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Since nursing education and training began 150 years ago, it has undergone many changes. Nursing education has evolved from hospital-based apprenticeships to college and university-based programs.
Along the way, there has been much debate about the best way to prepare nurses. Hospital setting or academic setting? ADN or BSN?
Today multiple educational pathways for entry into nursing exist.
Nurses can receive their education and training in nursing education programs at the diploma, ADN, baccalaureate or even master’s level.
One thing that is agreed upon is that, regardless of educational preparation, all eligible graduates take the same licensing exam, called the National Council Licensure Examination (NCLEX). Prior to the NCLEX, nurses took the State Board Test Pool Examination.
The National Council of State Boards of Nursing (NCSBN) renamed the test to the NCLEX in 1982. The first version was a paper and pencil-proctored test. Candidates had to wait months to take it, as it was only offered twice a year. Nurses from that time recall traveling to huge testing centers where they would hear “Pencils down. Booklets closed” and test for two days.
Under the direction of the NCSBN, the exam has since evolved to computerized adaptive testing.
In the year 1873 three nursing educational programs—the New York Training School at Bellevue Hospital, the Connecticut Training School at the State Hospital (later renamed New Haven Hospital) and the Boston Training School at Massachusetts General Hospital—began operations.
It’s generally acknowledged that organized, professional nurse education in the United States began with these 3 programs.
Diploma programs all, they were called “Nightingale” programs because they were based on Florence Nightingale’s teachings. Aspiring nurses trained in hospitals under an apprentice-like system. Graduates of diploma programs recall being trained to stand up and offer their chair whenever a doctor came into the nurse’s station.
Labor was exchanged for training, room, and board. Student nurses provided the patient care, sometimes supervised, sometimes not. Hospital servitude was the first priority and education was secondary.
In time, it was realized that the needs of the hospital trumped the needs of the nursing students. In other words, if patient care was needed on a surgical unit, the student nurses would forfeit their planned Peds training to provide care where it was needed, on the surgical unit. Likewise, classes were canceled if nurses were needed on the floors.
Diploma programs still exist but are far less common than ADN or BSN programs.
After WWII some forward-thinking leaders began to promote moving nursing education from hospitals and into universities. Nurse leaders argued for an educated workforce that would adhere to practice standards. Hospitals opposed the change, fearing the loss of free labor.
At the same time, patient care was becoming more complex. Intensive care units became more common in hospitals, requiring greater nursing expertise. Nurses now needed a theoretical base to their practice. However, the four-year nursing programs were not able to turn out enough nurses to meet the nation’s demand.
ADN Programs and Role Differentiation
Meanwhile, as an economic fix, community college programs began offering ADN programs in the 1950s, which seemed a happy compromise and became a popular track. ADN programs supplied large numbers of nurses, relieving the nursing shortage. Students without access to four-year educations could still earn a nursing degree.
It was originally thought that ADN nurses would be “technical” nurses working under the supervision of BSN or “professional” nurses but hospitals never differentiated practice based on educational preparation. As a result, Diploma, ADN, and BSN prepared nurses all have the same role and responsibilities in clinical practice.
The RN license, and not educational preparation, drives the practice role of the RN.
BSN vs. ADN Entry Level Degree
In 1964 the American Nurses Association stated that nurses should all be prepared at the baccalaureate level. This began a deep and bitter divide within the profession between ADN and BSN prepared nurses that continues to this day.
In 1982, the National League in Nursing (NLN) supported the BSN as the minimum educational level for entry-level nurses. With much debate, many other organizations adopted the same position over the next 3 decades. However, in the 1990s, concerns over a nursing shortage pushed the argument to the background.
In 2010, the Institute for Medicine (IOM) issued a statement that 80% of all nurses should hold a BSN by 2020. New York and New Jersey followed with a “BSN in 10” law requiring nurses to obtain their BSN within 10 years of licensure, but to date, there is still not a national, standard educational entry level.
In most recent years, employers themselves have begun to require BSN prepared nurses, taking the debate out of the hands of nurses and nursing organizations and into the marketplace. Magnet hospitals employ a higher percentage of BSN nurses.
Today there are a number of masters level programs including clinical nurse specialists, nurse practitioners, midwives, anesthetists, clinical nurse leaders (CNL). In addition, there are doctoral programs that prepare nurses to influence healthcare policy and assume advanced leadership roles.
Established in 1893 and called the American Society of Superintendents of Training Schools for Nurses until 1912, the National League for Nursing Education was one of the first professional nursing organizations. The purpose of the National League for Nursing Education was to establish and maintain a universal standard of training for nursing, released as the first Standard Curriculum for Schools of Nursing in 1917.
Accreditation is a voluntary, self-regulatory process. The Accreditation Commissions for Education in Nursing (ACEN) accredits diploma, associates, bachelors, and master’s nursing education programs.
The Commission on Collegiate Nursing Education (CCNE) accredits only bachelor and master’s level nursing education programs
In 1952 the National League for Nursing Education and the Association for Collegiate Schools of Nursing joined together to become what is now known as the National League for Nursing (NLN). Accreditation of nursing schools was the purpose of the newly formed NLN.
The primary problem with nursing education now is the gap between school and practice. Nursing students lack sufficient clinical experience to function independently. Residency programs help to close the gap, but residency programs are not mandated or regulated.
One hospital might orient its new grads for 4 weeks, another for 16 weeks. Residency programs follow a quasi-medical model where new grads are supervised and supported for a period of time before practicing independently.
Career advancement requires a BSN or higher degree. Universities and colleges must work together for a seamless transition to academically higher education. Mobility programs facilitate articulation and transition from one nursing degree to a higher nursing degree, in which ADN prepared nurses return to school and obtain their BSN or masters degrees. Fortunately, many online programs provide easy access for the adult learner.
It’s interesting to see where the next 150 or even just 50 years will take us. Will educational preparation drive practice differentiation?
Will nursing adopt a formalized and standard residency status for new graduates?
What is known is that healthcare is changing rapidly and nursing operates in a contextual environment of society, regulations, and reimbursement. Nurses will be an important part of the change and assume new roles in managing and providing our nation’s care.
Education must prepare nurses who can practice effectively and lead effectively.