Following World War II, an increased demand for nurses occurred because many nurses returning from military service did not reenter the workforce. Also, changes in health care, including hospital-based births, surgical procedures, and anesthesia, necessitated more nurses working in hospitals (Haase, 1990). In 1946, Congress passed the Hill-Burton Act, which provided federal grants and guaranteed loans to improve the physical plant of the nation’s hospitals, nursing homes, and other health care facilities. In return, these agencies agreed to provide a reasonable volume of services to persons unable to pay and to make their services available to all persons residing in the facility’s area, making the demand for nurses more urgent. At the time, hospital diploma programs were the primary source of new nursing graduates. Baccalaureate programs produced only 15% of the new nurses each year and could not meet the increasing demand for graduate nurses (Orsolini-Hahn & Waters, 2009).

In 1948, the Carnegie Foundation commissioned a sociologist, Dr. Esther Lucille Brown, to study nursing education and to address the critical nursing shortage in the United States due to a decreased supply of nurses and an increased demand following World War II. Brown’s report, Nursing for the Future, called for nurses to be educated in colleges and universities instead of hospital-based programs (Brown, 1948). The ANA and the National League for Nursing (NLN) supported the Brown report and urged the nursing education community to move nursing education into the college environment (Orsolini-Hahn & Waters, 2009). Simultaneously, President Harry Truman convened a National Commission on Higher Education, which called for the expansion of community colleges. In response to both documents, NLN representatives arranged a meeting with the Association of Community Junior Colleges (AAJC), now known as the American Association of Community Colleges (AACC), to explore the idea of teaching nursing in 2-year community college programs (Haase, 1990).

While these events transpired on a national level, faculty at Teachers College, Columbia University, were engaged in the exploration of new models of nursing education. A doctoral student, Mildred Montag, proposed in her dissertation that nurses be educated at community colleges as nursing technicians (Montag & Gotkin, 1959). Montag was influenced by a study group at Teachers College, chaired by Eli Ginzburg, which proposed two levels of nurse practitioners, a practical or technical level and a professional level. Dr. Montag’s dissertation, entitled, “Education for Nursing Technicians,” received funding to conduct research on this new model, and in 1952, under her leadership, faculty from seven original associate degree programs created the 2-year technical program. Although the course of study was referred to as technical and terminal, a term used at the time to signify that the entire course of study could be accomplished in a set time-frame, faculty in the new programs viewed their mandate as more than development of a shortened traditional program; they envisioned a program of learning that would revolutionize nursing education. The curriculum was no longer based on a “map of the hospital” (Waters, 2007). Rather, the concept of nursing was patient-centered (not disease-centered), and the curriculum was based on broader structures like fundamental concepts and adult nursing considerations (Haase, 1990). By 1980, associate degree programs were educating approximately 20% of new graduate nurses (Orsolini-Hahn & Waters, 2009). Simultaneously, professional nursing programs developed in baccalaureate programs, but not at the same pace as community college programs (Haase, 1990). The extraordinary growth of associate degree nursing education from the midpoint of the last century is compelling. Today associate degree nursing graduates account for slightly over 60% of new RN graduates each year (NLN, 2008) from over 900 associate nursing degree programs nationally.

Controversy followed the associate degree programs from their inception. For one reason, the educational model was not consistent with the way associate degree graduates were utilized in practice. Dr. Montag had proposed this new model based on a two-level system of nursing care delivery. She intended that associate degree graduates would function on teams led by baccalaureate prepared nurses. As noted, she used the term terminal course of study and never intended that programs would articulate, due to the significant difference in technical and professional education. But the practice environment used the new associate degree graduate almost immediately in management and leadership positions, where they performed satisfactorily (Orsalini-Hahn & Waters, 2009). By the 1970s, associate degree graduates were actively encouraged to pursue advanced study in baccalaureate programs in order to advance their career options.

