Saturday, December 23, 2006

ADN vs. BSN Education

Nursing education is bound by its contract with society to prepare nurses with the knowledge; skills and values that enable them to provide quality care within the contemporary health care system. Implicit in this process is that a layperson will be transformed into a competent professional (Lindeman, 2000). When addressed to nurses, the question of educational preparation into professional nursing practice has long been a source of frustration. This is not limited to educators; it is pervasive among all settings and at all levels of nursing practice. Societal changes, increased technology, the shortage of registered nurses (RN’s), and most notably, the increasing shift of health care from acute to community-based settings, has led nursing leaders to raise questions about past and future trends in nursing education (Speziale & Jacobson, 2003). Although associate degree nursing (ADN) education remains a viable choice for those wanting to enter the nursing profession, the ability of these programs to appropriately prepare students for the level of practice diversity that is inherent in the current system must be assessed, and their role defined with regard to the future.
In thinking about this question about entry into practice, I had to do some reflection. As I come from an AD program, I have to say that for the time (graduated 1986), and for the expectations of entry-level RN practice at that time, I received the most complete and comprehensive education that I could have ever asked for. I knew I was prepared to begin working as a safe, competent professional and I quickly learned as I worked alongside new BSN graduates that I was more clinically prepared in many ways. That being said, I also knew that if I wanted to have more choice with regard to my future, I would have to pursue at minimum a BSN. So, I find a definitive answered to the question posed to be difficult. Regarding ENTRY into practice, I believe that an AD program prepared nurse can be a huge asset to nursing practice, and in many ways is more prepared now than even I was with regard to some issues (e.g.: critical thinking and community integration into curricula). In light of the current shortage, as well as other issues, the reality is that AD program graduates are here to stay. I do believe that if possible, a student should pursue BSN education from the outset, but there are often obstacles to that for some students. The AD option alleviates those obstacles. I do believe that the baccalaureate (as a “gold standard”), if not received with basic RN education, should be a mandated requirement within a time frame, but not necessarily for ENTRY into practice. The AD programshould not be envisioned as a terminal degree, but the beginning of professional education. In that, nurses of all preparation levels must work for acceptance and joint advancement, not internal classification.
Patricia T. Haase, (as cited by Mahaffey, 2002) has discussed these programs and their origins at length, and gives evidence of the historical context. Associate degree nursing programs were “born” at a time when nursing was facing many of the same challenges that it is today. After World War II, many nurses who were in military or civilian practice were leaving nursing, therefore creating a nursing shortage. Fewer students were choosing nursing, and those that did were leaving nursing after only a few years of practice. Advances in medical science, improved medical facilities, and larger numbers of insured persons began to create an increased demand for nurses and nursing care. At this time, the growth in junior colleges, the increase in federal monies, and consumer concern, led to a discussion of possibly including nursing in junior college curricula. The shortage of nurses, the interest of moving nursing education into colleges and universities, and the desire to find more efficient ways to educate nurses became a large concern of nursing educators. Unexpectedly, ADN programs became instantly popular and grew exponentially throughout the 1960’s. These programs attracted innovative nurse educators who were willing to challenge traditions, experiment with new teaching strategies, and take risks as they worked out a new two-year curriculum as preparation for nursing practice (Nelson, 2002).
In 1965, the American Nurses Association (ANA) declared one of its chief concerns to be “what nursing is today and what it will be tomorrow” (Nelson, 2002). What followed this introduction was the first position paper on nursing education to be published by the ANA. In her doctoral dissertation, Dr. Mildred Montag had used the term “technical” to describe AD nursing education. The use of this term became one of the central themes in the discussion regarding change in nursing education with regard to nursing practice. The passage of the Comprehensive Nurse Training Act in 1964 prompted the ANA Committee on Education to study nursing education, practice, and scope of responsibilities. The study, as cited by Nelson in 2002, recognized the “increasing complexity of health care” and noted changes in the practice of nursing that included “major theoretical formulations, scientific discoveries, technological innovations, and the development of radical new treatments”. It was after this study that the baccalaureate degree as “minimum preparation for professional nursing practice” was recommended. This was the first major challenge to ADN education.
Throughout the past forty years, the need for the designation of two levels of nursing practice has been repeatedly reaffirmed, and target dates have come and gone for when all states would have put in place the educational and legal elements necessary to mandate baccalaureate education for nursing. The hope of the ANA was that professional nursing in the United States would begin the 21st century with one educational path to licensure. Supporters of this position, however, were not able to generate the support, and overcome the fear and resistance. The words “professional” and “technical” with regard to education and practice remain controversial and divisive. Throughout this debate, ADN programs have continued to grow, thrive, and prepare nurses for professional licensure along side the BSN graduate. Currently, there are 940 ADN programs in the United States, with over 600 of those in community colleges. There is a higher representation of minorities, males, and students that would otherwise have limited access due to financial or demographic issues, and these programs provide approximately 60% of the entry-level nursing graduates each year (American Association of Community Colleges (AACC), 2006). In 2004, the most common initial preparation for nursing was an associate’s degree (Health Resources and Services Administration (HRSA), 2004).
In March 2006, the National Organization for Associate Degree Nursing (N-OADN) issued it’s most recent position statement, addressing the mission of ADN education, as well as the competencies of ADN graduates:
· Associate degree nursing education provides a dynamic pathway for entry into professional nurse (RN) practice.
· It is continually evolving to reflect local community needs and current and emerging healthcare delivery systems. I
· Is responsible for instilling the tenants of advocacy, professional involvement, life-long learning, and leadership.
· Involves evidence-based practice, which prepares graduates to employ critical thinking, clinical competence, and technical proficiency in their healthcare setting.
Graduates of associate degree nursing programs are registered professional nurses who hold an associate degree and are
· Essential members of the interdisciplinary healthcare team in diverse healthcare settings.
· Able to derive strength from their ethnic, cultural, social, economic, and gender diversity, thereby enhancing the capacity to respond to the healthcare needs of a diverse nation.
· Able to collaborate with all stakeholders for the development of public policy, the delivery of quality outcome driven healthcare, and to ensure access to healthcare for all individuals.
· Caring, competent, and knowledgeable healthcare providers who engage in professional development activities in order to advance safe, effective, competent care.
· Legally, morally, and ethically accountable
This position statement will serve as an important tool with which to examine ADN education, and it’s current and future role in preparing nurses.
