Historical and Contemporary Nursing Practice PDF

# Chapter 1 Historical and Contemporary Nursing Practice ## Introduction Nursing today is far different from nursing as it was practiced years ago, and it is expected to continue changing during the 21st century. To comprehend present-day nursing and at the same time prepare for the future, one mu...

# Chapter 1 Historical and Contemporary Nursing Practice ## Introduction Nursing today is far different from nursing as it was practiced years ago, and it is expected to continue changing during the 21st century. To comprehend present-day nursing and at the same time prepare for the future, one must understand not only past events but also contemporary nursing practice and the sociologic and historical factors that affect it. ## Historical Perspectives Nursing has undergone dramatic change in response to societal needs and influences. A look at nursing’s beginnings reveals its continuing struggle for autonomy and professionalization. In recent decades, a renewed interest in nursing history has produced a growing amount of related literature. This section highlights only selected aspects of events that have influenced nursing practice. Recurring themes of women’s and men’s roles and status, religious (Christian) values, war, societal attitudes, and visionary nursing leadership have influenced nursing practice in the past. Many of these factors still exert their influence today. ## Women’s Roles Traditional female roles of wife, mother, daughter, and sister have always included the care and nurturing of other family members. From the beginning of time, women have cared for infants and children; thus, nursing could be said to have its roots in the home. Additionally, women, who in general occupied a subservient and dependent role, were called on to care for others in the community who were ill. Generally, the care provided was related to physical maintenance and comfort. Thus, the traditional nursing role has always entailed humanistic caring, nurturing, comforting, and supporting. ## Men’s Roles Men have worked as nurses as far back as before the Crusades. Although the history of nursing primarily focuses on the female figures in nursing, schools of nursing for men existed in the United States from the late 1880s until 1969. Male nurses were denied admission to the Military Nurse Corps during World War II based on gender. It was believed at that time that nursing was women’s work and combat was men’s work. During the 20th century, men were denied admission to most nursing programs. In 1971, registered nurse Steve Miller formed an organization called Men in Nursing, and in 1974, Luther Christman organized a group of male nurses. The two groups reorganized into the National Male Nurses Association with the primary focus of recruiting more men into nursing. In 1981, the organization was renamed the American Assembly for Men in Nursing (AAMN). The purpose of the AAMN is to “provide a framework for nurses, as a group, to meet, to discuss and influence factors, which affect men as nurses” (AAMN, n.d., "Vision," para. 2). The percentage of men included in the nation's nursing workforce does vary. For example, a survey by the National Council of State Boards of Nursing (Smiley et al., 2018) indicated a total of 9.1% male nurses in the workforce, an increase of 2.5% compared to the previous 2013 report. In 2017, the Health Resources and Services Administration (HRSA) reported 9.6%, which is less than the 12% male RNs as reported by Buerhaus, Skinner, Auerbach, and Staiger (2017b, p. 231). Men do experience barriers to becoming nurses. For example, the nursing image is one of femininity, and nursing has been slow to adopt a gender-neutral image. As a result, people may believe that men who choose the profession of nursing are emasculated, gay, or sexually deviant, which is not true (Hodges et al., 2017). Other barriers and challenges for male nursing students include the lack of male role models in nursing, stereotyping, and differences in caring styles between men and women (Zhang & Liu, 2016). Improved recruitment and retention of men and other minorities into nursing continues to be needed to strengthen the profession. This is illustrated by professional surveys. A 2016 National League for Nursing (NLN, 2017a) survey found that men in basic registered nursing programs represented 14% of the total enrollment, a 1% decrease compared to the 2012 survey. In comparison, bachelor of science in nursing (BSN) programs enrolled 15% male students, a 2% increase from 2012. In addition, a 2016 survey by the American Association of Colleges of Nursing (AACN, 2017) reflected that only 12% of students in baccalaureate and graduate programs were male. ## Evidence-Based Practice ### What Motivates Men to Choose Nursing? Yi and Keogh (2016) state that “knowledge of the factors that motivate men to choose nursing will assist in the development of evidence-based recruitment strategies to increase the number of men entering the nursing profession” (p. 96). As a result, they conducted a systematic literature review of data from qualitative studies that described male nurses’ motivations for choosing nursing. A comprehensive search of over 11,000 citations and screening for inclusion criteria resulted in six studies being included in the review. Analytic processes resulted in four themes. The first theme described how early exposure to nursing and other healthcare professionals influenced the male nurses’ decision to become nurses. Examples consisted of where the men received