Sister Rosemary Donley, SC, PhD, APRN, BC-ANP, FAAN
Sister Mary Jean Flaherty, SC, PhD, RN, FAAN
Updated article and ANA online CE contact-hour credit sare available on this article.
The mission of this article is to turn the clock back and compare the nursing education scene of the 1960s to contemporary educational practice. Specifically, the authors will re-examine their 2002 OJIN article, a discussion of the rationale and impact of the American Nurses’ Association’s 1965 statement on the education of nurses, in light of the recent statements of the American Association of Colleges of Nursing (AACN, 2003, 2004). As in the earlier article, the sentinel event examined is the enduring impact of the American Nurses Association’s First Position Paper on Education for Nursing (ANA, 1965). The authors conclude this article by asking: Will nursing’s most recent proclamations (AACN), which shift attention to advanced practice and raise the educational bar, affect the balance of power in healthcare?
Citation: Donley. R.; Flaherty, M.J. (April 30, 2008); "Revisiting the American Nurses Association’s First Position on Education For Nurses: A Comparative Analysis of the First and Second Position Statements on the Education of Nurses " OJIN: The Online Journal of Issues in Nursing Vol. 13 No. 2.
Editor’s Note: This article is an update of an article previously published in OJIN on May 31, 2002 by Donley & Flaherty entitled, Revisiting the American Nurses Association’s First Position on Education For Nurses.
Key Words: American Nurses Association First Position on Nursing Education, American Association of Colleges of Nursing Position Statement on the Practice Doctorate in Nursing, nursing education, entry into practice, nursing autonomy, financial control, nature of nursing, nursing supply
The mission of this article is to turn the clock back and compare the nursing education scene of the 1960s to contemporary educational practice. The mission of this article is to turn the clock back and compare the nursing education scene of the 1960s to contemporary educational practice. Specifically, the authors will re-examine their 2002 article, a discussion of the rationale and impact of the American Nurses Association (ANA) 1965 statement on the education of nurses, in light of the recent statements of the American Association of Colleges of Nursing (AACN, 2003, 2004; Donley & Flaherty, 2002). The October, 2004 pronouncement of the AACN, public and professional concern with safety and the quality of patient care (Kohn, Corrigan, & Donaldson, 2000), the serious nursing and nurse faculty shortages (Yordy, 2006), and the recent statement of the Institute of Medicine (2003) about the preparation of health professionals have prompted the authors to re-look at perennial questions about the educational preparation of nurses.
As in the earlier article, the sentinel event to be examined is the enduring impact of the American Nurses Association’s First Position on Education for Nursing, published in December 1965 (ANA, 1965). Although the educators who authored the 1965 position paper were concerned with pre-service education, it seems appropriate to take another look at this first position statement on nursing education as the profession contemplates the implementation of another entry document, which establishes the doctor of nursing practice as the credential for the advanced practice of nursing.
...it seems appropriate to take another look at this first position statement on nursing education as the profession contemplates...
another entry document, which establishes the doctor of nursing practice as the credential for the advanced practice of nursing. The 1965 document divided the health and nursing community by taking a stand on the level of education that the nurse should attain before she/he entered practice: “Education for those who work in nursing should take place in institutions of learning within the general system of education” (Committee on Nursing Education, 1965, p. 107). In times of shortage, there is usually a call to reduce educational requirements and to change licensing and accreditation standards. Early responses to the millennial nursing shortage illustrated this pattern. In the spring of 2002, the AACN responded to a public relations campaign that claimed that the AACN sought to close associate degree (AD) programs; deny the RN license to AD graduates, and limit their entry into practice (P. Bednash, personal communications, May 1, 2002; AACN, 2002a). The campaign appeared to be directed toward forcing the Commission on Collegiate Nursing Education (CCNE), the accreditation arm of the AACN, to change its mission and accredit associate degree programs in addition to baccalaureate and higher degree programs (P. Bednash, personal communication, May 1, 2002). However, it soon became apparent that the AACN had a different agenda, one that transcended traditional entry into practice issues. In 2003 and 2004, the AACN announced two radical propositions to transform graduate education: the Clinical Nurse Leader (CNL) and the Doctor of Nursing Practice (DNP). These proposals did not substantively address entry level programs or evaluate the merits of specialty education at the master’s level, an educational pathway begun in the 1950s that had gained acceptance within the nursing and health communities. However, when the leaders of the organization that represents the interests of clinical nurse specialists, the National Association of Clinical Nurse Specialists (NACNS) (2004), examined the rationale for the CNL program, they failed to find evidence that established the need for this new level of nursing education and practice.
While the writers of the first position paper on education for nurses, the Committee on Nursing Education of the ANA, envisioned an orderly transition to an educational system with two levels – technical and professional, the AACN leadership group set an actual date, 2015, when the transition, at least for the DNP programs, would be accomplished (AACN, 2004). They proposed that baccalaureate- or master’s-prepared nurses, who wished to study for advanced practice roles, as midwives, nurse anesthetists, clinical nurse specialists, or nurse practitioners, should enroll in DNP programs. Nurses who envisioned research-oriented careers should pursue the traditional PhD program of study (AACN, 2004). The DNP was presented as the clinical path into specialized advanced practice. The curriculum would be structured to allow for the entry of either baccalaureate or master’s degree graduates. Several arguments presented in support of this new DNP plan of study included: recognition of the growth in knowledge and the complexity of care, appreciation for public concern with safety and the quality of care, acknowledgement that contemporary care requires the enlightened work of a professional health team, and expression of the desire to stop the proliferation of a variety of doctoral practice degrees in nursing (AACN, 2006a).
Associate degree (AD) or Bachelor of Science in Nursing (BSN) degree nurses who wished to prepare for clinical leadership and management roles, at any level of practice, but perhaps most especially in acute care hospitals would be advised to enter a new, master’s-level, graduate program and study to be CNLs . This course of study would prepare graduates to be generalists, not specialists or advanced practice nurses (AACN, 2003). The AACN (2003) advised that the successful implementation of CNL programs was dependent upon active engagement of clinical partners, especially acute care hospitals, where the clinical leadership practica and internships would take place.