Many changes in healthcare have occurred over the past fifty years, but a major change that ADN education has had to address has been the increasing diversity of practice settings, particularly the shift of care from hospitals to the community. “Community care” is a general term that refers to many settings with diverse responsibilities for nurses. Community care settings include long-term care environments, case management, home health care, schools, and ambulatory clinics. As the majority of nursing graduates each year are coming from ADN programs, this change has become one of major importance in ADN education.
Traditionally, ADN students had been prepared for, and practiced in, the acute care environment. As early as 1993, as cited by Nelson (2002), the NLN was beginning to address the changes occurring regarding the environments of care. The NLN maintained:
“All nurses, regardless of educational background or area of practice, should be prepared to work in a community based, community-focused care system. Graduates from all programs should be prepared to intervene at the macro-level, to exert greater authority, responsibility, and autonomy, and depend less on institutional structures, authority, and policies.”
In response to the changes in care delivery, ADN programs began to change curricula to include the “community as client”. Many programs expanded the number of credits to much more than is required for associate degrees in other areas. It is not unusual for ADN programs to require 75 or more credits that can take three years or longer to complete. Program goals began to include the preparation of practice for all settings, increased community health content and community experiences were added, and programs began to describe themselves as community based (AACC, 1999).
Simple systems combine with other simple systems to form more complex systems. Nursing education can be viewed as a “component system”. In a component system, there are two basic requirements. First, each must have well-integrated components and function well internally. Second, it must intersect and interact with other related systems in order to make up the larger system and promote effectiveness (Porter-O’Grady & Malloch, 2003, p.55). In the context of nursing educational change, leaders must require ADN, BSN, and graduate programs to work together and not focus on their individual agendas, therefore causing an undermining of the common goal of educating professional nurses. Nursing leaders must ensure the effective operation of the larger system. As per the principle of complexity, those that come in contact with the smaller system (ADN) should see a picture of the whole system, including the mission, service, quality, and outcomes, all of which should be manifest in the work of ADN education.
Diversity is a necessity. Transformational leaders recognize that their main work is interpreting present activities in light of their potential to create the future (Porter-O’Grady & Malloch, p. 57). The future does not just happen. A good leader embraces diversities and differences, capitalizes on strengths located in components of organizations. Associate degree education is diverse, and its very existence has been an ongoing source of conflict in the larger system of nursing education. Conflict is always an essential factor in the decision of which direction an organization should take, it notes themes, and points out potential. Nursing leadership can build collective wisdom.
The principle of error is a major influence of change, is everywhere, and is embedded in complex systems. Leadership should uses past error to promote future change. Associate degree education remained too traditionally stagnant for too long, separate from BSN education, in a vertical structure of “upper and lower” division nursing education. Systems thrive at the highest level when all of the functions intersect and interact (Porter-O’Grady & Malloch, 2003, pg. 60). Leaders of ADN education must insist on being included in multi-directional, whole oriented and relational educational change in order to promote future practice.
Transformational leadership states change is generated from the center, out. Recognition of the need for change is the first step. Mildred Montag took the first step and developed AD nursing education in response to the changes at the time. Most change is evolutionary, occurring over a long period. Revolution occurs when many changes at the local level come together to alter prevailing reality, usually when components of a system jointly make enough of a demand for significant change (Porter-O’Grady & Malloch, 2003, p.97). With regard to professional nursing, a revolution would be welcomed by many with regard to educational change, especially involving the BSN entry level into practice issue. Even in this changing health care environment, the blanket change regarding the ADN ability to be licensed as a professional is unlikely to ever occur. Too many programs linked to too many profitable institutions exist. It is unreasonable to think that ADN education is going away completely. Through the processes of organizational leadership and support, transformational change will be able to occur as necessary within the larger system to have associate degree education remain viable and contributory. I project that an imminent change for associate degree education is going to be the requirement for a BSN degree within a ten-year period after initial nursing education at the AD level. Although ADN education will remain valuable from an educational standpoint, and certainly regarding access and the ability of these programs to help to maintain RN populations and stave off more severe shortages than we have now, the requirement of a professional degree has become a necessity in this competitive healthcare environment.
The educational gap between nursing and other health professions continues to grow. Occupational and Physical Therapy require a master’s degree in many states, as well as social work, pharmacy and audiology. In a climate in which strong cooperative relationships and interdisciplinary teamwork are becoming increasingly important, educational differences matter. A Baccalaureate degree is needed if nurses are to maintain equal stature with other health care professionals and participate as full partners in the health care team.
Environmental forces have a large impact on how organizations approach leadership and change. The ongoing debate with regard to BSN level of entry into professional practice is far from resolved. Nurses with varying educational preparation will continue to practice for many years to come, but decisions about the future education of nurses need to be made now.
Political, financial, professional, and legislative concerns have certainly affected ADN programs, as well as their content and scope. As an organization, nursing education at all degree levels must address the changes in the health care system relative to nursing education and nursing practice. Most significantly, this must be done at the ADN level, as it is the largest educator of nurses entering practice at this time. Long-standing traditional educational models, so deeply embedded in nursing history, must be reformed and innovated to provide educational settings that are appropriate for the current state of education and care delivery. Innovation must call into question the nature of schooling, learning, and teaching, and how curricular designs promote or inhibit learning, as well as excitement about the profession of nursing, and the spirit of inquiry necessary for the advancement of the discipline. (NLN, 2003). Nursing educators and nursing service must collaborate to prepare a workforce that can practice in new and rapidly changing environments, at multiple levels of complex care, incorporating a community-based, multidisciplinary approach.
The qualities that enable nurses to succeed in the most difficult of circumstances: determination, persistence, dedication, and resourcefulness can move us forward or pull us back (Nelson, 2002). Associate degree nursing programs have evolved into a strong partner on the front line of nursing education, and with recent changes to curriculum have become an even more valuable asset. With ongoing curriculum assessment, respect and support from nursing leadership, ADN programs will for many years to come continue to facilitate entry into professional practice to a diverse student population. The time has come for nursing leaders to leave old debates behind. Education must move forward to focus on the importance of developing a better educated professional, to their best ability, at all degree levels. In this partnership, we can create a brighter future for nursing.

