Nursing Education

A Joint Statement on Academic Progression for Nursing Students and Graduates (2012) was made by the Tri-Council for Nursing policy (2010) and endorsed by both community college–registered and university-registered nursing programs with the understanding that both student nurses and practicing nurses need to be encouraged and supported to achieve higher levels of education (AACN, 2012a). What does all this mean to you as a nurse? It means that educational programs as well as employers throughout the country are striving to find ways to make it easier for nurses to further their education. More community colleges and universities are expanding their nursing programs to meet the needs for health care reform. Add to this the advancing computer technology that makes it easier to provide comparable education via distance learning and simulation, and you have an environment that beckons nurses to further their education. Whatever your basic nursing education program, you will now find it easier to advance in your profession. Instead of seeing roadblocks, you will see more doors and windows opened to allow you to advance your education. Are you ready for the challenge?

After struggling to complete your basic educational preparation for nursing, you are probably looking forward to that first paycheck as a registered nurse. The last thing on your mind is returning to school for more education! The purpose of this chapter is not to discuss the issue of entry into practice or to debate which educational program is best. Instead, the goal of this chapter is to help you look at where you are educationally and to offer direction regarding educational opportunities to enhance your career goals and to continue on the path of lifelong learning. Before looking down the path at the variety of educational offerings available to help you meet those goals, let us look at the variety of pathways that lead to the basic educational preparation for an RN.

Which path did you travel? There are three primary paths (diploma, associate’s degree, and bachelor’s degree) that lead to one licensing examination: the National Council Licensure Examination for Registered Nurses (NCLEX-RN^® Examination). These programs usually require a high school diploma or the equivalent for admission. Some of the other paths include master’s and doctoral nursing degree programs, both of which accept college graduates with liberal arts majors. Other paths are becoming more popular, including career ladder programs (from practical nurse to associate degree or baccalaureate degree nurse), concurrent enrollment program (from associate’s degree to bachelor’s degree), accelerated baccalaureate program for non-nursing college graduates, entry-level master’s and doctorate programs, and community college–based BSN programs. Still another source for nursing education is the online option. Online programs are particularly popular for people who are place-bound and unable to travel to distant sites to obtain or continue their education. Some of these programs require brief visits to a campus, whereas others are completely online.

The distribution of the RN population according to basic nursing education is illustrated in Fig. 7.1. In 1980, the diploma education track was the highest level of education for most nursing graduates. Since 1996, there has been a continued increase in the number of RNs receiving their initial preparation in either an associate’s degree or a baccalaureate program. The National Workforce Survey of Registered Nurses (2013) indicates that initial preparation in a diploma program accounted for 18%, the associate’s degree accounted for 39%, and the baccalaureate degree program accounted for 36% of the registered nurses. Furthermore, it is estimated that 3% of RNs received their initial nursing education at either a master’s or doctoral level (Budden et al., 2013, p.7).

Standards and competencies for diploma programs are developed and maintained by the National League for Nursing (NLN) Council of Diploma Programs. Graduates of diploma programs are awarded a certificate and are eligible to take the NCLEX-RN^® Examination for licensure.

Associate degree nursing education has helped to bring about a change in the type of student who enrolls in nursing programs. Before the emergence of associate degree nursing programs, nursing students were traditionally single white females younger than 19 years of age who came from middle-class families (Kaiser, 1975). Associate degree programs attract a more diverse student population that includes older individuals, minorities, men, and married women from a variety of educational and economic backgrounds. Many of these individuals have baccalaureate and higher degrees in other fields of study and are seeking a second career. Along with their maturity, these students bring life experiences that are applicable to nursing. The students tend to be more goal oriented and have a more realistic perspective of the work setting. The community college curriculum is conducive to students who want to attend school on a part-time basis. Graduates of associate degree programs are eligible to take the NCLEX-RN^® examination for licensure.

Dr. Montag’s (1951, 1959) original proposal for the associate degree program to be a terminal degree is no longer applicable. In 1978, the American Nurses Association proposed a resolution regarding associate degree programs that recommended they be viewed as part of the career upward-mobility plan rather than as terminal programs. Recommendation 4 of the recent IOM report, proposing to increase to 80% by 2020 the proportion of nurses with BSN degrees, further supports the need for ADNs to consider advancing their educations (IOM, 2010). The associate degree program has provided students with the motivation to further their education and the opportunity for career mobility. Although many nursing students end their education with an associate’s degree, many others enter the associate degree program with every intention of continuing their nursing education to the baccalaureate level or even further.