In 1965, educational advice had taken another form. The Committee on Nursing Education of the ANA recommended that in the future, all nursing education, technical and professional, would be based in colleges or universities. Persons interested in technical practice would enroll in junior or community colleges and earn associate degrees in two-year programs: “…minimum preparation for beginning technical nursing practice at the present time should be associate degree education in nursing” (Committee, 1965, p.108). Those interested in professional nursing would enroll in four-year programs in colleges or universities: “…minimum preparation for beginning professional nursing practice at the present time should be baccalaureate degree education in nursing” (Committee, 1965, p. 107). Education for assistants in health service occupations would take place in short term, intensive, pre-service programs in vocational-technical schools rather than through on-the-job-training programs. Colleges and universities were challenged to expand their programs, and hospitals were encouraged to work with junior and senior colleges in planning for the transition of their nursing programs. The authors of the 1965 position statement also recommended that associate degree programs replace practical nursing programs. The cost of nursing education would be borne by all tax payors not just those who were hospitalized in institutions that operated schools of nursing.
By 1965, hospitals had been engaged in nursing education for almost one hundred years. By the mid sixties, most diploma students spent between 24 to 30 hours a week in clinical experiences, which included evening, night, and weekend assignments. Because the curriculum focused on illness, students learned to meet the needs of ill patients, to work with the hospital’s nursing and ancillary staff, and to accommodate to the hospitals’ medical and nursing routines. Hospital schools produced a steady stream of new graduates whose transition from senior students to new graduates was seamless. New graduates required little orientation and many graduates practiced in the settings where they completed their training.
...it is interesting to see deans of nursing reach out again to hospital nursing colleagues and to hospital management teams. The AACN proposal for the education of the CNL envisions a similar, co-operative relationship between hospitals and schools of nursing. In their proposal, hospital nurses would supervise CNL students during their internships, and hospitals would be called upon to provide tuition and other support for these students. Some schools of nursing have also made arrangements, often called bridge programs, to enable hospital nursing staffs to provide clinical education to students, especially their senior students, as a way of preparing them for practice (Olson, et al., 2001). While no one has compared the CNL initiative to diploma education in the mid- twentieth century, it is interesting to see deans of nursing reach out again to hospital nursing colleagues and to hospital management teams.
The impact of the 1965 Medicare program and its funding provisions for hospital-based education were not factored into discussions of ANA’s 1965 position statement. The thirteen authors of the 1965 position statement did not refer to then current Congressional activity to pass some form of national health insurance or address how improving access to care for older or poor people would affect nursing education and nursing practice (ANA, 1965). This is interesting because the legislation that we know as Medicare and Medicaid was on the agenda of the Congress of the United States when the ANA’s Committee on Education was drafting its document. The rationale underlying the first ANA position paper considered the new role of government, especially its investment in nursing education and manpower training, the changing pattern of education in the United States, the increasing availability of collegiate education to women, and the expansion and impact of science and technology on healthcare (ANA, 1965).
The AACN (2004), at least in its discussion of the doctor of nursing practice, noted that most members of the health team were better educated than the nurse members. Without quoting the data from the Department of Health and Human Services (DHHS) (DHHS, 2006) on the levels of educational preparation for the approximately 2.9 million nurses (only 34.2% of whom held the BSN, while 13 % had graduate degrees), the AACN discussed the educational preparation of pharmacists and physical therapists arguing that nurses, who lack the educational credentials of their peers, are not taken seriously and are not compensated adequately for their contributions to health service delivery and patient outcomes (Accreditation Council for Pharmacy Education, 2007; American Physical Therapy Association (APTA) Vision 2020, 2007; AACN, 2004). The drafters of the AACN (2004) document did clearly recognize that federal and private insurance reimbursement for service was a driving force in nurses’ seeking advanced degrees and certification.
The 1965 statement reflected historical recommendations. A decade earlier, Roberts (1954) had described the struggles to strengthen nursing education through the publication of curriculum guides and a national effort to accredit schools of nursing. Esther Lucille Brown (1948) had observed that the extant system of nursing education was totally inadequate to meet the needs of society for nursing care, that professional schools of nursing should be placed in autonomous, degree-granting institutions, and that the schools should emphasize student education rather than responsibility for patient care (Brown, 1948). The historical roots of the DNP and CNL are less defined (AACN, 2003, 2004, 2007b). In the case of the DNP, the School of Nursing faculty at Case Western Reserve University, under the direction of Dean Rozella Schlotfeldt and her successor, Dr. Jannetta McPhail, suggested in the late seventies that nurses pursue an educational route that paralleled medical education, advocating for a doctor in nursing, a ND degree, as the first professional degree (Schlotfeldt, 1978). Specialization would require additional education and credentialing. This approach to nursing education did not gather momentum in the nursing community although three other institutions (Rush University, University of Colorado, and the University of South Carolina) offered the degree (Lenz, 2005). Other schools of nursing did establish programs which placed the entry level into professional nursing and specialty practice at the master’s level. While this approach was more popular, and may have become the prototype for some accelerated degree programs, it did not change mainstream nursing education. Most college- and university-based faculty of nursing followed the 1965 directive and created specialized programs at the master’s level. In the late nineties, several nurse specialist groups pondered the educational preparation of advanced practice nurses. The National Association of Nurse Practitioner Faculties, the National Council of State Boards of Nursing, the National Association of Clinical Nurse Specialists, and many organizations that represent clinical specialties presented conflicting definitions of advanced practice, licensing, and standards for certification. Dreher, Donnelly, and Naremore (2005) asserted that only one DNP program existed when the AACN passed its DNP resolution. Yet early in the millennium, the National Organization of Nurse Practitioners Faculties, recognizing the opportunity, began to examine the impact of the doctor of nursing practice proposal on practitioner education (O’Sullivan, Carter, Marion, Pohl, & Werner, 2005).
