Nursing Education Policy: The Unending Debate over Entry into Practice and the New Debate over Doctoral Degrees

Nursing Education Policy

The Unending Debate over Entry into Practice and the New Debate over Doctoral Degrees

Elaine Tagliareni and Beverly L. Malone

“In the ongoing improvisation of leadership—in which you act, assess, take corrective action, reassess, and intervene again—you can never know with certainty how an intervention is received unless you listen over time.”

—R. A. Heifetz and M. Linsky, Leadership on the Line: Staying Alive through the Dangers of Leading.

The issue of educational entry level into nursing practice has been debated for decades. The old debate about entry into professional nursing at the prelicensure level and the latest debate about doctoral education and entry into advanced nursing practice are two specific issues that have emerged. Both debates stimulate the expression of strong beliefs by leaders in nursing education and nursing practice. The early debate focused on entry at the prelicensure level, more specifically, the movement of professional nursing practice into the academic setting. The current debate moves the dialogue to consideration of doctoral education, challenging the position of the traditional research-focused doctorate, calling for the Doctor of Nursing Practice (DNP) to be the profession’s accepted credential for the advanced practice of nursing. Both debates concern the transformation of nursing practice in the midst of changing health care system and practice demands (Box 50-1).

BOX 50-1

Concerns Voiced by the Nursing Community about the DNP

1. The place for schools that do not have the option or the desire to offer a doctorate degree. Many programs had successfully offered nurse practitioner programs at the masters degree level. How would these programs survive if the DNP was mandated for advanced practice?

2. The premature release of the AACN document prior to adequate analysis and support from the nursing community. Deans who voiced concern about the timing of the release also questioned the validity of diverting their energy away from discussions about the critical shortage of nurses and national policy decisions about new models of care delivery to a debate about a new degree. “The timing for developing, implementing, and evaluating this degree is, in a nutshell, disastrous to the potential involvement of nurses to make a substantial difference in the safety and quality of healthcare” (Meleis & Dracup, 2005).

3. The separation of practice and research in the program’s curriculum. Opponents of the DNP argued that nursing had worked tirelessly to bridge the schism between research, practice, theory, and policy, and now the profession was proposing a separate research and practice doctorate. The thinking was that nursing requires more integration rather than fragmentation (Meleis & Dracup, 2005; Donley & Flaherty, 2002).

4. The research-intensive environment of higher education. Nursing faculty struggle in an environment that requires substantial acquisition of resources and, in particular, funding through research. A decrease in research-intensive doctorally prepared faculty might negatively affect the ability of deans and their faculty to maintain the research productivity that has become a standard for survival.

The belief that a nurse’s educational entry point impacts the quality and competence of the nurse’s work has fueled both debates. This notion, that entry affects practice, has resulted in numerous position statements from professional organizations describing the nature of education needed for the future. The first of these statements, the American Nurses Association (ANA) 1965 “First Position on Education for Nursing” (ANA, 1965) sought to change the trajectory of nursing education and move education out of the service sector and into academic settings. The paper’s authors saw a future with two levels of nursing—technical and professional; 2-year colleges would provide “minimum preparation for beginning technical nursing practice” (Committee on Nursing Education, 1965, p. 108), and 4-year programs would prepare graduates for beginning professional practice. This document also called for practical nursing programs to eventually be replaced by technical programs. Its publication created controversy and debate in the nursing education and practice community. Since 1965, other nursing organizations have published position statements calling for the baccalaureate degree to be entry level into professional nursing (e.g., American Association of Critical-Care Nurses [AACN], American Organization of Nurse Executives [AONE]).

Following the 1965 ANA position paper, colleges and university nursing programs created specialized masters programs. This educational approach became the norm, and credentialing and licensing of advanced practice roles recognized the masters degree as entry into advanced practice. The 2004 position paper of the American Association of Colleges of Nursing (AACN), which called for the establishment of the DNP, proposed that study for advanced practice roles—as midwives, nurse anesthetists, clinical nurse specialists, or nurse practitioners—should no longer exist on the masters level. The DNP was, as proposed, now viewed as the clinical path into specialized advanced practice (Donley and Flaherty, 2002). This was a radical departure from specialized masters programs and represented a new form of entry into advanced roles in nursing.

Both debates occurred at unique times, in the framework of complex and evolving health care environments. Both debates placed new emphasis on shifting the educational trajectory of the nursing workforce. The intent of both debates was to elevate the status of nurses and improve patient care. Certainly, the most viable vision for nursing education must be nestled within the vision for the nation’s health care system. This intent does not minimize nursing/education contributions of a strong, diverse workforce of well-prepared health care providers to the vision; it only reinforces and strengthens nursing’s unique focus on patient-centered, community responsive care. But both debates sought to achieve this vision through new entry requirements, which has the appearance of self-enhancement, rather than focus decision making on the nation’s health care needs. This may be the most powerful lesson learned from nursing’s unending debates over entry into practice.

The Entry into Practice Debate

Historical Perspective

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.

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.

Current Climate: The Realities of the Workforce

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.

The Entry into Advanced Practice Debate

Historical Perspective

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:

• In the late 1990s, nurse-managed health centers emerged as safety net providers for underserved populations, extending the range of primary care services offered by nurse practitioners in autonomous practice settings (Hansen-Turton & Kinsey, 2001). These centers were operated and managed by advanced practice nurses and offered both primary care services as well as wellness-based health promotion and disease prevention services. These centers provided new opportunities for advanced practice nurses to create comprehensive models to serve vulnerable populations and helped to offset the decreasing numbers of physicians interested in primary care careers (O’Sullivan, Carter, Marion, Pohl, & Werner, 2005).

• The nursing community recognized that the demand for new models of care to manage complex chronic co-morbidities, specifically of an aging population, required movement away from illness management to non-traditional approaches to case management involving multiple intersecting systems of care. Nurse leaders raised the question of whether or not these new models could be addressed adequately in the current advanced practice masters curriculum.

• Nurse faculty teaching in nurse practitioner programs called for parity with other allied health professions. These disciplines (e.g., pharmacy, audiology, and physical therapy) had expanded their masters degree programs and created practice doctorates in response to the need for advanced practice professionals to work within complex systems, advocating for evidence-based quality care in an interdisciplinary environment. Nursing leaders argued that parity for nursing was not simply a matter of status but a necessary credential for credibility in leadership and policy positions (Lenz, 2005).

• The Institute of Medicine (IOM) proposed changes in practice (IOM, 2003) calling for a reduction of medical errors and an increase in competencies necessary to deliver quality health care, including utilization of informatics, understanding of quality improvement, a focus on patient-centered care, wide acceptance of evidence-based practice, and movement to interdisciplinary care models. Changes in practice would require new approaches to the education of advanced practice health care professionals, including courses in health care finance and policy, process, and outcomes measurement and analysis and use of evidence-based methods to plan and implement care (O’Sullivan, Carter, Marion, Pohl, & Werner, 2005). As these new educational demands resulted in increased clinical and classroom hours in nurse practitioner programs, the credit allotment had not increased commensurately. It became apparent to faculty in nurse practitioner programs that nursing may be under-credentialing its advanced practice graduates to the point where they far surpassed requirements for masters programs in other clinical disciplines (Lenz, 2005).

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Mar 18, 2017 | Posted by in NURSING | Comments Off on Nursing Education Policy: The Unending Debate over Entry into Practice and the New Debate over Doctoral Degrees

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