encouragement from female and male friends and relatives who were nurses. Some men were exposed to nursing through experiences of caring for a sick or dying loved one, which became a factor in their decision-making process. The second theme described how the men chose nursing by chance, based on their circumstances at the time of the decision. For example, some men were looking for work and had friends who were nurses and thus decided to try nursing. Some chose nursing because they were not accepted into their preferred program. The third theme described extrinsic motivating factors such as job opportunity and salary. The fourth theme described intrinsic motivating factors such as personal satisfaction and enjoyment with helping people. Other intrinsic motivating factors included a sense of altruism and caring and their perception of nursing as a vocation. ### Implications A limitation expressed by the researchers was that the review would have provided a more comprehensive description if both quantitative and qualitative studies had been included. Three of the themes were congruent with previous literature reviews. However, the theme of entering nursing by chance, depending on the men's circumstances, was new. As a result, the authors recommended that strategies to enhance retention within the nursing program be developed for those males who pursued nursing by chance. Examples could include providing male role models during clinical experiences and supporting male nurses' caring abilities in a welcoming environment to promote intrinsic motivating factors during the program. ## Religion Religion has also played a significant role in the development of nursing. Although many of the world's religions encourage benevolence, it was the Christian value of “love thy neighbor as thyself” and Christ's parable of the Good Samaritan that had a significant impact on the development of Western nursing. During the third and fourth centuries, several wealthy matrons of the Roman Empire, such as Fabiola, converted to Christianity and used their wealth to provide houses of care and healing (the forerunner of hospitals) for the poor, the sick, and the homeless. Women were not, however, the sole providers of nursing services. The Crusades saw the formation of several orders of knights, including the Knights of Saint John of Jerusalem (also known as the Knights Hospitalers), the Teutonic Knights, and the Knights of Saint Lazarus (Figure 1.1 □). These brothers in arms provided nursing care to their sick and injured comrades. These orders also built hospitals, the organization and management of which set a standard for the administration of hospitals throughout Europe at that time. The Knights of Saint Lazarus dedicated themselves to the care of people with leprosy, syphilis, and chronic skin conditions. During medieval times, there were many religious orders of men in nursing. For example, the Alexian Brothers organized care for victims of the Black Plague in the 14th century in Germany. In the 19th century, they followed the same traditions as women's religious nursing orders and established hospitals and provided nursing care. The deaconess groups, which had their origins in the Roman Empire of the third and fourth centuries, were suppressed during the Middle Ages by the Western churches. However, these groups of nursing providers resurfaced occasionally throughout the centuries, most notably in 1836 when Theodor Fliedner reinstituted the Order of Deaconesses and opened a small hospital and training school in Kaiserswerth, Germany. Florence Nightingale received her training in nursing at the Kaiserswerth School. Early religious values, such as self-denial, spiritual calling, and devotion to duty and hard work, have dominated nursing throughout its history. Nurses' commitment to these values often resulted in exploitation and few monetary rewards. For some time, nurses themselves believed it was inappropriate to expect economic gain from their “calling.” ## War Throughout history, wars have accentuated the need for nurses. During the Crimean War (1854–1856), the inadequacy of care given to soldiers led to a public outcry in Great Britain. The role Florence Nightingale played in addressing this problem is well known. Nightingale and her nurses transformed the military hospitals by setting up sanitation practices, such as hand washing. Nightingale is credited with performing miracles; the mortality rate, for example, was reduced from 42% to 2% in 6 months (Donahue, 2011, p. 118). During the American Civil War (1861–1865), several nurses emerged who were notable for their contributions to a country torn by internal conflict. Harriet Tubman and Sojourner Truth (Figures 1.2 and 1.3) provided care and safety to slaves fleeing to the North on the Underground Railroad. Mother Biekerdyke and Clara Barton searched the battlefields and gave care to injured and dying soldiers. Noted authors Walt Whitman and Louisa May Alcott volunteered as nurses to give care to injured soldiers in military hospitals. Another female leader who provided nursing care during the Civil War was Dorothea Dix (Figure 1.4). She became the Union’s superintendent of female nurses responsible for recruiting nurses and supervising the nursing care of all women nurses working in the army hospitals. The arrival of World War I resulted in American, British, and French women rushing to volunteer their nursing services. These nurses endured harsh environments and treated injuries not seen before. A monument entitled “The Spirit of Nursing” stands in