Contemporary interest in magnet hospitals, analysis of nurse retention and turnover, and the cultural components of the workplace have led nurse leaders to address the lack of educational preparation for those who hold leadership positions at the point of service... It is more difficult to trace the beginnings of the CNL movement although management of nursing practice, at what the hospital industry calls points of service, is challenging. The position and the responsibilities of the nurse in charge, once known here and in other countries as head nurse, ward sister, or nurse co-coordinator, is blurred in contemporary corporate hospital structures in the United States. Nurses responsible for care delivery and outcomes, at unit or service levels, may not report to a Vice President for Nursing or even through nursing organizational lines. Contemporary interest in magnet hospitals, analysis of nurse retention and turnover, and the cultural components of the workplace have led nurse leaders to address the lack of educational preparation for those who hold leadership positions at the point of service, particularly in acute care hospitals. Framed in this way, the CNL program is another response of the academic nursing community to the nursing shortage, especially retention.
How have nursing’s position papers been received by the health community? Although the Brown report did not disrupt the status quo, the ANA position paper, published in the December, 1965 issue of the American Journal of Nursing did not fall on inattentive ears. Dissemination of the paper explains some of the response to the ANA document. Organized nursing and the academic nursing community were the audience for Brown’s report, which had been commissioned by the Russell Sage Foundation. However, the American Journal of Nursing, the forum for the 1965 position paper, was accessible to the majority of registered nurses and their employers. Other social factors also contributed to the attention given to the ANA’s position statement on education for nursing. In 1965, the era of the Great Society, Medicare and Medicaid legislation gave health insurance cards and access to care to older people and to the poor. As hospitals were positioning themselves to treat older patients who would require more nursing care, a fact recognized by early Medicare reimbursement formulas, the ANA made its statement about hospital-based nursing education. Simply speaking, organized nursing recommended that hospitals close their schools of nursing and get out of the business of nursing education. The position paper was not received in the hospital or medical community as a friendly document.
The response to the AACN’s 2004 DNP manifesto has been less dramatic, and limited to debates among deans of nursing and among nursing organizations. The main thrusts of objections to the DNP proposal center around: the premature release of the document; the confusion that already exists around nursing’s current educational programs and degrees; the separation of practice and research in the program’s curriculum; the negative effect of another level of doctoral study on nursing’s PhD programs, nursing scholarship and nursing science; the impact of two new graduate programs on faculty and clinical resources; the availability of tenure-track positions to DNP graduates; and the potential loss of influence in the academic hierarchy for deans of nursing and DNP faculty (Dreher, et al., 2005; Meleis & Dracup, 2005).
The National Association of Clinical Nurse Specialists (NACNS) (2004) has expressed its lack of support for both the CNL and the DNP proposals. Its objectives flow from the shortage of nurses, the waste of scarce resources, and concern that these new curriculum initiatives will disenfranchise clinical nurse specialists. The President of NACNS, supportive of the thesis of this article, also posited a relationship between the two position papers. Based on the work of a recent summit of NACNS members, President Murray (2007) cast doubt on the merits of and the rationale for developing DNP programs. She argued that there is no evidence that this new level of nursing education is needed, and described the present political milieu as a new battle in “nursing’s civil war” (p. 224).
However, faculty of nursing who have responded to the AACN mandate want to apply a broader model of scholarship, like that proposed by Boyer (1990), to the discipline of nursing. In 2006 a blogger noted that there were 19 DNP programs in 17 states and another 180 in development (Weeks, 2006). The AACN’s (2008) web site reported that there were 71 schools of nursing with DNP programs; one other school offers a hybrid, PhD/DNP. There are 140 schools who reported that they are considering offering the DNP degree. Smolowitz and Tenebaum (2005) described the response of schools of nursing to the DNP proclamation as “spreading like a wild fire” (p. 4). Lenz (2005), who served on the AACN task force, described the DNP degree as a relevant idea.
Loomis, Willard, and Cohen (2005), found in their survey that the majority of the 69 respondents, from five of the ten existing DNP or DNSc programs, envisioned academic careers. The AACN (2007b) also noted that more than 40 schools offer hybrid programs leading to either the DNP or the traditional PhD (AACN, 2007b). Most schools have not closed or begun to phase out their specialty-oriented, master’s degree, advanced practice programs although some schools are transitioning these programs into DNP programs. Lack of a response is also related to public and hospital interest in preparing more staff level RNs. In 2007 over 50 schools offered the CLN program (AACN, 2007b), a plan of study that did not exist before 2003.
The American Medical Association (AMA), another critic of the DNP initiative, passed Resolution 211 at the AMA 2006 House of Delegates meeting in Chicago, Illinois. This resolution expressed organized medicine’s position as: “the need to expose and counter nurse doctoral programs’ (NDP) misrepresentation” (AMA, 2006). Specifically, the AMA objects to the use of the title, doctor, by persons who did not graduate from medical school, and to the degree, doctor of nursing practice, itself (AMA, 2006). Physicians have argued that this title will confuse patients and other health team members and interfere with the doctor-patient relationship. Weeks (2006) labeled the action of the AMA, a response to the “emerging medical matriarchy” in healthcare (p. 3). The lack of widespread controversy around the AACN proposal may be related to the fact that HRSA estimates that 0.2% of the 2.9 million nurses have doctoral degrees (DHHS, 2006, p. B13). The majority of nurses with advanced degrees are prepared at the master’s level.
Aware that its positions are far reaching, affecting academic governance, licensing in each state, and certification standards, the AACN has continued working on its initiatives, commissioning white papers and developing a roadmap to guide the strategic planning... It is hard to predict if the 2004 directive of the AACN will create a paradigm shift in graduate nursing education. By 2015, it will be possible to record the schools preparing doctors of nursing practice and schools which have closed their specialty masters programs. Another sign of acceptance will be the recognition given by licensing and credentialing boards to master’s-prepared advanced practice nurses and to graduates of DNP programs. Interest among nurses, hospitals, and universities in both the DNP and the CNL programs, and the career trajectories of graduates from these programs are also factors to be considered in evaluating the impact of the AACN statements (2003, 2004) on the field of nursing.
