Overhauling Nursing Education

Laura A. Stokowski, RN, MS


January 28, 2011

In This Article

Nursing Degrees: What's in Their Future?

Nursing is unique among the healthcare professions in the United States in that multiple educational pathways lead to an entry-level license to practice.[1] A key recommendation of the Future of Nursing initiative was that all nursing schools should offer defined academic pathways that promote seamless access for nurses to higher levels of education.[1]

The nursing diploma. Once the most popular route to becoming a nurse, the hospital-based nursing diploma program has been all but phased out in the United States. Among still licensed RNs, 20% received a hospital diploma for their initial "nurses training," but this number is steadily declining.[7]Only 3.1% of registered nurses who graduated after 2004 were educated in a diploma program.

It is believed that diploma programs should be phased out over the next 10 years and, their resources consolidated with schools providing AD or preferably, BS degrees.[1]

The associate's degree in nursing. As of 2008, the Associate's Degree in Nursing (ADN) was still the most common initial nursing education degree, earned by 45% of all licensed registered nurses.[7] A common misconception exists that the AD is a 2-year degree; whereas, in nursing, the ADN usually takes at least 3 years to complete because of course prerequisites.[1] In the United States, 21% of nurses who initially earn an ADN go on to earn higher nursing degrees.[7]Many rural and other medically underserved communities would not be able to staff their hospitals, clinics, and long-term care facilities without ADN prepared nurses.

I asked Dr. Bleich if the ADN degree will still have a place in the hierarchy of nursing education. He explained that "it's an important entry point for many nurses, a portal to get into nursing as a career, but it shouldn't be a terminal degree. We did address the role of the ADN nurse, but were more focused on the public's need for expanded nursing competencies and this translates into nurses obtaining higher education and not stopping at the associate's level. The need for education and development of the nurse if far greater -- we need more advanced practice nurses, more faculty, more nursing leaders."

Healthcare organizations need to step up and encourage nurses with ADN (and diploma) degrees to enter baccalaureate nursing programs within 5 years of graduation by offering tuition reimbursement, creating a culture that fosters continuing education, and providing salary differentials and promotion opportunities.[1]

Hand-in-hand with the future of the ADN degree is the future of nursing education in community colleges. In rural and medically underserved areas, most nursing education takes place in these settings. The Future of Nursing initiative believes that community colleges must either join an educational collaborative or develop innovative and easily accessible programs that seamlessly connect students to schools offering the BSN and higher degrees, or if possible, develop their own BSN programs.[1]

The bachelor's degree/baccalaureate. Only approximately 34% of nurses (in 2008) had received their initial nursing education in a bachelor's program, but 50% of licensed nurses eventually earned a bachelor's degree.[7]Despite an average gap of 10.5 years before nurses with an AD or diploma earned their bachelor's degrees, this reflects the recognition on the part of many nurses that higher degrees are important for professional and career development.

The goal established by the Future of Nursing initiative is to increase the proportion of nurses with a baccalaureate degree to 80% by the year 2020.[2] Furthermore, at least 10% of these baccalaureate graduates must matriculate into a master's or doctoral program within 5 years of graduation.[1]

Increasing the percentage of nurses with a BSN degree is in line with what the public needs from nurses in terms of growing expectations for quality, and as the settings where nurses are needed proliferate and become more complex.[1] More BSN nurses will be necessary to expand competencies in areas such as community and public health, leadership, systems improvement and change, research, and health policy; and to provide a pool of potential candidates to move on to master's and doctoral education in nursing.

The American Organization of Nurse Executives and the American Association of Colleges of Nursing have called for a mandated baccalaureate degree as a point of entry to nursing practice.[8] Studies demonstrate better patient outcomes in hospitals staffed by a greater proportion of nurses with baccalaureate degrees to those with associate degrees.[8]

The master's degree. Currently, 13.2% of licensed registered nurses hold a master's, or higher, degree.[7] These nurses work in a variety of roles, including clinical nurse specialist, nurse practitioner, nurse midwife, and nurse anesthetist. Master's degrees prepare RNs for leadership roles -- in administration, clinical, or teaching -- or for work in other advanced practice roles, and serve as a springboard to doctoral pursuits.

The fate of the master's degree depends in part on whether consensus is reached on requiring the doctoral degree for entry into advanced practice. At this time, however, the Future of Nursing Education group did not think that the evidence was sufficient to require the doctoral degree for entry into advanced practice nursing.[2] Therefore, other than increasing the numbers of nurses who earn a master's degree, no specific recommendations were made about the master's degree in nursing.

The doctoral degree. The current goal is to double the number of doctorally prepared nurses by 2020. Two primary degrees in nursing at this level are the PhD and the DNP (doctor of nursing practice). The latter has been increasing in popularity throughout the last decade. A shortage of nurses prepared at the highest levels of education and working in primary care, education, and research is viewed as a barrier to advancing the profession of nursing and improving the delivery of care to patients.[1]

Dr. Bleich spoke about the concern that the rise in numbers of nurses obtaining a practice doctorate (rather than the PhD) will influence the growth of nursing research, and if we will have enough PhDs to sustain and expand nursing research? "Newly emerging data suggest that this is not the case," replied Dr. Bleich." It's true that nurses who seek the DNP usually don't want to be researchers, but anecdotally, through their education, some are becoming attracted to the PhD. The DNP is engaging nurses in research and inquiry."

Why Go Back to School?

I asked Dr. Bleich why, considering the expense and time commitment, should nurses go back to school for another degree? For example, if I have an associate's degree, why do I need to get my bachelor's?

"It starts with one's personal desire to develop oneself -- investing in oneself is a fundamental tenet of a professional. We live in a time when knowledge is exploding, technology is adding complexity to our work, and there are more opportunities for nurses to work in more settings than we've ever known in the history of nursing (Table). Many organizations are expecting more highly educated nurses. The public also wants nurses to be more knowledgeable and more adept. This is part of the nurse's reality."

Table. Nontraditional Nursing Careers

Transitional Care Nurse
Care Manager/Coordinator
Telehealth Nursing
Nursing Informatics
Forensic Nurse
Legal Nurse Consultant
Hospice Nurse
Palliative Care Nurse
Nurse Epidemiologist
Occupational Health Nurse
Travel Health Nurse
Cruise Ship Nurse
RN Operating Room First Assistant
Wound Care Nurse

From Olmstead J. Nurs Manage. 2009;40:52.[9]


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