During the first 2 years of a traditional baccalaureate nursing program, the student is usually enrolled in liberal arts and science courses with other non-nursing students. It is usually not until late in a student’s sophomore or early junior year that nursing courses are introduced. However, some baccalaureate programs incorporate nursing courses throughout the 4-year nursing curriculum. The emphasis in the baccalaureate nursing program is on developing critical decision-making skills, exercising independent nursing judgment, and acquiring research skills.

The graduate of a baccalaureate program must fulfill both the degree requirements of the nursing program and those of the college. On completion of the program, the usual degree awarded is a Bachelor of Science in Nursing (BSN).

The graduate of a baccalaureate program is prepared to provide health promotion and health restoration care for individuals, families, and groups in a variety of institutional and community settings. Graduates of baccalaureate nursing programs are eligible to take the NCLEX-RN^® examination for licensure. BSN graduates are also prepared to continue their education by moving directly into graduate education. An increasing number of BSN graduates are continuing their nursing education by going directly into graduate programs.

Besides the traditional pathways for entering the nursing profession such as diploma, associate degree, and baccalaureate programs, new pathways are emerging. Entry-level master’s programs, accelerated programs for non-nursing graduates, community college–based baccalaureate programs, and registered nurse degree completion programs for licensed practical nurses and other health care providers are a few of the many options, and it is anticipated that there may be others in the near future.

Just as there are new pathways to enter the nursing profession, there are also new pathways for those nurses who are interested in advancing their nursing education including baccalaureate to doctoral programs, master’s degrees for advanced generalist roles, such as the clinical nurse leader (CNL), as well as the Doctor of Nursing Practice (DNP).

It truly is an exciting time to be in nursing, and there is no one right career pathway for everyone. Each person needs to consider what his or her professional end goal is and what works best for him or her. Is an online program that provides more flexibility in scheduling for family and work obligations the best choice or perhaps a blended or hybrid program? Is the program respected in the nursing community and known for producing great nurse educators, researchers, or advanced practice nurses? Is it an accredited program? Will course work transfer? It is important to ask yourself what you are willing to invest in your education besides the time and monetary expenses.

In assessing the available educational options, one source of information is the American Association of Colleges of Nursing (AACN) website (http://www.aacn.nche.edu/students). There is a section for students that includes information on nursing careers, financial aid, scholarships, and nursing programs. Potential students should also contact individual schools for information regarding their particular programs. After you are ready to begin the application process, you will also find that the Nursing Centralized Application Service (CAS) has simplified the process by providing a service for students to use to apply to nursing programs at participating schools nationwide (http://www.aacn.nche.edu/nursingcas). At the end of this chapter is a complete list of additional relevant websites and online resources for advancing your nursing education.

The career ladder or bridge concept focuses on the articulation of educational programs to permit advanced placement without loss of credit or repetition. There are many variations on this type of program. Multiple-exit programs provide opportunities for students to exit and reenter the educational system at various designated times, having gained specific education and skills. An example is a program that ranges from practical nurse to RN at the associate’s, baccalaureate, master’s, and doctoral levels. A student in such a program may decide to leave the educational system at the completion of a specific level and be eligible to take the licensure examination applicable to that educational level. On termination, the student may choose to work for a while and later return for more education at the next level without having to repeat courses on previously acquired knowledge or skills. Information on the three types of articulation agreements— individual, mandated, and statewide—can be found on the AACN website. Growing numbers of basic nursing education programs within the community college setting are beginning to offer career ladder programs and concurrent enrollment programs, affiliating themselves with upper-division colleges in the area. A student can enter the community college to spend 1 year studying to become a practical or vocational nurse. After a year, the student can decide to stop and take the practical nurse licensure examination or continue and complete the associate’s degree in nursing. At the end of the second year, the student is eligible to take the RN licensure examination and may choose either to exit with an associate’s degree or to attend an affiliated upper-division college to obtain a bachelor’s degree (Fig. 7.2).

The usual length of such programs is 1 to 3 years, depending on the number of course requirements completed at the time of admission to the program. To meet the needs of the returning student, many BSN-completion programs offer flexible class scheduling, which allows the student to continue working while going to school. Another innovation being implemented to address the needs of individuals seeking baccalaureate degrees in outlying geographic areas is telecommunication-assisted studies and Internet courses. More than 400 programs have part of their curriculum online, whereas an increasing number of programs are available completely online (AACN, 2015c).

