Nursing Education

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Pathway to career goals.
After completing this chapter, you should be able to:
• Compare the various types of educational preparation for nursing.
• Describe the educational preparation for a graduate degree.
• Compare nontraditional pathways of nursing education.
• Describe the purpose of nursing program accreditation.
• Set personal educational goals for yourself.

Education should not be a destination—but a path we travel all the days of our lives.

Anonymous

Unless we are making progress in our nursing every year, every month, every week, take my word for it we are going back.

Florence Nightingale

What an exciting time to be a nurse. Never before have the doors been so open for nurses to further their education. The Institute of Medicine (IOM) report, The Future of Nursing: Leading Change, Advancing Health (2010), set forth recommendations that would change the future of nursing and nursing education in ways never dreamed possible. Recommendation 4 discussed increasing the number of nurses with baccalaureate degrees to 80% by the year 2020, whereas Recommendation 5 proposed to double the number of nurses with doctorate degrees by 2020. Recommendation 6 explained the need for nurses to engage in lifelong learning. Based on these three recommendations alone, educational systems across the country began diligently brainstorming and working collaboratively to address these goals.
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).

Path of Diploma Education

What Is the Educational Preparation of the Diploma Graduate?

The current preparation of a diploma nurse varies in length from 2 to 3 years and takes place in a hospital school of nursing. This type of program may be under the direction of the hospital or incorporated independently. The diploma program may include general education subjects such as biology and physical and social sciences, in addition to nursing theory and practice. Graduates of diploma programs are prepared to function as beginning practitioners in acute, intermediate, long-term, and ambulatory health care facilities. Because there is a close relationship between the nursing school and the hospital, graduates are well prepared to function in that institution. On graduation, many diploma graduates are employed by that same hospital and therefore may experience an easier role transition.
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FIG. 7.1 Type of nursing degree/credential that qualified respondents for first U.S. nursing license. (Adapted from Budden, J., Zhong, E., Moulton, P., & Cimioti, J. (2013). Highlights of the national workforce survey of registered nurses. Journal of Nursing Regulation, 4(2), 5–13.)
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.

Path of Associate Degree Education

What Is the Educational Preparation of the Associate Degree Graduate?

The current preparation of an associate degree nurse usually begins in a community college, although some programs are based in senior colleges or universities. The associate degree program lasts 18 to 21 school calendar months. The NLN recommends that associate degree nursing programs consist of 60 to 72 semester credits (90 to 108 quarter credits) and that there is a balanced distribution of no more than 60% of the total number of credits allocated to nursing courses (NLN, 2001). In some programs, the student must complete the general education and science course requirements before beginning the nursing courses. At the end of the program, the student receives an associate’s degree in nursing (ADN) or Associate in Applied Science (ASN or AAS).
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.

Path of Baccalaureate Education

In this discussion, only the “generic” baccalaureate programs are addressed. A generic student is one who enters a baccalaureate nursing program with no training or education in nursing. A traditional generic baccalaureate program includes lower-division (freshman and sophomore) liberal arts and science courses with upper-division (junior and senior) nursing courses. RNs entering baccalaureate programs are discussed later in this chapter.

What Is the Educational Preparation of the Baccalaureate Graduate?

The current preparation of a baccalaureate nurse is 4 to 5 years in length (120 to 140 credits) and emphasizes courses in the liberal arts, sciences, and humanities. Approximately one-half to two-thirds of the curriculum consists of non-nursing courses. To qualify for a baccalaureate program, the student must first meet all of the college’s or the university’s entrance requirements. Usual entrance requirements include college preparation courses in high school (e.g., foreign language, advanced science, and math courses) and a specified cumulative grade-point average (GPA). Most colleges also require a college entrance examination such as the Scholastic Aptitude Test (SAT) or the American College Test (ACT).
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.

Other Types of Nursing Education

What Are the Other Available Educational Options?

In the 1960s, baccalaureate programs made it very difficult for the RN to return to school to earn a baccalaureate in nursing. Most of the time, these nurses found themselves receiving no credit for their past education or experience. A resolution was passed in 1978 by the American Nurses Association (ANA) that helped to change this philosophy. This resolution urged the creation of quality career-mobility programs with flexibility to assist individuals desiring academic degrees in nursing. Following the IOM report, developers of nursing educational programs have been challenged to rethink nursing education. The Tri-Council’s 2010 statement for access to nursing education for all nurses, providing for a seamless academic progression (AACN, 2012a), has further widened the pathways toward advanced education. It is anticipated that nursing education will be transformed to create a health care workforce that is better prepared in ways that can only be imagined at this time.
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 (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 (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).