The response of the nursing community to this education/practice role confusion was to engage in differentiation of practice debates. For almost 50 years, nursing attempted to define and articulate differences between graduates of the two types of nursing programs. Because these debates focused on practice in acute care both at the bedside and in management, where roles of both graduates were blurred and overlapped, they failed to clearly define differences (Haase, 1990). Waters (2007) reports that at a meeting in California in the 1980s faculty from baccalaureate and associate degree programs met to distinguish curricula and were unsuccessful in creating a document that delineated distinctive core content. In both education and practice, no clear distinctions between the two levels emerged.

As early as 1965, organized nursing attempted to bring clarity to the differentiation debate. The ANA convened the Committee on Education to study nursing education, practice, and scope of responsibilities, due to the increasing complexity of health care and changes in practice. The study group recommended that the minimum preparation for beginning professional nursing practice should be the baccalaureate degree. The Committee on Education’s statement became ANA’s “position paper” and contained a description of three levels of nursing education: baccalaureate education for beginning professional nursing practice, associate degree education for beginning technical nursing practice, and vocational education for assistants in the health service occupations (ANA, 1965). The authors of the 1965 position statement also recommended that associate degree programs replace practical nursing programs, further alienating vocational and practical nurses and faculty. During the same year, the NLN published Resolution 5, a document that called for examination of the differentiated functions of the two levels of nursing education (Haase, 1990). Subsequently, the 1965 ANA position paper was reaffirmed by a 1978 ANA House of Delegates resolution that resulted in the recommendation that by 1985 the minimum preparation for entry into professional practice would be the baccalaureate degree.

In 1969, the AACN was established to advance nursing education at the baccalaureate and graduate levels. Since the 1970s, the organization called for quality standards for bachelor’s and graduate degree nursing education and actively promoted public support of baccalaureate and graduate education, calling for the baccalaureate degree in nursing as the educational basis for the profession. In 1982, the NLN published Position Statement on Nursing Roles—–Scope and Preparation, emphasizing that professional nursing practice required a baccalaureate degree and that preparation for technical nursing practice be accomplished through associate degree or diploma education (Kaiser, 1983). The designation of two levels of nursing practice, professional and technical, was reaffirmed by NLN, at a time when both ANA and AACN called for the baccalaureate degree as the minimum entry for professional nursing practice. The nursing education community envisioned an orderly transition to professional entry at the baccalaureate level and an educational system of two levels with subsequent differentiated practice. This never occurred.

What did happen was a divided health and nursing community (Donley & Flaherty, 2002). Many associate degree nurse educators became disillusioned with the ANA and NLN, leaving both organizations to start a new organization in 1986, the National Organization for the Advancement of Associate Degree Nursing, which later became the National Organization for Associate Degree Nursing (N-OADN). The NLN established separate councils for associate degree and baccalaureate educators. The councils rarely interacted, and strained relationships developed between faculty in both types of programs. This resulted in few opportunities for constructive dialogue about ways to create articulation between programs and build a more educated workforce, which had been the primary intent of the Brown report, the ANA 1965 position statement, and the NLN early documents. The central focus of the early debate to move nursing education to higher education, away from hospital-based certificate programs, had been to improve educational preparation, elevate the status of nurses, and ultimately improve the quality and safety of patient care, thereby addressing nursing’s long-held vision. Yet nursing had become mired in differentiation debates that only served to sidetrack the discussion. As a result, over 50 years later, the need for a more educated workforce remains at the core of the entry into practice debate.

In adopting the 1965 ANA Position Statement, the nursing community declared that they were ready to set their own standards, apart from those dictated by the physician-driven (or led) hospital system. ANA commission members clearly determined that professional nurses must be grounded in science and critical thinking, and not merely follow ritualistic practices (Donley & Flaherty, 2002). Nurse leaders were also making the case that more educated nurses would improve patient care and have a greater impact on the health care system. This same belief lies at the foundation of nursing’s current debate about the educational level that best prepares nurses to deliver safe and efficient nursing care.

The current health care reform agenda, led by the Obama administration, calls for new models of chronic care delivery and a greater focus on health promotion and disease prevention. This will require knowledge of research, centralized care coordination, outcomes management, risk assessment, and quality improvement—educational core content traditionally assigned to the baccalaureate curriculum. Furthermore, new models of service delivery will require a systems approach to address the consequences of disparities in access to health care services that preclude quality care for all individuals. These approaches require advanced study and practice implementation.

