Upheaval within the Profession
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.