Pathways of Nursing Education

Joan L. Creasia, PHD, RN and Kathryn B. Reid, PHD, RN

At the completion of this chapter, the reader will be able to:

• Trace the history of nursing education from its inception to the present.

• Compare nursing education programs for similarities and differences.

• Classify nursing education programs according to role preparation, scope of practice, eligibility for licensure, and eligibility for specialty certification.

• Identify and analyze trends in nursing program development, including eligibility for admission, career mobility and advancement opportunities, and program accessibility.

• Evaluate the effectiveness of mechanisms to ensure program quality.

• Analyze the merits and shortcomings of the current nursing education system.

PROFILE IN PRACTICE

Mary Gunther PhD, RN Associate Professor, University of Tennessee College of Nursing, Knoxville, Tennessee

I was never one of those little girls who wanted to be a nurse. In fact, if early favorite toys and after-school activities had been a predictor, I now would be a truck driver or a librarian. The high school I attended did not provide academic counseling to educate families about tuition assistance or scholarships. My grandmother, who was raising me, made it clear that a college education was beyond our financial means. It was her fervent wish that I always be able to take care of myself (that is, be able to get a well-paying job) without relying on anyone else. She gave me two choices: become a nun or study nursing. I chose the latter.

I completed a 2-year nursing diploma program at a community hospital in Chicago. It was the type of program common at the time: students staffed the hospital around the clock 5 days a week and worked weekends for pay. The opportunity for hands-on clinical experience was unsurpassed. When it came time to look for a job, I chose to specialize in pediatrics, since children were less intimidating to me than adults. Furthermore, they were easier to physically move! Over the first 10 years of my career, I became “a good nurse,” developing both my intuitive and technical skills. I could recognize what needed to be done and when. What I did not know was why. I decided to take advantage of working at a university hospital and returned to school. It took me 15 years of on-again, off-again study to get my BSN. (Obviously, I was not exactly driven; it’s more like I meandered through the undergraduate program.) By that time, I was a head nurse and had a whole new set of skills to learn.

Flushed with the success of being the first one in my family ever to graduate from college, I went back for a master’s degree in nursing administration. What a difference! Almost everyone in my class had worked as a nurse for several years. Everyone had a story to tell about where they had been and where they wanted to go. The classes were not necessarily harder than those in the undergraduate program—just more interesting because they were directly applicable to our various jobs. I fell in love with nursing all over again. I finished my MSN degree in 18 months, just in time to become the director of a large pediatric nursing department. Within a few years, I was the budget director for the entire division of nursing. Suddenly, I was explaining to administrators just what it is that nurses do that makes them irreplaceable and invaluable. It was a very challenging and stressful (although not necessarily intellectually stimulating) job. I was homesick for the College of Nursing. There were so many more things I wanted to know. So back I went.

My days as a doctoral student were among the happiest in my life. It was both the hardest and the most rewarding program I had undertaken. I also found out that I enjoy teaching, mainly because I like to talk about nursing and its place in the real world. Over the past several years, I have become increasingly interested in nursing conceptual models and theories and their role in guiding nursing research, practice, and education. Studying the various models has given me an appreciation of the values and philosophies of nursing, while enabling me to answer clearly the question, “What is it that nurses do, and why do they do it?” I hope the fascination never wanes.

Introduction

For individuals seeking a career in nursing, deciphering the various types of educational programs and the relationship of each program type to future nursing practice can be daunting. Many types of programs at all levels provide multiple pathways to one or more nursing credential. Chapter 1 described the social, political, and economic forces that influenced the evolution of nursing as a profession and the system of nursing education. This chapter analyzes the various educational opportunities with some considerations for selecting among the options. A brief historical overview of each type of program helps build greater understanding of the factors influencing nursing education. More important, this chapter highlights the contributions each type of program provides for contemporary health care systems, advancement of the nursing profession, and promotion of a professional workforce dedicated to lifelong learning.

In 1965, the American Nurses Association (ANA) designated the baccalaureate degree as the educational entry point into professional nursing practice (ANA, 1965). Now, more than 40 years later, three educational pathways for RN licensure still exist: baccalaureate, associate degree, and diploma programs (Figure 2-1). The existence of multiple pathways contributes to a confusing landscape of nursing education and creates challenges for aspiring nurses as they try to choose the most appropriate type of program in which to enter the profession. No matter which type of entry into practice program one chooses, “the demands placed on nursing in the emerging health care system are likely to require a greater proportion of RNs who are prepared beyond the associate degree or diploma level” (Pew Health Professions Commission, 1998, p. 64). The nursing education system is challenged to balance the goal of providing adequate numbers of baccalaureate-prepared nurses while simultaneously advancing the educational level of nurses prepared at the associate degree or diploma level.

