The 1965 Entry Into Practice Proposal - Is It Relevant Today?

[NRSKarenRN, BSN, RN]

from ojin---check out these series of articles

overview and summary: the 1965 entry into practice proposal - is it relevant today?

davina j. gosnell, phd, rn, faan

http://www.nursingworld.org/ojin/topic18/tpc18ntr.htm

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," http://www.nursingworld.org/ojin/topic18/tpc18_1.htm

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" http://www.nursingworld.org/ojin/topic18/tpc18_2.htm

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" http://www.nursingworld.org/ojin/topic18/tpc18_3.htm

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" http://www.nursingworld.org/ojin/topic18/tpc18_4.htm

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 morificecript which will further elucidate the issue of entry into practice. we look forward to hearing from you.

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© 2002 online journal of issues in nursing

article published may 31, 2002

edited to include links. karen

[oramar]

I remember 1965 very well and I remember the original Entry Into Practice Proposal very well also. Anything that is this big of a flop for so long a period needs to die once and for all. I am tired of the whole thing and I am starting not to care.

[fedupnurse]

I'm with Oramar on this one. Could you imagine having to have a graduate level degree and starting at 20 bucks an hour? Won't happen! Once again. These organizations needs to start focusing on IMPORTANT ISSUES like why are all of us leaving? Working conditions, lousy pay for what we are expected to do and lousy retirement packages, lack of health care benefits upon retirement and A TOTAL LACK OF RESPECT FROM THE SUITS!! Enough already with the studies and hospital committees that get nothing accomplished. Put that money and energy into retaining nurses. As the Nurse on 60 minutes said last Sunday night "we know the reasons for this shortage, we haven't acted on them". So very true. Frankly, I'd rather have an experienced clinician taking care of me and mine than someone with a ton of book knowledge and questionable clinical competence.

[NRSKarenRN, BSN, RN]

Quote:

"If you view the 1965 statement as a call to close hospital schools of nursing and move all nursing education inside the walls of colleges or universities, then the American Nurses Association was successful.

If, however, you view the position as a mandate for a more educated nurse force to better patient care, the goal has not been achieved. Registered nurses are undereducated members of the health care team, when compared with physicians, social workers, physical therapists, pharmacists, and dieticians to name a few. Looking beyond the clinical environment, the nurse work force also lacks the educational credentials of persons in the business, investor, and insurance communities that now play significant roles in health care decisions. Under-educated members of the health team rarely sit at policy tables or are invited to participate as members of governing boards. Consequently, there is little opportunity for the majority of practicing nurses to engage in clinical or health care policy.

http://www.nursingworld.org/ojin/topic18/tpc18_1.htm

[-jt]

I think the lack of respect comes in part because we are seen as work horses & not as academic as the social workers, pharmacists, therapists, etc. precisely because of the different levels of degree. While I have an ADN degree myself with no desire to go back to school, & I know the majority of nurses in this country hold ADN degrees, I do believe that until we have a uniform entry level degree, we wont be taken seriously as a profession by any of the other professionals. A new grad pharmacist starting salary in Florida just hit more than $79,000/yr. What do new RNs in Florida earn? In questioning this, I was told "well, pharmacists have to go to school for a 6yr degree & that should be compensated."

PHARMACY GRADS CASH IN ON SHORTAGE WITH $79,000 STARTING SALARIES

Bloomberg News/South Florida Sun-Sentinel

http://www.healthleaders.com/news/newspage1.php?contentid=34912

[NRSKarenRN, BSN, RN]

Quote:

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

...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....

http://www.nursingworld.org/ojin/topic18/tpc18_2.htm

[NRSKarenRN, BSN, RN]

Quote:

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.

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).

http://www.nursingworld.org/ojin/topic18/tpc18_3.htm

[gr8nurse4u]

Okay ... this is one I just can't keep still about.

Back in the mid 80's, North Dakota had the bright idea of setting a new standard for entry into practice. Thus, the Associate Degree LPN was born. Today, North Dakota requires a minimum BSN degree for RN's and an ASN degree for LPN's.

I must have had "IDIOT" stamped on my forehead. I am one of those who did get my ASPN degree.

If I had only just crossed the river into Minnesota, I would be an RN today.

What are the benefits of having an Associate LPN degree over any other LPN degree? NOTHING! What are the differences? I paid about twice as much for my LPN license as other LPN's paid for theirs!. That's it in a nutshell.

I am still "Just an LPN". I get the same pay and treatment as other LPN's. I do not get considered before other LPN's because I hold a higher degree. In the job market, I'm still an equal.

This whole issue has become the thorn in my side. My degree differs from most ASN (RN) programs by ONE class (Acute Care Nursing). ONE CLASS!!! Of course, you'd think, "Hey, I can take that one class and then take NCLEXRN ... right?" Guess again.

I've decided that I will get my RN anyway, but have reluctantly resigned myself to the notion that my 2 year degree doesn't matter. I'm prepared to start again ... perhaps another 2 years of nursing school to get my BSN ... the same as any other LPN would have to go.