Yet the most recent workforce data (U.S. Department of Health and Human Services [USDHHS], 2006) reveal that too few nurses are pursuing graduate degrees needed to assume advanced roles. These data show that about 6.4% of those initially educated in associate degree programs and 11.7% of those prepared in diploma programs had obtained post-RN graduate degrees in nursing or related fields. Additionally, only 22.1% of nurses prepared initially in a baccalaureate program had obtained post-RN masters or doctoral degrees. Comprehensive analyses of these same data 4 years later were not available at the time of publication. But preliminary data indicate that the number of RNs with masters and doctorate degrees rose by 46% from 2004, suggesting that, finally, more nurses are progressing to advanced practice roles. This slow movement to advanced practice may be an unintended consequence of the differentiation wars that occurred over the past 50 years.

Debates about entry into practice at the prelicensure level have been divisive and counterproductive. Nurses enter the profession today from a wide variety of access points: LPN progression programs; generic pre-licensure programs in diploma, associate degree, and baccalaureate programs; accelerated baccalaureate programs for graduates of non-nursing disciplines; and entry-level masters programs. All of these options contribute to the diversity and expanding numbers of RNs available to meet the current nursing shortage. Certainly, one of the strengths of the current nursing education system is the multiple entry points currently available to individuals who desire to pursue a nursing career. In fact, it is our belief that recognition of multiple access points to the profession is not in conflict with the current need for a more educated nursing workforce.

To make this happen, innovative and expanded educational opportunities must be available and utilized by increasing numbers of nurses currently employed in the RN workforce. This is the heart of the current entry into practice debate: How will the nursing community improve patient care and increase the educational level of its workforce while accepting multiple educational access points?

A critical goal for the nursing profession must be to sidestep the old argument of baccalaureate entry and move to the option of RN to BSN or RN to MSN (not based on entry but for lifelong learning) and take fullest advantage of the diversity offered by multiple progression points. The NLN contends that creative approaches need to be conceptualized and implemented so that the capacity of baccalaureate and masters programs to accommodate all RNs who would be required to earn the advanced academic degree is addressed. Current efforts to seek federal and state funding to offer tuition reimbursement and/or loan repayment options are actively supported by members of nursing’s Tri-Council—ANA, NLN, AACN, and AONE. The nursing community has begun to come together around this issue and, rather than focus on entrance to the profession, are working collaboratively to improve patient care and address the needs for a more educated workforce.

In 1965, nurse leaders made a clear statement of autonomy (Donley & Flaherty, 2002) by declaring the need for a more educated nurse. For the next 50 years, the nursing community became sidetracked about how to achieve that goal, and the differentiation debates diverted nursing’s productive energy away from its fundamental vision to meet the needs of a changing practice environment. It is imperative now that the nursing community return to this original intent and that a new conversation emerge—one centered on improving health care through active dialogue about progression within the profession.

Advanced practice nursing emerged as a response to the physician shortage in the late 1950s (Joelle, 2002). By the mid-1960s, nurse practitioner programs existed throughout the U.S. as postbaccalaureate certificate programs of varying length (O’Sullivan, Carter, Marion, Pohl, & Werner, 2005). In 1990, the National Organization of Nurse Practitioner Faculties (NONPF) published Advanced Nursing Practice: Nurse Practitioner Curriculum Guidelines and called for nurse practitioner education to be grounded in graduate-level programs (NONPF, 1990). Within the next decade, the shift away from certificate nurse practitioner programs was complete, with less than 1% of all nurse practitioner programs representing non-masters education tracks (O’Sullivan, Carter, Marion, Pohl, & Werner, 2005).

Since that time, a growing movement within nursing emerged to reconsider nurse practitioner educational preparation; the practice doctorate was discussed as a means to meet the demand for increased knowledge and skills. The following societal changes and emerging health care trends sparked this movement:

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