Nursing education online is a rapidly expanding part of the Internet. In the past these programs were called external degree or distance education; however, more commonly now the programs are considered nursing online education. Online nursing programs are accredited either by the Accreditation Commission for Education in Nursing (ACEN) (formerly the National League for Nursing Accrediting Commission [NLNAC]), National League for Nursing Commission for Nursing Education Accreditation (CNEA), or by the Commission on Collegiate Nursing Education (CCNE), which is an autonomous accrediting agency associated with the AACN. In the undergraduate nursing programs, all students are required to pass specific college-level tests and performance examinations in two components: general education and nursing. On completion of the undergraduate external degree programs, students are eligible in most states to take the RN licensure exam. One of the largest CCNE-approved programs for BSN completion and graduate education is the University of Phoenix online campus.

Graduate nursing education, like other graduate programs, is responding to changes in social values, priorities in the public sector, and student demographics, in addition to technological advances, knowledge development, and maturity of the profession. According to the 2013 National Nursing Workforce Survey of Registered Nurses (NCSBN, 2013), there is an increase in the percentage of nurses who indicate a BSN as their initial education. Approximately 36% reported their initial education as BSN, while 3% reported their initial education as a graduate degree. After initial licensure, 24% of the nurses went on to receive advanced formal education (NCSBN, 2013), indicating that RNs in the workforce are recognizing the need for additional education and are returning to college to further their education either in nursing or nursing-related fields such as public health and health care administration.

Graduate education programs are available on either a part-time or a full-time basis. Graduate programs require a good GPA at the undergraduate level. Prerequisites for most graduate programs are satisfactory scores on the Graduate Record Examination (GRE) or the Miller Analogies Test (MAT). Although an increasing number of graduate programs are waiving the entrance examination requirements, it is strongly recommended that all students, whether they plan to pursue graduate studies or not, take the GRE after completing their undergraduate studies. Taking another test may be the last thing you want to do, but it is much easier to do it now, while the information is current in your mind, than later when you decide that you want to continue your education.

Sure, an advanced degree may not be in your career plans right now, but later, after you have been practicing nursing, you may change your mind. Policy statements from the nursing profession reflect the need for more education in preparation for the changing role of nursing, a result of health care reform. As care delivery moves increasingly from the acute care center to the community setting, there will be an increased need for advanced clinical practice nurses. Nursing programs are already responding to this changing need.

Master’s nursing programs vary from institution to institution, as do the admission and course requirements and costs. The master of science (MS) and the master of science in nursing (MSN) are the most common degrees. The usual requirements for admission include a baccalaureate degree from an ACEN, CCNE, or Commission on Nursing Education Accreditation (CNEA, the accrediting body of the NLN since 2013) accredited program in nursing, licensure as a registered nurse, completion of the GRE or MAT, and a minimum undergraduate GPA of 3.0.

The majority of programs are at least 18 to 24 months of full-time study. Unlike undergraduate students, master’s students usually choose an area of role preparation, such as education or administration, as well as an area of clinical specialization, such as pediatrics or adult health. Some of the more common areas of role preparation include education, administration, case management, health policy/health care systems, informatics, and the increasingly popular advanced clinical practice roles.

An evolving area of role preparation is that of the clinical nurse leader (CNL). The CNL role is different from the role of manager or administrator. The CNL is prepared at the master’s level as a generalist managing the health care delivery system across all settings. Any person interested in the CNL role is encouraged to read the Competencies and Curricular Expectations for Clinical Nurse Leader Education and Practice (AACN, 2013) found on the AACN website. Upon completion of a formal CNL program, a graduate is eligible to take the CNL Certification Examination. In Fall 2014/Winter 2015, 109 of 229 nurses taking the CNL certification exam passed, for a pass rate of 68% (AACN, 2015a).

Areas of specialty within the master’s nurse practitioner programs include family, acute care, pediatric, psychiatric, and adult-gerontology nursing practice. There are more family nurse practitioner programs than any other program. The AACN supported the position of the practice doctorate (DNP) as the entry level for the advanced practice registered nurse (APRN) by the year 2015 (AACN, 2015d). Although there is a growing number of DNP programs, less than 25% of the schools with nurse practitioner programs have met this goal (Martsolf et al., 2015). An excellent resource for nurses who are considering becoming an APRN can be found at the American Association of Nurse Practitioners website http://www.aanp.org/education/student-resource-center/planning-your-np-education.