The group that developed the first position paper on nursing education (1965) was an ad hoc committee. The implementation of this plan was in the hands of the ANA leadership which was not in a position to directly influence nursing faculty or State Boards of Nursing. By contrast, the 2003 and 2004 initiatives have the endorsement and support of an influential academic organizational body whose members are the nation’s deans of nursing. Aware that its positions are far reaching, affecting academic governance, licensing in each state, and certification standards, the AACN has continued working on its initiatives, commissioning white papers and developing a roadmap to guide the strategic planning, especially for the implementation of the DNP (AACN, 2006b). Clinton and Sperhac (2006) have advocated for a national agenda for advanced practice.
The intent of the directives of the two policy groups, the ANA and the AACN...is surprisingly similar. Both proclamations are oriented to improving educational preparation, elevating the status of nurses, and enhancing the quality and safety of patient care. In 1962, when the ANA published its Inventory of Professional Registered Nurses, 63% of the 532,118 registered nurses worked in hospitals (Marshall & Moses, 1965) and between 75 and 85 percent of the nurses, in the states providing data, were graduates of hospital schools (Marshall & Moses). At the time of the 1965 position paper, approximately 72 percent of all nursing students studied in hospital schools. Diploma graduates were the matrix of hospital staffs. Years later, a country western song would describe the plight of a farmer whose wife left him at harvest time. At the end of 1965, hospital and diploma school administrators, who contemplated the effect of ANA statement on their schools, could resonate to the refrain, “You picked a fine time to leave me, Lucille.” Forty years later, the face of education and the educational preparation of the practicing nurse have changed. Today, approximately 17.5% of practicing nurses are diploma graduates; 34% of the practicing nurses hold associate degrees; and 34.2% have baccalaureate degrees (DHHS, 2006). American healthcare finds itself unable to control its costs, faces a serious shortage of nurses, and anticipates another surge in its aging patient population when baby boomers reach 65 years of age in 2010.
The intent of the directives of the two policy groups, the ANA and the AACN, separated by forty years and addressing different points on nursing’s educational continuum, is surprisingly similar. Both proclamations are oriented to improving educational preparation, elevating the status of nurses, and enhancing the quality and safety of patient care. It will be interesting to observe how the DNP and the CNL graduates will fare in the healthcare market place and to trace the implementation of the AACN timeline.
Donley and Flaherty (2002) argued that the controversy around the 1965 position paper could be examined under three rubrics: autonomy and financial control, the nature of nursing practice, and the nursing supply. Because this framework also resonates with contemporary efforts to reform graduate education, it will inform this comparative discussion of the 1965 educational scene and the educational scene of the AACN 2003 and 2004 Position Statements.
Autonomy and Financial Control
The 1965 position paper, nursing’s statement of autonomy, remains a declaration of independence. In 1965, nursing, especially hospital nursing, was highly controlled by hospitals and physicians. Today, insurance companies, notably the Center for Medicare and Medicaid Services (CMS), shape medical, nursing, and hospital practice. Although hospitals in the sixties valued nurses, the culture of hospitals diluted the autonomy of nursing and gave decisional authority, even over matters of nursing practice, to attending physicians. Hospital schools were gateways into the profession, and as the major employers of nurses, hospitals influenced supply and demand. Hospitals also exerted an amazing influence over nursing’s public identity. Representing and speaking for nursing, hospitals so shaped public opinion that nursing practice became almost synonymous with hospital practice. The writings of the mid sixties also suggest that hospitals exerted influence over the nursing curriculum and the selection of faculty. However, their most direct influence occurred on hospital units where practice standards and protocols set the template for the study and practice of nursing. Here, students learned what Walker (1967) called the ritualistic practices of nursing. This “received tradition” was not based on evidence or science. Rather, the tradition contained practices that were developed over time to assist and guide nurses as they provided care to patients who were acutely ill. Although unexamined, these practices were deeply imbedded in the ward culture, imprinted on the minds and hearts of nurses, and passed on to the next generation. By wresting control of the education and socialization of nurses from hospitals, the ANA leadership sought to do for nursing what the Flexner (1910) report did for medicine. The 1965 position paper, nursing’s statement of autonomy, remains a declaration of independence.
The current acute care environment does not resemble the hospital world of 1965. The values of loyalty and trust, which characterized earlier hospital cultures, have been replaced by accountability for meeting performance standards and outcomes, bottom lines, clinical pathways, and evidence-based practice. Today, major nursing organizations and deans of nursing, who document the difficulty in recruiting and retaining a diminishing group of faculty, have once again given hospitals and hospital nurses more significant roles in the education of students of nursing. Faculty at all levels of nursing recognizes that access to particular patient populations is essential for implementing the curriculum. Dedicated units where staff nurses assume direct responsibility for the education of undergraduate students are common. The inauguration of new partnerships and clinical agreements with hospitals preceded the 2003 and 2004 proclamations of the AACN. Deans realize that “buying” time of staff nurses or developing some clinical practice/clinical teaching job sharing expanded the schools’ clinical faculty without creating longterm contractual obligations. Hospitals have always recognized that students who affiliate at their institutions are likely to work there after graduation. It is also more efficient and economical to recruit staff nurses from among a pool of students who have studied and participated in the hospitals’ mode of care delivery and its culture.
In adopting its 1965 position statement, the nursing community expressed its belief that nursing was prepared to set its own standards. Nurse leaders were also making a case that better educated nurses could improve the care of patients. This rationale also contributed to the 2003 and 2004 statements of the AACN. Contemporary leaders have envisioned advanced practice nurses as recognized and respected health team members, providing leadership at practice and policy tables. Both the first and second position papers were statements that advocated for growth in the advancement of nursing science and nursing research. In attempting to differentiate the practice of nursing and create a hierarchy in education and practice, the writers of the second position paper are following the pattern of nurse leaders in 1965. They are attempting to use educational preparation to distinguish and differentiate among the 2.9 million professional nurses.