Arlington National Cemetery (Figure 1.5). It honors the nurses who served in the U.S. armed services in World War I, many of whom are buried in Section 21, which is also called the “Nurses Section” (Arlington National Cemetery, n.d.). Progress in healthcare occurred during World War I, particularly in the field of surgery. For example, advancements were made in the use of anesthetic agents, infection control, blood typing, and prosthetics. World War II casualties created an acute shortage of caregivers, and the Cadet Nurse Corps was established in response to a marked shortage of nurses (Figure 1.6 □). Also at that time, auxiliary healthcare workers became prominent. “Practical” nurses, aides, and technicians provided much of the actual nursing care under the instruction and supervision of better prepared nurses. Medical specialties also arose at that time to meet the needs of hospitalized clients. During the Vietnam War, approximately 11,000 American military women stationed in Vietnam were nurses. Most of them volunteered to go to Vietnam right after they graduated from nursing school, making them the youngest group of medical personnel ever to serve in wartime (Vietnam Women’s Memorial Foundation, n.d.). Near the Vietnam Veterans Memorial (“The Wall”) stands the Vietnam Women’s Memorial (Figure 1.7). Nurses served in the Afghanistan and Iraq wars. A total of 6,326 nurses deployed to Afghanistan, Iraq, or both between September 1, 2001 and July 31, 2015. Of these deployed nurses, 55% were male. During this time six army nurses were killed, four in Afghanistan and two in Iraq (Berry-Caban, Rivers, Beltran, & Anderson, 2018). ## Societal Attitudes Society’s attitudes about nurses and nursing have significantly influenced professional nursing. Before the mid-1800s, nursing was without organization, education, or social status; the prevailing attitude was that a woman’s place was in the home and that no respectable woman should have a career. The role for the Victorian middle-class woman was that of wife and mother, and any education she obtained was for the purpose of making her a pleasant companion to her husband and a responsible mother to her children. Nurses in hospitals during this period were poorly educated; some were even incarcerated criminals. Society’s attitudes about nursing during this period are reflected in the writings of Charles Dickens. In his book Martin Chuzzlewit (1844), Dickens reflected his attitude toward nurses through his character Sairey Gamp (Figure 1.8). Mrs. Gamp was portrayed as a drunk, disreputable nurse who neglected, stole from, and physically abused the sick. This literary portrayal of nurses greatly influenced the negative image and attitude toward nurses in the 19th century. In contrast, the guardian angel or angel of mercy image arose in the latter part of the 19th century, largely because of the work of Florence Nightingale during the Crimean War. After Nightingale brought respectability to the nursing profession, nurses were viewed as noble, compassionate, moral, religious, dedicated, and self-sacrificing. Another image arising in the early 19th century that has affected subsequent generations of nurses and the public and other professionals working with nurses is that of the doctor’s handmaiden. This image evolved when women had yet to obtain the right to vote, when family structures were largely paternalistic, and when the medical profession increasingly applied scientific knowledge that, at that time, was viewed as a male domain. Since that time, several images of nursing have been portrayed. The heroine portrayal evolved from nurses' acts of bravery in World War II and their contributions in fighting poliomyelitis— in particular, the work of the Australian nurse Elizabeth Kenney. Other images in the late 1900s include the nurse as sex object, surrogate mother, and tyrannical mother. The nursing profession has taken steps to improve the image of the nurse. In the early 1990s, the Tri-Council for Nursing (the American Association of Colleges of Nursing, the American Nurses Association [ANA], the American Organization of Nurse Executives, and the National League for Nursing [NLN]) initiated a national effort, titled "Nurses of America," to improve the image of nursing. Launched in 2002, Johnson & Johnson corporation's “Campaign for Nursing's Future" promotes nursing as a positive career choice. Through various outreach programs, this campaign increases exposure to the nursing profession, raises awareness about its challenges, and encourages people of all ages to consider a career in nursing. ## Nursing Leaders Florence Nightingale, Clara Barton, Linda Richards, Mary Mahoney, Lillian Wald, Lavinia Dock, Margaret Sanger, Mary Breckinridge, Luther Christman, and Ernest Grant are among the leaders who have made notable contributions both to nursing's history and to American history. These nurses were all politically astute pioneers. Their skills at influencing others and bringing about change remain models for political nurse activists today. ### Nightingale (1820–1910) The contributions of Florence Nightingale to nursing are well documented. Her achievements in improving the standards for the care of war casualties in the Crimea earned her the title “Lady with the Lamp.” Her efforts in reforming hospitals and in producing and implementing public health policies also made her an accomplished political nurse: She was the first nurse to exert political pressure on government. Through her contributions to nursing education—perhaps her greatest achievement—she