What Is a BSN/MSN Completion Program?

A BSN-completion program is a baccalaureate program designed for students who already possess either a diploma or an associate’s degree in nursing and hold a current license to practice as an RN. Depending on the part of the country, these programs may also be known as RN baccalaureate (RNB) programs, RN/BSN programs, baccalaureate RN (BRN) programs, two-plus-two programs, or capstone programs. There are more than 679 BSN-completion programs. In addition to the BSN-completion programs, 209 RN-to-master’s degree program options are available, and there are 28 additional nursing schools planning to implement a BSN and 31 planning to implement an MSN completion program in the near future (AACN, 2015c). In most of these programs, nurses receive transfer credit in basic education courses taken at other institutions plus either some transfer credit for their previous nursing courses or the opportunity to receive nursing credit by passing a nursing challenge examination.
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).

What Is an External Degree Program?

In the early 1970s, the external degree program was a nontraditional program that allowed a student to gain credit, meet external degree requirements, and obtain a degree from a degree-granting institution without attending face-to-face classes. One of the earliest external degree (or distance education) programs was offered through the New York Board of Regents external degree programs (REX), which is now Excelsior College. External degree programs may offer an ADN as well as a BSN and a master of science in nursing (MSN). These programs are designed to allow individuals to obtain degrees in nursing without leaving their jobs or their communities.
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FIG. 7.2 What are other available education programs?
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.

Online (Web-Based) Programs

More and more traditional colleges and universities are offering courses and even entire programs through the Internet. In fact, it is possible to earn ADN, BSN, master’s, and doctoral degrees in web-based or web-enhanced formats. At times, it can be confusing and overwhelming to find the right programs. Several sites are available to help users locate specific web-based or web-enhanced courses (and course descriptions). See the Internet resources listed on this book’s Evolve website. It is important to take into consideration the cost not only of an online program but also of out-of-state tuition when considering which program is the best fit for your career goals.

Proprietary Nursing Schools

In addition to the colleges and universities that are offering these types of courses, an influx of new proprietary nursing programs has emerged. A proprietary nursing school is a for-profit school with a nursing program. Many proprietary schools have nursing programs in more than one state. Since not all nursing boards have the same requirements for licensure, it is important to review the requirements in your state to make sure that you will be eligible for licensure once you complete the program. A prospective student should also make sure that the program is accredited and ask about the pass rates on the NCLEX examination for their graduates.

What Is an Accelerated Program?

Accelerated programs are offered at both the baccalaureate and master’s degree levels; they are designed to build on previous learning to help a person with an undergraduate degree in another discipline make the transition into nursing. In 2013, there were 293 accelerated baccalaureate programs and 62 accelerated master’s programs available at nursing schools nationwide. In addition, 13 new accelerated baccalaureate programs are in the planning stages, and 9 new accelerated master’s programs are also taking shape (AACN, 2015b).

Nontraditional Paths for Nursing Education

What About a Masters Degree as a Path to Becoming an RN?

MSN programs are particularly attractive to the growing number of college graduates who decide later in life to enter nursing. Generally, the program is 24 to 36 months long. Upon graduation these students are expected to demonstrate the same entry-level competencies in nursing as baccalaureate graduates. MSN graduates from these programs are then eligible to take the NCLEX-RN® examination. Currently, there are 62 entry-level master’s programs in the United States (AACN, 2015b).

What About a Doctoral Path to Becoming an RN?

The last and least common path leading to the RN licensure examination is the doctoral degree, where the graduate has a non-nursing baccalaureate degree. This program began in 1979 at Case Western Reserve University in Cleveland, Ohio. Rush University in Chicago initiated a similar program in 1988, and the University of Colorado began one in 1990 (Forni, 1989). These programs, such as the one at the University of Texas at Austin, provide basic nursing courses, along with advanced nursing courses. Upon completion, the graduate is eligible to take the NCLEX-RN® examination. There are currently 81 baccalaureate to research-focused doctoral programs (PhD) and 153 practice-focused baccalaureate to doctoral programs (DNP) (AACN, 2014a).
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