OJIN is to be congratulated for the excellent historical and extremely thorough review of the most controversial and embarrassing dilemma in nursing, namely entry into practice. The lack of a mandatory BSN entry level is the heart of the poor nursing image, nursing shortage, attrition for students entering nursing, and poor retention of seasoned nurses. It is also the reason why bright, career-oriented students and second career individuals should be directed away from entering nursing education in its present format. These individuals are being deceived and mistakenly led to believe that they are entering into a profession, when indeed nursing is a vocational trade group. The primary identity of any group is based on the established education entry level. Attorneys, physicians, social workers, engineers, clergy, physical therapists, to list a few examples, share in common an essential education at the bachelor’s level. Advance degrees are required in many professions for entry positions at the professional level. Only nursing continues the hypocrisy of pretending that education is unimportant and does not make a difference. Only nursing allows individuals with no college course work, or with limited college study that lacks a well-rounded global college education, to lay claim to the same licensure and identity as that held by nurses having a baccalaureate education.
The first BSN program opened in 1904. Previous to this time, all nursing graduates came from the hundreds of available, hospital-based, training schools. These training schools performed an admirable job at the time; but they are inadequate for the standards of today. The nursing literature clearly emphasizes the need for nurses who have received a baccalaureate education and are able to practice in an autonomous manner basing their nursing care decisions on scientific findings, a practice that they learned in their baccalaureate programs (Floyd, 2001; Ryan & Brewer, 1997; Young & Sewell, 1997). The approximately 75 remaining diploma programs focus more on providing technical apprenticeship programs. They do not reflect the professional preparation needed for a career in nursing today. Presently, they produce fewer than 3000 graduates annually.
In 1952, as the authors in this OJIN topic explain, Mildred Montag, designed a two year education program as a shortsighted approach to the pending nursing shortage (Haase, 1990). This has led to the most contentious struggle within nursing. It is difficult for the general public and health care community to comprehend how nursing can attempt to justify 2 year, 3 year, and 4 year graduates of different educational tracts, all of whom claim to be professional nurses. In other fields of study where a junior college level entry exists, these individuals are titled "assistant" to the professional, e.g., dental assistant, engineering assistant, physical therapy assistant. It is incomprehensible that nursing leaders can continue to permit the current situation to exist. It is dishonest to allow these graduates to think they are professionals. Rather they have the degree that prepares them to work as an assistant or helper to the registered nurse. Presently, approximately 900 ADN programs produce 40,000 graduates each year.
Each year approximately 500 BSN programs graduate 30,000 students who enter into the war zone of the nursing career track identity crisis. It is extremely misleading to permit these individuals to believe that they are entering into a profession that welcomes their credentials. Their salary will not reflect the rigors of their baccalaureate education in a manner similar to that of other baccalaureate graduates in other fields.
Although the authors writing for this Entry Into Practice issue of OJIN have elegantly outlined the educational issue in nursing, as have many others, no well-designed plan has been put forth for rectifying the problem. I am convinced that nursing cannot or will not solve this glaring problem without governmental intervention, for example by limiting funding under the Nurse Education Act. Should nursing wish to control its own destiny, I strongly urge three steps be initiated immediately:
1. Closure of the remaining diploma schools, as recommended by the Institute of Medicine (IOM) Report and Pew Health Professions Commission (Pew Health Professions Commission, 1995; Wunderlich, Sloan, & Davis, 1996).
2. Insist that the NCSBN develop two different licensure examinations, a separate exam for ADN and for BSN graduates. This step is long overdo to halt the confusion and deception created by a single exam for vastly different education tracks.
3. Demand a title change for the ADN graduate, to registered nurse assistant, which would follow suit with other established junior college programs.
If nursing waits long enough, the problem will resolve itself. The brightest, most promising young students will continue to seek true professional and career opportunities. The baby boomer generation will continue to retire early or seek opportunities where they can have an undisputed identity. Finally, nursing will be appropriately classified as a humanitarian and technical vocational group.
Thank you for your consideration of my views,
Christy Price Rabetoy, NP
Nephrology Nurse Practitioner
Salt Lake City, Utah
Floyd, J. (2001). Envisioning new nursing roles and scopes of practice. Reflections on Nursing, 2nd Quarter, 52-53.
Haase, P. (1990). The origins and rise of the associate degree nursing education. Durham: Duke University Press.
Pew Health Professions Commission. (1995). Reforming health care workforce regulation: Policy considerations for the 21st Century. San Francisco: Pew Health Professions Commission.
Ryan, D., & Brewer, K. (1997). Mentorship and professional development in the undergraduate nursing education. Nurse Educator, 22(6), 20-24.
Wunderlich, G., Sloan, F., & Davis, C. (1996) Nursing staff in hospitals and nursing homes: Is it adequate? Washington, D. C.: National Academy Press, Institute of Medicine.
Young, S., & Sewell, R. (1997). The case management curriculum model: The challenge for nursing education, Nurse Educator, 22(5), 13-18.