In 1969, when I began my nursing training, everyone “knew” that the best nurses came from hospital-based diploma programs. At the hospital, we believed that the students who attended a baccalaureate program had book learning but lacked practical skills and common sense.
But lurking in the background was the “American Nurses Association's [ANA's] First Position on Education for Nursing,” published in AJN in 1965, which asserted that “the education for all those who are licensed to practice nursing should take place in institutions of higher education” and that “minimum preparation for beginning professional nursing practice at the present time should be baccalaureate degree education in nursing.” In the same paper, the ANA proposed that the “minimum preparation for beginning technical nursing practice” should be an associate's degree education.
As a student, I was concerned. What would my diploma education mean in the future? We were assured by our nursing instructors that we would be grandmothered in and that our license as a professional nurse, an RN, would be secure. It is now more than 40 years since I graduated from my hospital-based diploma program and almost 50 years since the ANA position paper was published. Rather than worrying about the status of my nursing license, I am worried about the profession of nursing.
In 1965, the ANA argued that the knowledge needed by the nurse practicing today “differs greatly from that needed 20 or even 10 years ago. She is now being required to master a complex, growing body of knowledge and to make critical, independent judgments about patients and their care.” At the time of my prelicensure education, though, there was far less technology to master on the usual hospital unit. Even in ICUs and dialysis units, the technology was basic. But after four decades as a direct care provider, as an administrator, and in faculty positions in associate's degree and baccalaureate programs, I believe that the increased complexity of the work and the explosion of knowledge require nurses who have a minimum of a baccalaureate education. Students need more than two years to prepare to take their place as members of an interprofessional health care team in a variety of complex health care settings.
Countries large (Brazil, South Korea, China) and small (Portugal, Ireland, Sweden) have implemented a baccalaureate requirement or a near equivalent for entry into professional nursing practice. For 10 years, New York State has flirted with a proposal popularly known as the “BSN in 10” initiative. If enacted, all new nurses would need to obtain a baccalaureate within 10 years to maintain their license (currently licensed RNs and current nursing students are exempt). However, this bill has languished in the legislature.
Other states, such as Oregon, have also developed initiatives to promote baccalaureate education. But encouraging education is not the same as passing legislation that makes it a requirement, and North Dakota, the one state that had successfully established the requirement of a baccalaureate for entry into practice, rescinded it in 2003.
While state boards of nursing and legislatures fail to act to change the entry requirements for professional nursing, in many areas of the country the baccalaureate is becoming the de facto requirement. Major medical centers in the Boston area no longer hire nurses with associate's degrees. At least one large, for-profit hospital chain has decreed that their nurses must obtain a baccalaureate within a stipulated period of time, typically three to five years. Nurses with associate's degrees are limited in both their initial employment opportunities and their long-term options.
While the leaders of 1965 were visionary in their proposal of baccalaureate education as the entry to professional nursing, they were less effective in creating the change that they proposed. Will our current nursing leaders be successful in completing this unfinished business?