleratedProg. htm (accessed July 2, 2010). Bleich, M. R., B. L. Cleary, K. Davis, B. J. Hatcher, P. O. Hewlett, and K. S. Hill. 2009. Mitigating knowledge loss: A strategic imperative for nurse leaders. Journal of Nursing Administration 39(4):160-164.

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33 APPENDIX E Boldt, M. 2003. Legislature approves relaxed education standards for nurses. The Associated Press State & Local Wire, April 16. Gebbie, K. M. 2009. 20th-century reports on nursing and nursing education: What difference did they make? Nurse Outlook 57(2):84-92. HRSA (Health Resources and Services Administration). 2010. The registered nurse population: Find- ings from the 200 National Sample Survey of Registered Nurses. HRSA. lpntraining.org. 2010. The history of practical nursing. http://www.lpntraining.org/the-history-of- practical-nursing.html (accessed September 9, 2010). Lynaugh, J. E. 2008. Kate Hurd-Mead lecture. Nursing the great society: The impact of the Nurse Training Act of 1964. Nursing History Review 16:13-28. Lynaugh, J. E., and B. L. Brush. 1996. American nursing: From hospitals to health systems. Cam- bridge, MA and Oxford, U.K.: Blackwell Press. NCSBN (National Council of State Boards of Nursing). 2010. Nurse licensure and NCLEX examina- tion statistics. https://www.ncsbn.org/1236.htm (accessed August 20, 2010). Orsolini-Hain, L. 2008. An interpretive phenomenological study on the influences on associate degree prepared nurses to return to school to earn a higher degree in nursing, Department of Nursing, University of California, San Francisco. Smith, T. G. 2010. A policy perspective on the entry into practice issue. OJIN: The Online Journal of Issues in Nursing 15(1).

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