References:

Brown, E. L. (1948). Nursing for the Future: A report prepared for the National
Nursing Council, NY: Russell Sage Foundation, pp. 174- 198. Committee
on Curriculum (1937). A Curriculum Guide for Schools of Nursing

Lindeman, C.A., (2000). Nursing’s socialization of nurses. Creative Nursing,
4, 3-4

Mahaffey, E., (2002). The relevance of associate degree nursing education: Past,
present, future. Online Journal of Issues in Nursing, 7 (2), 1-12.
Retrieved September 30, 2006 from http://www.nursingworld.org/ojin/topic18/tpc18_2.htm

National Association for Associate Degree Nursing (2006). Position statement of associate degree nursing. Retrieved September 30, 2006 from http://www.noadn.org/all.php?l=about&x=0

National League of Nursing (2003). Innovation in nursing education: A call to reform. Retrieved September 30, 2006 from http://www.nln.org/aboutnln/PositionStatements/innovation.htm

Nelson, M., (2002). Education for professional nursing practice: Looking backward into the future. Online Journal of Issues In Nursing, 7 (3),1-13. Retrieved September 30, 2006 from http://www.nursingworld.org/ojin/topic18/tpc18_3.htm

Porter-O’Grady, T., & Malloch, K. (2003). Quantum Leadership. A Textbook of New Leadership. Sudbury, MA: Jones and Bartlett Publishers

Speziale, H.J., & Jacobson, L., (2003). Trends in registered nurse education programs. Nursing Education Perspectives, 26 (4), 230-234.

5 Comments:

Blogger Karen said...

Hello there. While I was researching for my first paper in my RN to BSN program, I happened upon your article here. Thank you for putting this information out in a public forum.

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Blogger bkdug said...

I also was doing my first paper in my BSN program. I am an RN of twenty years and have embarked on this trek to BSN partly because of mandates from my employer to have it by 2015 or lose my leadership position. Sure hope my new found BSN knowledge gets me through another 20 years.

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