The Nature of Nursing Practice: 1965 and 2008
It was clear to the leaders in 1965 that professional nurses must be grounded in science and critical thinking, not ritualistic practices. Medical and nursing practice became more specialized and technologically sophisticated after the Second World War. In the sixties, this differentiation affected nursing practice and education and the staffing patterns in hospitals. The demands of monitoring and giving “high technology” care to an older population of patients, the increased volume of paper work because of Medicare’s payment systems, and the responsibility for coordinating care provided by ancillary workers stimulated a rethinking of the scope of nursing practice. These practice evolutions also affected nursing education. However, even at the time of the 1965 position statement, the seamless web between diploma schools of nursing and hospitals was beginning to unravel. New hospital graduates were not competent to practice in complex, unpredictable, specialized high technology environments. It was clear to the leaders in 1965 that professional nurses must be grounded in science and critical thinking, not ritualistic practices. By 2004, the care delivery environment was deeply fragmented.
The Prospective Payment legislation of 1982 paid hospitals on a new formula based on diagnostic- related groups (Tax Equity and Fiscal Responsibility Act (TEFRA), 1982). This payment schema limited inpatient care by encouraging late admissions and early discharge of patients. After the Prospective Payment legislation was implemented, the acuity of illness of hospitalized patients and the level of high technology medicine required hospital-based nurses to provide more complex nursing care to sicker persons in shorter periods of time. Nurses were also busier after 1982 because they “substituted,” for other health workers, that is, nurses assumed responsibility for additional patient care services because of budget-driven reductions in ancillary staff. At a time when hospitals’ demand for nurses was insatiable, hospitals also experienced their first real competition for professional nurses. Ambulatory clinics, day surgery centers, home care, and skilled-nursing facilities, expanded because sick persons were not admitted or were discharged soon after admission. These centers competed with hospitals for their experienced nurse force. Agency and travel nurses, who once constituted a small segment of the nursing community, become a factor in the hospital workforce. Some hospitals become dependant on agencies to staff special care units.
The Nursing Supply
...55.4 percent of the RNs, who obtained their initial nursing education in the past 5 years, graduated from associate degree programs... Perhaps the most dramatic response to the 1965 position paper occurred in associate degree education. Students in associate degree programs completed two, not three or four year programs and joined the work force more quickly. Data obtained from the most recent National Sample Survey of Registered Nurses (DHHS, 2006) show pre and post-licensure educational patterns of registered nurses. Twenty-three percent hold diplomas, 34.3 percent hold associate degrees, and 32.7 percent have a baccalaureate education. However, 55.4 percent of the RNs, who obtained their initial nursing education in the past 5 years, graduated from associate degree programs, 38 percent from baccalaureate degree programs, and 6 percent from diploma schools (DHHS, 2006).
In the past, the typical response to an increased demand for nurses was to increase the nursing supply. However, the severe shortages in the late 1980s and in the millennium introduced new variables into nursing’s supply/demand equation. One supply-oriented trend, labeled “trouble in the pipeline,” described a six-year decline of students in all nursing programs (Green, 1987). Interviews with guidance counselors and teachers in the eighties and nineties revealed that young men and women were not that interested in nursing. For the academically oriented student, and especially for academically oriented women, medicine, pharmacy, business, or computer science held more appeal. Nursing was judged to be too demanding, too undervalued, and too unrewarding. The female dominance of the profession challenged young men and feminists. By 2004, when the deans of nursing adopted their position paper on graduate education, the enrollment and the staffing patterns had changed again. Enrollment had risen, and hospitals had increased nursing salaries and hired older nurses and graduates of foreign nursing schools (Buerhaus, Staiger, & Auerbach, 2000). Other factors helped explain the turn around in enrollment in schools of nursing. The federal government “reinvested” in nursing, creatively redesigning its nurse manpower programs to offer more financial assistance to students, encouragement to recruit minorities, and stimulation of initiatives to develop respectful, professional cultures in the worksite (Nurse Reimbursement Act, 2002).
How do the issues of autonomy and financial control of nursing education and the continuing flux in nursing practice and nursing supply play out in the millennium? In the area of autonomy and control, there are similarities and differences between the state of nursing in 1965 and in 2004. Hospitals no longer dominate healthcare delivery, although they continue to employ the largest group of nurses. In 2004, fifty-six percent of approximately 2,921,461 registered nurses worked in the nations’ hospitals (DHHS, 2006).
The struggle to achieve autonomy continues, but it is now played out in varied work sites, at meetings of nursing and medical societies, and in the legislature of each state. The struggle to achieve autonomy continues, but it is now played out in varied work sites, at meetings of nursing and medical societies, and in the legislature of each state. Professional and financial autonomy and career advancement are directly correlated with higher education. However, the level of education that has given nurses and clinicians more autonomy, professional control, and income has been a master’s degree in primary care or a clinical specialty and certification in a field of advanced practice. The AACN (2004) document, in proclaiming a new level of education, changes the playing field and sets a new standard to measure clinical acumen, expertise, and professional practice.
The nursing shortage of the millennium has refocused attention on nursing practice, nurse retention, and workforce issues. Failure to resolve workplace issues contributes to nursing shortages in all settings, but most notably in acute care hospitals. Efforts to describe, quantify, and address these issues and to measure their relationship to healthcare outcomes, cost, and patient well being is methodologically complex. The Institute of Medicine (IOM) in their study of nursing staff in hospitals and nursing homes listened to nurses' concerns about the lack of satisfaction in their work (Wunderlich, Sloan, & Davis, 1996). Specifically, they heard testimony about the serial effects of reorganizations on staffing patterns and quality of care. Unfortunately, the IOM committee was unable to document the relationships of organizational restructuring and staffing patterns on the quality of care in hospitals (Wunderlich et. al., 1996). Later, Aiken and her team (2002) would do this. Two decades earlier, the National Commission on Nursing (1981) had derived five themes from public hearings about professional practices, held in six regions of the country: status and image of nursing; interface between education and practice; effective management of nursing resources (salaries, schedules, benefits); relationships among nursing, medical staff, and hospital administration; and the maturing of nursing as a self-determining profession (autonomy, scope of practice) (National Commission on Nursing, 1981).