Just a word of advice to any of you who might be thinking about getting that 2 year LPN degree... Don't bother unless you plan to spend the rest of your nursing career in North Dakota. Besides those people who live and work as nurses in North Dakota ... nobody will care how long it took you to get your LPN degree.

and if you hadn't noticed ... other states are not exactly stampeding to follow those "trend-setting" North Dakotans and their standard for entry into practice.

Thanks for letting me vent.

[NRSKarenRN, BSN, RN]

Quote:

....we continue to be constrained by institutional policies in the care of our patients, reticent to monitor the practice of our peers, fearful of transgressing the territorial boundaries of other disciplines, comfortable in a dependency which is more familiar than the unknown, lacking assertiveness to demand what is rightfully ours, and sometimes inappropriately reliant on external regulation and the opinions of others. We resist many of the developmental patterns that have been common to all professional fields: recognition of the need for assisting categories of technical manpower, educational up-grading, and the application of the products of scientific investigation to practice. ...

http://www.nursingworld.org/ojin/topic18/tpc18_4.htm

[jurbyjunk]

Okay, I'm going to be irritating a couple of you with what I'm about to say. And as an aside, I took that "older than dirt" quiz, on another thread, and got 25/25. Therefor, being older than dirt, and having graduated in 1965 (with a BSN, which is completely immaterial to my argument), and having worked continuously since then (sigh, my feet hurt), and having worked in many different milieus (including 1 war zone, 3 foreign countries, numerous states, numerous types of units), I just have to put in my oar.

I can hear the irritation with the old ADN/BSN argument ( and I think that we as individuals should find it irritating), nevertheless, the premise of a "degreed" profession, holds water.

Let me state right now that having a BSN makes not make anyone a "better" bedside nurse, neither does it make one a better person. I've worked with hospital grads, ADNs and BSNs, so I speak from my own experience. They all bring their own contribution to the unique mix of nursing.

Initially, hospital-trained nurses are far ahead of either "degrees" in their "hands-on" nursing capabilities. However, as ADN/BSN grads acquire hands-on experience, the difference basically disappears. In other words, "hands on" is something which can be learned through repetition. But nursing has to be more than repetition.

What remains, and I know that I'm going to have a lot of offended people on this one, is that the ADN/BSN grad, who has had extensive sciences in school, has a much better grounding in the "why" something is done. Rather than basically concentrating mainly on the "how" something is done, with an emphasis on "book learning", degrees know (or should know) what happens at a cellular level because of the disease process, what happens at the cellular level because of what we do at the bedside. For example, by the time that I finished 5 years (yup, 5 years for my BSN) of "care plans" based on scientific principles, I knew exactly what the effect of, for example, a backrub had on the cellular gas exchange level.

Aha, someone is saying, doesn't look to be much difference between the ADNs/BSNs. Nope, not what I'm saying at all.

The difference between the ADNs and the BSNs, besides all those non-nursing/science credits (polisci, history, etc), is, in many cases, the depth of scientific knowledge. Okay, the dreaded "nursing statistics" course, as well.

BSN programs, by sheer length alone, allow for more of an in-depth learning, over a longer period of time than the 2 years of the ADN. But nurses who take specialty training also acquire that in-debth knowledge in re their specialty. BSNs also, as part of their education, learn to do "nursing research".

Okay, here's some more stuff. The practice of nursing should be research-based. "Omigod" I can hear some people out there saying "what is she talking about? Research, something the "ivory tower academics" (you know, those that can, do; those that can't, teach") do rather than "real nursing". But research-based nursing is "real nursing". We should all be asking ourselves, why do we do things in a particular manner, is the results what we want, can we do things differently and have better results? .....". When challenged on "what do nurses do for a living?", rather than concentrating on tasks alone and saying "nurses have always done it this way", we should be saying "because of nursing research, nurses ......."

So, why have a BSN? The simple answer is that "it levels the playing field". It increases the "respect factor". It increases the areas open to nurses.

Last summer, in British Columbia, nurses were involved in contract negotiations with our employers. Believe me, it wasn't pleasant, with the head of the employer's association (HEABC) exhibiting a complete lack of respect for nurses and for the head of our nurses' union. We were referred to as "greedy, putting patients' health at risk by our overtime ban", etc, etc, etc. Sound familiar? The public bought into it, hook line and stinker. Mr Moser and the provincial Health Minister still exhibit a complete lack of respect for nurses. They both continue to tell the public to blame our payraise for the 50% increase in MSP (provincial health insurance) fees and, in part, for the provincial government's decision to close hospitals (3) and other health care facilities. If anyone's interested in the cuts to health care in this province, they can check out the website http://www.bcnu.org.

At the same time, the Health Sciences Association (HSA), which represents pharmacists, dieticians, social workers, speech/physio pathologists, lab techs, was also trying to negotiate a new contract.

