Creating New Models In Nursing Education The evolution of nursing education has undergone significant changes over the past century, particularly in response to societal needs and emerging healthcare demands. This transformation has led to the development of various models of nursing education, including the Associate Degree in Nursing (ADN) and the Bachelor of Science in Nursing (BSN). Each model reflects different approaches and philosophies to nursing education, each with its own set of historical contexts, controversies, and outcomes.
The History of Associates Degree Nursing Education
The Associate Degree in Nursing (ADN) emerged in the mid-20th century, during a period marked by critical shortages in the nursing workforce, especially following World War II. Isabel Stewart, a pioneer in nursing education, noted in 1943 that there were significant efforts to redesign traditional diploma-based nursing education programs, and these efforts included experimenting with new models, such as the ADN. The ADN was proposed as a response to the growing demand for nurses while balancing the need for efficiency and cost-effectiveness in training (Stewart, 1943).
The Ginzberg Report of 1949 further bolstered the development of ADN programs by suggesting that a two-year nursing program could serve as a more efficient and economical alternative to the four-year baccalaureate programs. Ginzberg argued that not all nurses needed a baccalaureate degree to provide competent patient care; a shorter, more focused program could adequately meet the healthcare needs of the population by producing nurses capable of delivering safe and effective care (Ginzberg, 1949). This premise laid the foundation for the ADN model, which was formalized by Mildred Montag in 1951.
Montag proposed that two-year associate degree programs, offered in community colleges, could prepare registered nurses (RNs) to function as semi-professionals in healthcare settings. This approach aimed to provide a quick response to the nursing shortage by developing nurses with sufficient skills and judgment to provide patient care, while not necessarily equipping them with the full range of competencies expected of baccalaureate-prepared nurses. Montag’s further research in 1959 suggested that ADN-prepared nurses were performing at a level comparable to that of baccalaureate-prepared nurses in clinical settings, particularly in bedside nursing (Montag, 1959).
By the 1960s, the ADN model had gained popularity due to its focus on learning rather than merely fulfilling service needs for hospitals. The ADN’s accessibility and affordability through community colleges made nursing education more inclusive, offering an opportunity to many who otherwise could not access baccalaureate nursing programs. For the first time, individuals from diverse socioeconomic backgrounds could pursue a career as a registered nurse, thus broadening the nursing workforce (Hassenplug, 1965).
Emerging Controversies in Associate Degree Nursing Education
Despite the advantages and success of ADN programs, they faced significant controversies and criticism. In 1965, the American Nurses Association (ANA) issued a position paper asserting that all individuals licensed to practice nursing should be educated at the baccalaureate level within institutions of higher learning, such as universities. This stance equated professional nursing with baccalaureate education and implied that ADN-prepared nurses were less qualified to perform as RNs unless separate licensing standards were created for them (ANA, 1965).
The ANA’s position sparked a debate that has persisted for decades. Critics argued that ADN-prepared nurses were being unfairly marginalized, despite studies indicating that, in many clinical settings, ADN and BSN-prepared nurses performed similarly. Research from the 1980s and 1990s showed minimal differentiation in the quality of care provided by nurses prepared in ADN programs compared to those from BSN programs, especially in hospital environments (Bullough, Bullough, & Soukup, 1983; Haase, 1990).
However, studies from the 2000s began to highlight differences between ADN and BSN-prepared nurses. Current research indicates that BSN-prepared nurses are linked with better patient outcomes, are more likely to be hired by hospitals, and are more prevalent in “magnet” hospitals known for nursing excellence (Graf, 2006). These findings suggest that while ADN programs will likely continue to play an essential role in nursing education, there is an increasing emphasis on programs that facilitate ADN-prepared nurses in obtaining higher degrees, such as the BSN or advanced nursing degrees.
Understanding Associate Degree Nursing Education Today
The ADN remains a viable and popular pathway to becoming a registered nurse (RN). According to the US Department of Health and Human Services’ Health Resources and Services Administration (2006), more than half (52.8%) of aspiring nurses enroll in ADN or Associate Degree in Science (ASN) programs. These programs are highly regarded for their feasibility, providing a relatively quick and cost-effective entry into the nursing profession, thus helping to address the ongoing nursing shortage (Health Resources and Services Administration, 2006).