The National Council of State Boards of Nursing APRN Advisory Committee and leading professional nursing organizations formed an APRN Consensus Work Group to work toward establishing clear expectations for LACE (licensure, accreditation, certification, and education) for APRNs. This work group has been meeting for several years, and in July 2008 the landmark document, Consensus Model for APRN Regulation: Licensure, Accreditation, Certification, & Education, was finalized. This document will be used to shape the future of APRN practice across the nation and to allow APRNs to practice to the full extent of their education. APRNs will be educated in one of the four roles, certified registered nurse anesthetist (CRNA), certified nurse-midwife (CNM), clinical nurse specialist (CNS), or certified nurse practitioner (CNP), and in at least one of six population foci: family/individual across the lifespan, neonatal, pediatrics, adult-gerontology, women’s health/gender-related, or psych/mental health. All four of these roles will be given the title of advanced practice registered nurse (APRN). It is important for all potential APRNs to read this document, because it will change how APRNs are educated in the future (www.aacn.nche.edu/education-resources/APRNReport.pdf). See Table 7.1 for typical educational preparation and responsibilities of various advanced practice nurses.

According to The U.S. Nursing Workforce: Trends in Supply and Education report (2013), there has been a rapid growth of 69% in the number of nurse practitioner graduates from 7261 in 2001 to 12,273 in 2011. During that same time period, there also was a 111.1% increase in CRNAs from 1159 to 2447 graduates, although CNMs have not experienced as much of an increase from 285 in 2007 to nearly 400 in 2011.

In the more traditional master’s degree programs, the student takes the courses required for the degree and then, depending on institutional requirements, may also be required to take a written or oral comprehensive examination or write a thesis, or both. There are also nontraditional models that include outreach programs, summers-only programs, and programs for RNs who have bachelor’s degrees in other fields.

Advances in technology have also made it possible for graduate programs to become more creative in the way courses are being offered. It is now possible for students to obtain all or part of their course offerings by means of the Internet, distance learning, computer-based programs, and teleconferencing. This flexibility makes it easier for students in rural communities and part-time students to obtain advanced degrees.

After you have decided on a master’s degree, there are several resources available online, such as the Peterson’s Guide (www.petersons.com), to help you find the right school. Consider all the options, and do your homework. If you are considering an advanced practice degree, be sure to check with the Board of Nursing for the state in which you reside to see what the requirements are to be recognized as an APRN in your state. Believe it or not, the requirements are not the same for every state. After all, if you are going to expend the time, energy, and finances to obtain a graduate degree, you want to get the most from it.

Until recently, there were two basic models of doctoral education in nursing: the academic degree, or Doctor of Philosophy (PhD), and the professional degree, or Doctor of Nursing Science (DNS, DSN, or DNSc). For either of these degrees, you must first have a master’s in nursing. Nurses have other doctoral degree options available to them, such as the Doctor of Education (EdD), the Doctor of Public Health (DrPH), the Doctor of Philosophy (PhD) in a discipline other than nursing, the nontraditional external degree doctorate, and the practice-focused Nurse Doctorate (ND), which was initiated as an entry-level degree.

In October 2004, the AACN published a position statement on the practice doctorate in nursing (DNP). The term practice doctorate would be used instead of clinical doctorate, and the ND degree would be phased out. The DNP would become the educational preparation for all advanced practice nurses. This move toward a DNP is to take place throughout a 15-year period. There are currently 243 DNP programs with more than 70 additional nursing schools that are considering starting a DNP program (AACN, 2014a).

Is there an institution available to you that offers a doctorate in nursing, or would you have to consider moving? What are your career and professional goals? Do you want to teach? The PhD is considered the research-focused degree. It prepares an individual for a lifetime of intellectual inquiry and has an increased emphasis on postdoctoral study. In contrast, the DNP is viewed as the practice-focused degree. The goal of this program is to prepare an advanced practitioner for the application of knowledge with an emphasis on research. The original intent of the DNS was to prepare nurses to perform clinical research. The August 2015 Report from the Task Force on the Implementation of the DNP (AACN) is an excellent resource for those considering a DNP.

At the end of this chapter are additional relevant websites and online resources for continuing your nursing education.

In nursing, the educational credentials that an individual holds indicate not only academic achievement but also the attainment of a minimum level of competency in nursing skills. An ADN, a diploma in nursing, or a baccalaureate degree in nursing (BSN or BS) represents academic achievement. After academic preparation and successful completion of the NCLEX, you will have a legal credential—your nursing license—that permits you to practice as an RN. Additional nursing credentials may reflect practice in special areas, such as Critical Care Registered Nurse (CCRN) and Certified Addictions Registered Nurse (CARN).

Foreign nurse graduates who want to practice nursing in the United States must contact the board of nursing in the state in which they want to practice to obtain licensure, because each state controls its own requirements for licensure. The state’s board of nursing will review the candidate’s nursing education and determine requirements needed to obtain a license in that respective state. Most states require that foreign nurses take the Committee on Graduates of Foreign Nursing Schools (CGFNS) examination before the NCLEX-RN^® examination. This examination determines proficiency both in nursing and the English language, thus assisting in the prediction of success on the NCLEX-RN^® examination. All foreign graduates, regardless of licensure in their home countries, must successfully complete the NCLEX-RN^® examination.