The nursing shortage of the millennium has refocused attention on nursing practice, nurse retention, and workforce issues. The National Commission’s insight into the important role of the quality of the workplace on staff retention is supported in the literature on magnet hospitals, a concept which developed from the American Academy of Nursing’s sponsorship of the work of McClure, Poulin, Sovie and Wandelt (1983). These investigators sought to determine the shared organizational characteristics of 41 institutions that were successful in attracting and retaining nurses. In the original study (1983), magnet hospitals were work places where nurses had autonomy, control over practice settings, and working relationships with physicians. Kramer (1990) and Aiken, Havens, and Sloane (2000) have revisited the magnet concept. Their studies seek to link nurses’ perceptions about practice and organizational environments with outcomes and quality of care. Today many nurses, and the labor unions and professional associations that speak for them, cite workplace issues as a cause of the current shortage in nursing, at least in hospital practice (AACN, 2002b).
As noted earlier another significant difference in the contemporary practice environment is the loss of trust and loyalty that characterized the hospital and nursing community of the sixties. ANA’s online survey of 7,299 nurses revealed that 54 percent of those surveyed would not recommend nursing to their children or friends (ANA, 2001). For its part, hospital systems view nurses as free agents that have little commitment to the institutional mission or goals.
There continue to be demographically induced concerns about the adequacy of the nursing workforce. In 1965, concern about newly enrolled Medicare beneficiaries focused attention on the nurse supply. Today, analysts worry about the convergence of a nursing shortage and the influx of the baby boomer generation into healthcare systems at the end of the decade (Buerhaus, et al., 2000). In the sixties, nursing was an attractive option for young women. Interestingly, while women have many career options today, enrollment in all levels of nursing education is currently on the rise after a period of serious depression and decline. Graphs from the AACN (2007a) show enrollment in entry level baccalaureate nursing programs turned around after 2000. BSN enrollment increased by five percent in 2005-06; enrollment in all programs increased by 18 percent during the same year. Yet despite this good news, Because undereducated members of the health team rarely sit at policy tables...[w]ill nursing’s most recent proclamation, which shifts attention to advanced practice and raises the educational bar, affect...power in healthcare? the future of nursing is in jeopardy as aging faculty cannot be replaced quickly and the number of qualified students, turned away because of faculty shortage, increases each year (AACN, 2006c; Moskowitz, 2007; Yordy, 2006). The AACN data (2006c) showed that 42,866 qualified students were not admitted to undergraduate and graduate programs in 2006. The NLN (2006) faculty census showed a 7.9 percent vacancy rate in BSN and graduate programs and a 5.6 vacancy rate in associate degree programs.
In the 1966 Facts about Nursing, the authors reported that 621,000 persons were registered as professional nurses (ANA, 1966). The typical profile of the new graduate, who joined this group in the sixties, was a mid-twenties woman who completed her program of studies in a hospital school of nursing. Today’s new nurse is a mid-thirties graduate of an associate degree program. She or he joins a nurse force that has grown to almost 2.9 million nurses (DHHS, 2006). However, given the small enrollment in nursing for almost a decade, combined with the age of new graduates, it is not surprising that the average age of the practicing registered nurse is 46.8 (DHHS, 2006). In 1980, 26 percent of the RNs were under 30; by 2004, approximately 8 percent were under 30 (DHHS). In the sixties, concerns about nursing were framed within the environment of the acute care hospital. Today, diminishment of the nurse force is a concern of the entire healthcare delivery system. Unlike previous shortages, major nursing and health organizations have also identified the shortage of teachers as a major component in resolving the nursing shortage (AACN, 2007b; NLN, 2006).
If you view the 1965 statement as a call to...move all nursing education...[to] colleges or universities, then the ANA was successful in implementing its vision. If, however, you view...[it] as a mandate for a more educated nurse force...the goal has not been achieved. The face and profile of nursing have changed in the period following the publication of the first position paper. The number of registered nurses has increased dramatically and today represents three levels of nursing education. In the not too distant future, associate degree nurses will provide the majority of patient care in hospitals and community centers. If you view the 1965 statement as a call to close hospital schools of nursing and to move all nursing education inside the walls of colleges or universities, then the ANA was successful in implementing its vision. If, however, you view the 1965 Position Paper as a mandate for a more educated nurse force to enhance patient care, the goal has not been achieved. In the past decade, deans of nursing have been preoccupied with the undereducated nurse and her/his place on the health team. Registered nurses lack the educational credentials of persons in the business, investor, and insurance communities that now play significant roles in healthcare decisions. Because undereducated members of the health team rarely sit at policy tables or are invited to participate as members of governing boards, nurses are governed by the decisions of others. Will nursing’s most recent proclamation which shifts attention to advanced practice and raises the educational bar, affect the balance of power in healthcare?
Sister Rosemary Donley, SC, PhD, APRN, BC-ANP, FAAN
Sister Rosemary Donley is an Ordinary Professor of Nursing and Director of the federally funded Community/Public Health Nursing Advanced Practice Programs at The Catholic University of America, Washington, D.C., and First Councilor of the Sisters of Charity of Seton Hill. Sr. Rosemary Donley received a diploma from the Pittsburgh Hospital School of Nursing, and holds a B.S.N. degree from St. Louis University and M.N.Ed. and Ph.D degrees from the University of Pittsburgh. She is a certified adult nurse practitioner. Her clinical and research interests include health policy, clinical decision making and healthcare literacy.