is also recognized as nursing's first scientist-theorist for her work in Notes on Nursing: What It Is, and What It Is Not (1860/1969). Nightingale (Figure 1.9) was born to a wealthy and intellectual family. She believed she was “called by God to help others... [and] to improve the well-being of mankind” (Schuyler, 1992, p. 4). She was determined to become a nurse in spite of opposition from her family and the restrictive societal code for affluent young English women. As a well-traveled young woman of the day, she visited Kaiserswerth in 1847, where she received 3 months' training in nursing. In 1853 she studied in Paris with the Sisters of Charity, after which she returned to England to assume the position of superintendent of a charity hospital for ill governesses. When she returned to England from the Crimea, a grateful English public gave Nightingale an honorarium of £4500. She later used this money to develop the Nightingale Training School for Nurses, which opened in 1860. The school served as a model for other training schools. Its graduates traveled to other countries to manage hospitals and institute nurse training programs. These training schools, at the time, accepted only females because Nightingale viewed nursing as being unsuitable for men. It is believed, unfortunately, that this perception has played a role in the invisibility of male nurses (Yi & Keogh, 2016, p. 95). Despite poor health that left her an invalid, Florence Nightingale worked tirelessly until her death at age 90. As a passionate statistician, she conducted extensive research and analysis. Nightingale is often referred to as the first nurse researcher. For example, her record keeping proved that her interventions dramatically reduced mortality rates among soldiers during the Crimean War. Nightingale’s vision of nursing changed society’s view of nursing. She believed in personalized and holistic client care. Her vision also included public health and health promotion roles for nurses. ### Barton (1821–1912) Clara Barton (Figure 1.10 □) was a schoolteacher who volunteered as a nurse during the American Civil War. Her responsibility was to organize the nursing services. Barton is noted for her role in establishing the American Red Cross, which linked with the International Red Cross when the U.S. Congress ratified the Treaty of Geneva (Geneva Convention). It was Barton who persuaded Congress in 1882 to ratify this treaty so that the Red Cross could perform humanitarian efforts in times of peace. ### Richards (1841–1930) Linda Richards (Figure 1.11 □) was America's first trained nurse. She graduated from the the New England Hospital for Women and Children in 1873. Richards is known for introducing nurse's notes and doctor's orders. She also initiated the practice of nurses wearing uniforms (ANA, n.d.c). She is credited for her pioneering work in psychiatric and industrial nursing. ### Mahoney (1845–1926) Mary Mahoney (Figure 1.12 □) was the first African American professional nurse. She graduated from the New England Hospital for Women and Children in 1879. She constantly worked for the acceptance of African Americans in nursing and for the promotion of equal opportunities (Donahue, 2011, p. 144). The ANA (n.d.e) gives a Mary Mahoney Award biennially in recognition of significant contributions in interracial relationships. ### Wald (1867-1940) Lillian Wald (Figure 1.13 □) is considered the founder of public health nursing. Wald and Mary Brewster were the first to offer trained nursing services to the poor in the New York slums. Their home among the poor on the upper floor of a tenement, called the Henry Street Settlement and Visiting Nurse Service, provided nursing services and social services, and organized educational and cultural activities. Soon after the founding of the Henry Street Settlement, school nursing was established as an adjunct to visiting nursing. ### Dock (1858-1956) Lavinia L. Dock was a feminist, prolific writer, political activist, suffragette, and friend of Wald. She participated in protest movements for women's rights that resulted in the 1920 passage of the 19th Amendment to the U.S. Constitution, which granted women the right to vote. In addition, Dock campaigned for legislation to allow nurses rather than physicians to control their profession. In 1893, Dock, with the assistance of Mary Adelaide Nutting and Isabel Hampton Robb, founded the American Society of Superintendents of Training Schools for Nurses of the United States, a precursor to the current National League for Nursing. ### Sanger (1879–1966) Margaret Higgins Sanger (Figure 1.14 □), a public health nurse in New York, has had a lasting impact on women's healthcare. Imprisoned for opening the first birth control information clinic in America, she is considered the founder of Planned Parenthood. Her experience with the large number of unwanted pregnancies among the working poor was instrumental in addressing this problem. ### Breckinridge (1881–1965) After World War I, Mary Breckinridge (Figure 1.15 □), a notable pioneer nurse, established the Frontier Nursing Service (FNS). In 1918, she worked with the American Committee for Devastated France, distributing food, clothing, and supplies to rural villages and taking care of sick children. In 1921, Breckinridge returned to the United States with plans to provide healthcare to the people of rural America. In 1925, Breckinridge and two other nurses began the FNS in Leslie County, Kentucky. Within this organization, Breckinridge started one of the first midwifery training schools in the