The movement toward certification in nursing practice areas has grown significantly within the past 40 years. In 1946, credentialing was first required for entry into practice as a nurse anesthetist (i.e., CRNA). Twenty-five years later, nurse-midwives followed suit, needing certification through the American College of Nurse Midwives as an entry-level credential.

Since the establishment of the first certification program by the ANA in 1973, certification is the credential that provides recognition of professional achievement in a defined functional or clinical area of nursing practice. Credentials, such as professional certification, are the stamps of quality and achievement to communicate professional competence. The process of becoming certified engages a full circle of accountability to patients and families, along with professional colleagues. There are over 33 areas of specialty certification available from the ANCC (2014). In addition, magnet hospitals are more likely to have nurses that are specialty certified (McHugh et al., 2013).

Accreditation is a peer-review and voluntary process. Member schools for the peer-review evaluation process support the use of standards and criteria. The process of accreditation is similar for both accrediting organizations—the CCNE and the ACEN. The National League for Nursing Commission for Nursing Education Accreditation (CNEA) is a newly formed accrediting body that will begin the process of accrediting all types of nursing programs (PN/VN, diploma, associate’s, bachelor’s, master’s, post-master’s certificate, and clinical doctorate [DNP]) in 2016. The process of accreditation for NLN CNEA is similar to CCNE and ACEN.

Why should you be concerned whether the nursing program you are attending, or thinking about attending, is accredited? Accreditation assures you, the student, and the public that the program has achieved educational standards over and above the legal requirements of the state. It guarantees the student the opportunity to obtain a quality education. Accreditation is strictly a voluntary process. The U.S. Department of Education approves the professional association that is allowed to accredit nursing schools. Until 1997, the National League of Nursing (NLN) was the only accrediting body for nursing programs. In 1997 the National League for Nursing Accrediting Commission (NLNAC) was established, and responsibility for all accrediting activities was transferred to this new independent subsidiary. In 2013 the name was changed to ACEN.

Some graduate nursing programs require completion of an ACEN or CCNE-approved undergraduate program as a prerequisite for admission to their master’s or doctoral program. Both the ACEN and CCNE publish annually an official complete list of accredited programs. Accreditation becomes a major concern as more and more courses and programs are offered by means of distance learning.

With different organizations offering accreditation to schools of nursing, it was difficult for schools of nursing to develop competency statements that were consistent. Rather than listing competency statements for three levels of nursing, the competency statement accepted by the 1996 annual meeting of the NCSBN is presented. According to the NCSBN, “Competence is defined as the application of knowledge and the interpersonal, decision-making and psychomotor skills expected for the practice role, within the context of public health, safety and welfare” (NCSBN, 1996, p 47). The NCSBN continues to work on the concept of continued competence as it explores its regulatory role.

The promotion of competency requires a collaborative approach; it involves the individual nurse, employers of nurses, nursing educators, and the regulating board of nursing. The roles of each of these in competence accountability are described in Fig. 7.3.

These changes mean that nurse educators will have to address even further the needs of the adult learner. More programs will be needed that permit part-time study and allow students to work while attending school. One option may be for more night or weekend course offerings. There will continue to be a need for emphasis on remedial education such as developmental courses in math, English, and English as a second language. The diversity in the student population means diversity in learning rates, which may be addressed with more self-paced learning modules (Fig. 7.4).

The ability to earn more in the clinical and private sector is also attracting potential nurse educators to leave academia (AACN, 2015e). The American Academy of Nurse Practitioners (AANP) gives the average salary of a nurse practitioner as $91,310, whereas the AACN reported that master’s-prepared faculty had an annual income of $73,633. In addition, the shortage of nursing faculty was the primary reason that 13,444 qualified master’s program applicants and 1844 qualified doctoral program applicants were not accepted into their respective graduate programs (AACN, 2014c).

Nurses who have career plans and career goals will see the future trends in health care as a challenge and an opportunity for growth in roles such as case manager, independent consultant, nurse practitioner, nursing educator, nursing informatics, policy maker, and entrepreneur. In contrast, nurses without career goals may find themselves displaced or obsolete. There has never been a more exciting time to be entering the profession of nursing than right now. Opportunities in nursing are wide open to those with the sensitivity and the creativity to embrace the future.

I challenge you to get out a piece of paper and put your educational goals down in writing. After you do this, set some deadlines for when you want to achieve these goals. Place this piece of paper in a prominent place where you will see it every day.