Sr. Rosemary has served as Executive Vice President (1986-97) and Dean of Nursing (1979-86) at The Catholic University of America. She is past President of the National League for Nursing and the Sigma Theta Tau International Honor Society of Nursing, and past Senior Editor of Image: The Journal of Nursing Scholarship. She has also served as a member of the Secretary of Health and Human Service’s Commission on Nursing, and as a consultant to the U.S. Army and Navy Medical Commands. Sr. Rosemary is currently co-chair of the NLN think tank on Expanding Racial, Ethnic, and Gender Diversity in Nursing Education and a member of the Institute of Medicine. Sr. Rosemary has numerous publications and is a frequent presenter throughout the United States and abroad. In 2006, she was named a living legend by the Academy of Nursing.
Sister Mary Jean Flaherty, SC, PhD, RN, FAAN
Sister Mary Jean Flaherty is an Ordinary Professor of Nursing at The Catholic University of America, Washington, D.C. She received a diploma from the Pittsburgh Hospital School of Nursing and holds a B.S.N. degree from Duquesne University and a M.S.N. degree along with a PhD in Curriculum and Supervision from the University of Pittsburgh. She is a maternal-child clinical nurse specialist. Her research interests are grandmothers, post-partum care, breast-feeding, and mentorship. Her work has been funded by the Department of Health and Human Services, The Catholic University of America, and Sigma Theta Tau International.
Sister Mary Jean has served as Dean of Nursing (1992-2000), Director of the Doctoral Program (1988-1990), and Chair of the Graduate Program in Nursing of the Developing Family at the Catholic University of America, where she also served as Associate Director of Education, National Center for Family Studies. Sister Mary Jean has also been a World Health Organization nurse consultant, and an educational consultant and a program evaluator for the National League for Nursing (NLN). Additional roles include being a member, Vice Chair, and Chair of the Board of Review, Baccalaureate and Higher Degree Programs for the NLN. Sister Mary Jean has been a member of several college and health system boards, the National Commission on Nursing Implementation Project, the Committee of Graduate Nursing Education for the China Medical Board, and an evaluator for the Middle States and Southern Regional Colleges and Universities.
Accreditation Council for Pharmacy Education (2007, July 1). Accreditation standards and guidelines for the professional program in pharmacy leading to the Doctor of Pharmacy degree. Retrieved September 8, 2007, from www.acpe-accredit.org/shared_info/pharmd.htm
Aiken, L., Clark, S., Sloan, D., Sochalski, J. & Silbes, J. (2002). Hospital nurse staffing and patient mortality, nurse burnout and job dissatisfaction. JAMA, 288, 1987-1993.
Aiken, L., Havens, D. & Sloane, D. (2000, March). The magnet nursing services recognition program: A comparison of two groups of magnet hospitals. American Journal of Nursing. 100(3), 26-35.
American Association of Colleges of Nursing (AACN, 2008). Doctor of Nursing Practice (DNP) Programs. Retrieved May 4, 2008, from
American Association of Colleges of Nursing (AACN, 2007a). Enrollment growth slows in US colleges and universities despite calls for more registered nurses. Retrieved April 26, 2008 from www.aacn.nche.edu/Media/ppt/94-07EnrChgs.ppt
American Association of Colleges of Nursing (AACN, 2007b). Nursing faculty shortage. Retrieved September 9, 2007, from www.aacn.nche.edu
American Association of Colleges of Nursing, (AACN, 2006a). The essentials of doctoral education for advanced practice. Retrieved August 9, 2007, from www.aacn.nche.edu
American Association of Colleges of Nursing (AACN, 2006b, October). DNP roadmap task force report. Washington, D.C.: American Association of Colleges of Nursing.
American Association of Colleges of Nursing, (AACN, 2006c). Student enrollment rises in nursing colleges and universities for the 6th consecutive year. Retrieved April 26, 2008 from www.aacn.nche.edu/Media/NewsReleases/06Survey.htm
American Association of Colleges of Nursing (AACN, 2004). AACN position statement on the practice doctorate in nursing. Retrieved September 29, 2007, from www.aacn.nche.edu/DNP/DNPPositionstatement.htm
American Association of Colleges of Nursing (AACN). (2003). AACN (2003) DRAFT white paper on the role of the Clinical Nurse Leader. Washington, D.C.: American Association of Colleges of Nursing.
American Association of Colleges of Nursing (AACN) (2002a, January). Fact sheet: Associate degree in nursing programs and AACN’s support for articulation. Retrieved May 8, 2002, from www.aacn.nche.edu
American Association of Colleges of Nursing White Paper. (AACN) (2002b, January). Hallmarks of the professional nursing practice environment. Retrieved May 9, 2002, from www.aacn.nche.edu
American Medical Association (AMA) (2006). Resolution 211, Need to expose and counter nurse doctoral programs (NDP) misrepresentation. The Integrator Blog. Retrieved 24 August, 2007, from http://theintegratorblog.com/index.php?option=com_content&task=view&id=187&Itemid=93.
American Nurses Association (2001, February). Analysis of American Nurses Association staffing survey. Retrieved March 19, 2002, from www.nursingworld.org
American Nurses Association (1966). Facts about nursing. New York: American Nurses Association.
American Nurses’ Association (1965). A position paper. New York: American Nurses Association.
APTA Vision 2020 (2007, June). Working operational definitions of Vision 2020. Retrieved October 4, 2007, from 222.apta.org/AM/templace
Boyer, E. (1990). Scholarship reconsidered: Priorities for the professoriate. Princeton, New Jersey: The Carnegie Foundation for the Advancement of Teaching.
Brown, E. (1948). Nursing for the future. New York: Russell Sage Foundation.
Buerhaus, P., Staiger, D., & Auerbach, D. (2000). Implications of an aging registered nurse workforce. JAMA. 283, 2948-2954. 25
Clinton, P. & Sperhac, A. (2006). National agenda for advanced practice nursing: The Practice Doctorate. Journal of Professional Nursing. 22(1), 7-14.