FIGURE 2-1 Initial nursing preparation of the registered nurse population, 1980 to 2004. (From U.S. Department of Health and Human Services, Health Resources and Services Administration. [2006]. Preliminary findings: 2004 national sample survey of registered nurses. [Online]. Retrieved from http://bhpr.hrsa.gov/healthworkforce/reports/rnpopulation/preliminaryfindings.htm.)

History of Nursing Education in the United States

ASSOCIATE DEGREE EDUCATION

In 1952 the associate degree in nursing (ADN) became another program option for those desiring to become RNs. Designed by Mildred Montag, these programs were intended to be a collegiate alternative for the preparation of technical nurses and a response to the nursing shortage (Haase, 1990). In 1958 the W. K. Kellogg Foundation funded a pilot project at seven sites in four states. The success of the pilot project led to a phenomenal growth of associate degree programs in the United States. These programs multiplied in community colleges and also began to appear at 4-year colleges and universities. By 1973 approximately 600 associate degree programs existed in the United States. Today, NLNAC states that nearly 1000 state-approved associate degree nursing programs exist (Associate Degree Nursing, 2009), of which 652 are accredited (S. Tanner, personal communication, February 10, 2010).

Associate degree nursing programs are designed to be 2 years in length and consist of a balance between general education and clinical nursing courses, all of which carry academic credit. ADN programs prepare technical bedside nurses for secondary care settings, such as community hospitals and long-term health care facilities. Montag’s intent was that nurses with associate degrees would work under the direction of registered professional nurses who were prepared at the baccalaureate level. Some confusion arose about roles and relationships, so that by the time the first groups of students had graduated from ADN programs, they were declared eligible for the RN licensure examination, an eligibility that graduates of these programs retain today. The degree most often awarded on completion of the associate degree program is the ADN. A few institutions award the associate of arts in nursing (AAN) degree.

MASTER’S DEGREE EDUCATION

While the establishment of associate and baccalaureate degree nursing programs was proceeding, master’s programs were beginning to emerge on university campuses. The need for nursing faculty to teach in all the new and developing nursing education programs was apparent. Interest in master’s-prepared nurses also surged in the service sector as the roles of clinical nurse specialists, nurse practitioners, nurse anesthetists, nurse midwives, and nurse administrators became more clearly defined.

Master’s education in nursing traces its origins to 1899, when Teachers College in New York began to offer graduate courses in nursing management and nursing education. However, master’s programs did not begin to escalate and become nationally visible until the late 1950s and early 1960s. The first programs were strong on role preparation and light on advanced nursing content. This was not surprising because the nurses teaching in these programs did not themselves hold graduate degrees in nursing. As advanced nursing content became more clearly defined, and as increasing numbers of nursing faculty became proficient at teaching it, strong advanced nursing content became the prevailing characteristic of master’s programs in nursing. Role preparation received somewhat less attention as clinical emphasis increased, and by the 1990s advanced practice had become the predominant focus for most master’s degree programs. The expanding authority of advanced practice nurses (APNs) to serve as autonomous providers of care requires that the education of the clinicians be sound and that the consumers of APN care be able to have confidence in the quality of the educational experience (Booth & Bednash, 1994, p. 2).

Master’s programs in nursing are typically 1 to 2 years of full-time study and are built on the baccalaureate nursing major. The program content includes a set of graduate-level foundational (core) courses, including a research component, and clinical specialty courses. Other recommended core content areas include theoretical foundations of nursing practice, health care financing, human diversity and social issues, ethics, health promotion, health care delivery systems, health policy, and professional role development. For specialty tracks that prepare APNs, an additional clinical core consists of advanced pathophysiology, pharmacology, and advanced health/physical assessment (AACN, 1996).

Master’s degree programs in nursing have experienced phenomenal growth over the past several decades. In 1973 only 86 such programs existed. By 1983 the number had increased to 154, and in 2008 there were 475 (AACN, 2009a). During the late 1980s and early 1990s, enrollment in master’s degree programs increased rapidly as the demand for APNs escalated, but a slight decline (1.9%) was evident in 1999 (AACN, 2000). The decline in enrollment reversed itself in the early 2000s, and master’s program enrollment increased by an average of 5993 students per year from 2004 to 2008 in a select group of 391 schools for which trend data were available (AACN, 2009a). Master’s degree programs currently are offered in all states and territories of the United States.