The degree/non-degree argument was, at that time, also raging in my unit. I'm the only BSN there. Finally, Maureen said "give me one good reason to have a degree". The previous evening, on the local news, the spokesperson for the HSA, in an interview, said "most of our members have MUCH MORE education than a registered nurse. Registered nurses only need 2 years education to learn to do their job, whereas we have greater educational requirements in order to learn ours". There was this stunned silence at the nursing station, and then Maureen said "I see what you mean. A level playing field". Yup.

Nurses come into the profession by various means. We should appreciate each other for our different expertise and realize that this provides a rich mix. We can acquire "hands on", we can acquire 'book learning". But we need to be on a level-playing field with each other and with other health-care professions.

[rstewart]

Is the 1965 Entry to Practice Proposal relevant today? Evidently it was not sufficiently relevant in 1965 and in my view it is even less so today. Relevant to what one might ask. My answer is relevance to the world of work, the health care industry, the general public, mainstream media etc...nearly everyone outside of the walls of nursing academia.

Then as now, the nursing elite proclaims that nursing is becoming increasingly complex. Therefore, nurses must acquire critical thinking skills. Indeed, they envision that critical thinking will become the sole domain of the BSN prepared nurse. In turn these nurses by virtue of their critical thinking capabilities will be designated as the professional nurses. The BSN professional nurses will at long last be fully welcomed into the healthcare community. Increased respect and monetary rewards will naturally follow. Interest in the profession will skyrocket as will BSN program applications. More nursing professors will be needed to teach these aspiring professional nurses. All will be well in the ivory tower world if only......if only the BSN was mandated as the entry to professional nursing practice.

In the real world outside of nursing academia there exists a severe maldistribution of RNs; that maldistribution is at the bedside. Simply put, hospitals, nursing homes and home health agencies are not able to attract and retain the nurses who are willing and able to take care of patients even as there are more licensed RNs in the US than ever. The situation is expected to worsen as the aging nursing workforce begins to retire over the next few years. Are measures which would clearly slow the pipeline of new RNs prudent or feasible in an environment of apparent shortage? Some nursing leaders seem to think so, but few others.

Neither is there evidence that employers will be willing or even able to pay more for the all BSN professional nurse workforce. In fact, healthcare providers have been introducing LESSER skilled/educated workers over the past 10 years. Restructuring, redesign etc. have brought us unlicensed assistive personnel performing nursing duties; In some states the role of the LPN has been significantly expanded as well. In this environment of for-profit healthcare providers and declining reimbursements does it seem likely that they willl suddenly reverse course and increase the cost of direct care labor?

Should the BSN become the minimum entry to professional nursing practice, the ADN would likely assume the current role of the LPN to a substantial degree. There would be a resultant downward wage pressure. One would expect that the BSN positions/slots would be limited and the excess BSNs would be forced to work in the ADN slots. And the healthcare providers are aware that the ADNs will still be capable of performing all aspects of nursing including critical thinking just as they have done for years. At present, BSNs at the bedside rarely receive additional compensation for their education. But hospitals and Nursing Executive organizations support the BSN proposal because of the 2 tier system it would make possible. Their support is, of course, tempered due to the colleges/university's inability to deliver sufficient BSN graduates. Fully 60% of RNs are ADN prepared-----even in North Dakota, the only state to adopt the BSN as the minimum preparation for professional nursing practice.

[fedupnurse]

So if the suits respect us for having a 4 year degree, why is it that many hospitals around the country don't give you a single penny more for this degree?

I work with nurses who are working as bedside nurses that have their MSN and one who has a PhD. The pay cut those highly educated people would have to take to work as NP's and an epidemiologist wouldn't allow them to pay their kids college educations. The person with the PhD was offered a spot with the CDC. She couldn't afford to take that pay cut right now! So, in my experience, I haven't seen that there is a positive link between higher degrees and higher income or more respect.

Keep in mind, the main goal of the hosital executives is to obtain profits. The only way profits can be acheived is if they control the bedside nursing staff who WILL do what is right for each and every patient. That costs money! It is right for a high acuity ICU to have a maximum 1:2 patient ratio and a 1:1 ratio when higher acuity demands. Reaks havoc with the budget!!! Our suits base our staffing numbers on average daily census and the twist here is on the shifts when we have high turnover and admissions we can still never count over the 24 beds we have. SO even if we have 35 patients in a 24 hour period of time, 11 will never count. As suaul, it all comes down to money. These business people don't think anything of collecting 6 and 7 figure salaries but are irate when we suggest things to improve patient care and always site "the budget". In my hospital we range from Diploma to PhD at the bedside and we will never receive respect from the administrators we have on board now. They support physicians in their political battles but fight us every step of the way. It isn't educational degrees causing this rift between staff and suits, it is focus. We focus on quality patient care and they focus on profits. Thye do not take into account the cost of turnover and training. It would have been far cheaper for them to have staffed by ratios five years ago then to put out the money they are now for recruiting and training nurses, particularly nurses from foreign countries. Again, penny wise in the moment and pound foolish down the line.

I think it would be nice if we DID have some uniformity to an entry level but honestly, I can guarantee you that I wouldn't see a change in the attitude of the execs if all of us were BSN's.