ADN programs also have a significant role in preparing graduates for various nursing roles, including advocacy, leadership, professional engagement, lifelong learning, and evidence-based practice. Faculty members within these programs are committed to ensuring that graduates are well-prepared to enter the workforce as competent RNs (National Organization for Associate Degree Nursing [N-OADN], 2006).
Nevertheless, there is a relatively low progression rate from ADN to BSN or higher degrees, with only 20.7% of ADN-prepared nurses advancing their education (US Department of Health and Human Services, 2006). This statistic underscores the need for more robust strategies and incentives to encourage ADN-prepared nurses to pursue further education, thereby enhancing their professional development and improving patient care outcomes.
Bachelor of Nursing Education: The Shift Toward University-Based Programs
The push for baccalaureate nursing education gained traction in the early 20th century, spearheaded by leaders like Dr. Richard Olding Beard, who was heavily influenced by Florence Nightingale’s vision for nursing education. Nightingale advocated for a nursing education model that operated outside the confines of hospitals and the prevailing medical model (Stewart, 1943). Her approach aimed to avoid the pitfalls of apprenticeship-based learning, which often limited nursing students’ education to the needs of the hospital and left them underprepared in the foundational principles of nursing care.
Nightingale emphasized that nursing education should include rigorous instruction in anatomy, physiology, surgery, chemistry, nutrition, sanitation, and professionalism. She advocated for learning under the guidance of experienced nurses who were dedicated to the profession and promoted financial independence from hospitals for nursing schools (Stewart, 1943). This philosophy was initially embraced in the United States by institutions like the Bellevue School of Nursing in New York in 1873, but resistance soon emerged. Opponents argued that nurses did not need extensive education, that hospitals relied on nursing students for labor, and that funding independent nursing schools was unrealistic.
Despite significant support for diploma-based nursing education, proponents of baccalaureate education continued to champion the university-based model. Ethel Gordon Bedford Fenwick, the founder of the International Council of Nurses, argued in 1901 for the need to educate nurses in universities to produce practitioners who could address health issues on local, national, and international scales (Fenwick, 1901). Similarly, Dr. Beard worked to shift nursing education toward higher education institutions, convincing the University of Minnesota to initiate its first nursing program in 1909. While this program initially resembled diploma programs, it marked the beginning of a gradual movement toward baccalaureate education for nurses.
The Evolution and Advocacy for University-Based Nursing Education
The movement toward baccalaureate education was driven by the need for a more scientifically and academically grounded nursing workforce. Supporters like Dr. Beard and others recognized that to elevate the status and competency of nursing as a profession, nursing education needed to be rooted in universities. These institutions could provide a more comprehensive and interdisciplinary curriculum, which was crucial for preparing nurses to meet the increasingly complex demands of modern healthcare.
University-based nursing education offered several advantages over the traditional diploma model. It allowed for a broader and more diverse range of academic subjects, fostering critical thinking and analytical skills that are essential in clinical practice. Additionally, university programs could integrate public health principles, leadership training, and advanced practice skills, which were often lacking in diploma programs that focused primarily on bedside care.
By the mid-20th century, the push for baccalaureate education was gaining momentum. The ANA’s 1965 position paper called for the baccalaureate degree to become the minimum standard for entry into professional nursing practice. This shift was seen as necessary to align nursing with other healthcare professions that required higher education credentials for entry-level practice.
Conclusion: A Continuing Evolution in Nursing Education
The evolution of nursing education reflects the profession’s ongoing adaptation to changing societal needs, scientific advancements, and the complexities of modern healthcare. While the ADN model continues to play a crucial role in addressing the nursing shortage and providing accessible entry points into the profession, there is a growing emphasis on baccalaureate and higher education as the gold standard for professional nursing practice.
As the healthcare landscape evolves, nursing education must continue to adapt, incorporating new models, innovative teaching methods, and strategies to support lifelong learning. By doing so, the profession can ensure that nurses are well-equipped to meet the diverse needs of patients, communities, and the broader healthcare system, both today and in the future.