RN-MSN and Nonnurse Master’s Entry Options

The bachelor of science in nursing (BSN) degree or its equivalent is usually a requirement for admission to a master’s program in nursing, but several interesting models that accommodate other types of students have emerged. Some master’s programs admit RNs without a baccalaureate degree or with a baccalaureate degree in another field into a streamlined track that includes both baccalaureate and master’s level courses. Other programs admit students who are not nurses at all. Approximately 158 RN-MSN programs are in existence nationwide (AACN, 2009a).

The impetus for opening admissions to other types of students was the recognition of the kinds of students who were applying in significant numbers to associate degree and baccalaureate nursing programs. Frequently nonnurses with baccalaureate or graduate degrees in other fields were seeking admission to basic nursing programs. RNs from associate degree and diploma programs who had completed baccalaureate degrees in fields other than nursing were applying for admission to baccalaureate nursing programs to present the appropriate credential for admission to a master’s program in nursing. These students brought a rich and diversified background to their educational programs and were highly motivated, self-directed adult learners with a strong and clearly defined career orientation. Some of these students were well served by an accelerated second baccalaureate degree offered by several institutions, but master’s programs could clearly accommodate them and take them to the master’s level in educationally sound and cost-effective ways.

Master’s programs in nursing that admit nonnurse college graduates and RNs without a baccalaureate degree in nursing take the necessary steps to ensure that both groups complete whatever undergraduate or graduate prerequisite courses are needed to acquire the equivalent of a baccalaureate nursing major. They then pursue the same graduate-level foundational, specialty, and cognate courses required of master’s students; thus they exit the program having met the same program objectives that all graduates of both programs must meet. Nonnurses are eligible to take the NCLEX-RN examination on completion of the generalist or baccalaureate equivalent portion of the program or at program completion. In 2008, 55 nonnurse master’s entry programs and nearly 300 programs that offered RN-MSN options existed (AACN, 2009a).

Dual Degree Programs

Another option regarding master’s programs in nursing is the joint program leading to two master’s degrees awarded simultaneously. This type of program is especially relevant for nurses seeking administrative positions that require both advanced nursing knowledge and business management skills. Several joint program models now exist across the country, reflecting nursing’s responsiveness to documented student need and interest and also demonstrating nursing’s ability to collaborate with other academic disciplines. Among the available programs in conjunction with the master’s degree in nursing are the master’s degree in business administration (MSN/MBA), master’s degree in public administration (MSN/MPA), and master’s degree in hospital administration (MSN/MHA). Degree candidates must be admitted to both programs and must fulfill requirements for both programs. However, requirements common to both programs may be consolidated. More than 130 such programs are currently in existence, with several more in development (AACN, 2009a).

Clinical Nurse Leader Program

A relatively new nursing role is that of the clinical nurse leader (CNL), a master’s-prepared nurse who “oversees the care coordination of a distinct group of patients and actively provides direct patient care in complex situations” (AACN, 2005b, p. 1). The concept was developed in collaboration with leaders from education and practice settings. The AACN (2003) further describes the CNL role: “Along with the authority, autonomy, and initiative to design and implement care, the CNL is accountable for improving individual care outcomes and care processes in a quality cost-effective manner” (p. 7). The CNL role differs from advanced practice nursing roles in that the CNL is a generalist and not a specialist, as are nurse practitioners and clinical specialists. A more in-depth presentation of the role and expectations of the CNL can be found in the White Paper on the Role of the Clinical Nurse Leader (AACN, 2007). Approximately 100 schools of nursing partnering with almost 200 health care delivery organizations in 35 states and Puerto Rico were involved in a pilot project to develop the CNL role, integrate it into the health care system, and evaluate the outcomes. Currently, 77 schools of nursing are admitting students into CNL programs, and more programs are being developed (AACN, 2009b).

A number of master’s programs in nursing across the United States have multiple entry options such as those described here, and more are being developed as adult learners from diverse backgrounds migrate toward nursing. The degree most often awarded on completion of a master’s degree program is the master of science in nursing degree (MSN). At least 90% of nursing master’s degrees are MSN degrees. Other degree designations include the master’s degree in nursing (MN), master of science degree with a major in nursing (MS), and master of arts degree with a major in nursing (MA). The degree designation is more a matter of institutional policy than a reflection of program type or content. In fact, no substantive distinction can be made among these various degree designations for master’s-level nursing programs.