Committee on Nursing Education, American Nurses Association (1965, December). American Nurses Association’s first position on education for nursing. American Journal of Nursing; 65(12), 106-107.
Department of Health and Human Services (DHHS), (2006). The registered nurse population. Washington, DC: Government Printing Office.
Donley, Sr. & Flaherty, Sr. MJ. (2002). Revisiting the American Nurses Association first position on education for nurses. OJIN, 7(2). Retrieved 15 August, 2007, from www.nursingworld.org/.
Dreher, H., Donnelly, G. & Naremore, R. (2005). Reflections on the DNP and an alternate practice doctorate model: The Drexel DrNP. OJIN, 10(3). Retrieved August 24, 2007, from www.nursingworld.org/ojin.
Flexner, A. (1910). Medical education; A comparative study. New York: The MacMillan Company.
Green, K. C. (1987, Jul.-Aug.). The educational “pipeline” in nursing. Journal of Professional Nursing, 3(4), 247-1957.
Institute of Medicine (IOM). (2003). Health professions education: A bridge to quality. Washington, DC: The National Academies Press.
Kohn, L., Corrigan, J., & Donaldson, M. (Eds.) (2000). To err is human: Building a safer health system. Washington, DC: The National Academies Press.
Kramer, M. (1990). The magnet hospitals. Excellence revisited. Journal of Nursing Administration, 20(9), 35-44. 26
Lenz, E. (2005). The Practice Doctorate in nursing: A idea whose time has come. OJIN, 10(3). Retrieved October 12, 2007, from www.medscape.com/viewarticle/514543_2.
Loomis, J., Willard, B. & Cohen, J. (2005). Difficult professional choices: Deciding between the PhD and DNP in nursing. OJIN. 10(3), w1-12
Marshall, E.& Moses, E. (1965). The nation’s nurse: The 1962 Inventory of professional registered nurses. New York: American Nurses Association.
McClure, M., Poulin, M., Sovie, M., & Wandelt, M. (1983). Magnet hospitals: Attraction and retention of professional nurses. Kansas City, MO: American Nurses Publishing.
Meleis, A. & Dracup, K (2005). The case against the DNP: History timing, substance and marginalization. OJIN, 1-5. Retrieved September 10, 2007, from http://nursingworld.org/.
Moskowitz, M. (2007). Academic health centers CEOS say faculty shortages are major problem.Association of Academic Health Centers.
Murray, T. (2007). President’s message: Notes from the Board. Clinical Nurse Specialist. 21(5), 223-224.
National Association of Clinical Nurse Specialists (NACNS) (14 March 2004). NACNS position statement on the clinical nurse leader. Retrieved on August 24, 2005, www.nacns.org/LinkClick.aspx?fileticket=3%2bip4nbDLho%3d&tabid=116
National Commission on Nursing (1981). Summary of public hearings. Chicago, Ill: The Hospital Research and Educational Trust.
National League for Nursing (2006). NLN’s 2006 Faculty Census Survey shows increased vacancy rates. Retrieved on August 17, 2007, from www.nln.org/newsreleases/nurseeducators2006.htm.
Nurse Reinvestment Act, PL 107-205 (2002). Washington, DC: US Government Printing Office.
Olson, R., Nelson, M., Stuart, C., Young, L., Kleinsasser, A., Schroedermeier, R. & Newstrom, P. (2001). Nursing student residency programs: A model for a seamless transition from nursing student to RN. JONA, 31(1), 40-48.
O’Sullivan, A., Carter, M., Marion, L., Phol, J. & Werner, K. (September 30, 2005). Moving forward together: The practice doctorate in nursing. Online Journal of Issues in Nursing. 10(3). Retrieved on September 20, 2007, from www.nursingworld.org/ojin.
Roberts, M. M. (1954). American nursing, History and interpretation. New York: MacMillan Company.
Schlotfeldt, R. (1978). The professional doctorate: Rationale and characteristics. Nursing Outlook, 2(5), 302-311.
Smolowitz, J. & Tenebaum, J. (2005). Case studies: The Doctor of Nursing Practice DNP. New York: The Columbia University Press.
Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA), P.L. 97-248 (1982). Washington, DC.: The Government Printing Office.
Walker, V.H. (1967). Nursing and ritualistic practices. New York: Macmillan Company.
Weeks, J. (2006). AMA targets nursing doctoral and ND license: Old boys vs. the emerging medical matriarchy. The Integrator Blog. Retrieved 25 August 2007, from http://theintegratorblog.com/index.php?option=com_content&task=view&id=64&Itemid=93, pp. 1-7.
Wunderlich, G., Sloan, F., & Davis, C. (Eds.). (1996). Nursing staff in hospitals and nursing homes. Is it adequate? Washington, DC: National Academy Press.
Yordy, K. (2006). The nursing faculty shortage: A crisis for health care. Association of Academic Health Centers. Retrieved June 15, 2007, from www.aahcdc.org/policy/AAHC_OutofTime_4WEB.pdf
© 2008 Online Journal of Issues in Nursing
Article published April 30, 2008
- A Policy Perspective on the Entry into Practice Issue
Timothy G. Smith, PhD, MPA, BA, LPN (October 5, 2009)
- Education for Entry into Nursing Practice: Revisited for the 21st Century
Lucille A. Joel, EdD, RN, FAAN (May 31, 2002)
- Education for Professional Nursing Practice: Looking Backward into the Future
Martha A. Nelson, PhD, RN (May 31, 2002)
- The Relevance of Associate Degree Nursing Education: Past, Present, Future
Elizabeth H. Mahaffey, RN, PhD (May 31, 2002)
- Revisiting the American Nurses Association’s First Position on Education for Nurses
Sister Rosemary Donley, RN, PhD, C-ANP, FAAN;Sister Mary Jean Flaherty, RN, PhD, FAAN (May 31, 2002)