United States. ### Christman (1915–2011) Luther Christman, one of the founders of the AAMN, graduated from the Pennsylvania Hospital School of Nursing for Men in 1939 and experienced discrimination while in nursing school. For example, he was not allowed a maternity clinical experience, yet he was expected to know the information related to that clinical experience for the licensing exam. After becoming licensed, he wanted to earn a baccalaureate degree in nursing but was denied access to two universities because of his gender. After receiving his doctorate, he accepted the position as dean of nursing at Vanderbilt University, making him the first man to be a dean at a university school of nursing. He accomplished many firsts: (a) the first man nominated for president of the ANA; (b) the first man elected to the American Academy of Nursing (AAN), which presented him with its highest honor by naming him a “Living Legend"; and (c) the first man inducted into ANA's Hall of Fame for his extraordinary contributions to nursing. The ANA currently bestows the Luther Christman Award, which acknowledges the valuable role of men in nursing (ANA, n.d.d). ### Grant (1958–) Ernest Grant made professional nursing history when he became the first male president of the American Nurses Association in January 2019. He is also the first African American man to serve as ANA vice president (Trossman, 2018). Grant began his distinguished nursing career as a student in a licensed practical nurse (LPN) program and progressed through baccalaureate and graduate nursing programs to earning a PhD in nursing from the University of North Carolina-Greensboro. After working early in his career at a burn center, he made this work his mission and is now recognized as an internationally known expert on burn care and fire safety. In 2002, President George W. Bush gave Grant a Nurse of the Year Award for his work treating burn victims from the 2001 terrorist attack on the World Trade Center in New York. His top priorities include ensuring that nurses have the educational opportunities and tools needed for the best client outcomes, encouraging nurses to become more politically involved, and encouraging young nurses to become involved with their national and state nursing associations (Nelson, 2019, p. 66). ## Political Nurse Activists Today The nursing profession continues to provide dynamic challenges to all nurses to keep current with the needs of the public and the role of the nurse. Current nursing leaders include presidents of national professional organizations; members of national foundations that contribute to high-quality, safe, client-centered care; and nurses who serve in public office. For example, in 2017 three nurses served in Congress (ANA, n.d.f) and a nurse, Dr. TrentAdams, became the first individual who is not a physician to serve as surgeon general (NLN, 2017b). Nursing leader Linda Burnes Bolton was vice chair of the Institute of Medicine Commission on the Future of Nursing and in 2011 was named one of the top 25 women in healthcare. Dr. Linda Cronenwett led the Quality and Safety Education in Nursing (QSEN) project, which identified the knowledge, skills, and attitudes (KSAs) that nurses must possess to deliver safe, effective care (AACN, n.d.b). In the 2018 midterm elections, Eddie Bernice Johnson (D-Texas), a former psychiatric nurse and the first nurse elected to Congress, was re-elected to a 14th term, and Lauren Underwood (D-Illinois), an RN who specializes in public health nursing and is a health policy expert, won the race for Illinois’ 14th Congressional District. These are just a few examples of contemporary nursing leaders. ## Nursing Education The practice of nursing is controlled from within the profession through state boards of nursing and professional nursing organizations. These groups also determine the content and type of education that is required for different levels or scopes of nursing practice. Originally, the focus of nursing education was to teach the knowledge and skills that would enable a nurse to practice in a hospital setting. However, as nursing roles have evolved in response to new scientific knowledge; advances in technology; and cultural, political, and socioeconomic changes in society, nursing education curricula have been revised to enable nurses to work in more diverse settings and assume more diverse roles. Nursing programs are based on a broad knowledge of biological, social, and physical sciences, as well as the liberal arts and humanities. Current nursing curricula emphasize critical thinking and the application of nursing and supporting knowledge to health promotion, health maintenance, and health restoration as provided in both community and hospital settings (Figure 1.16). There are two types of entry-level generalist nurses: the registered nurse (RN) and the licensed practical or vocational nurse (LPN or LVN). Responsibilities and licensure requirements differ for these two levels. The majority of new RNs are graduates of associate degree or baccalaureate degree nursing programs. In some states, an individual can be eligible to take the licensure exam through other qualifications such as completing a diploma nursing program or challenging the exam as a military corps person or LVN after completing specified coursework. The U.S. Navy and Marine Corps have a pathway to a commission in the Nurse Corps. Qualified enlisted men and women serving on active duty can apply to participate in the Medical Enlisted Commissioning Program (MECP). This program has been successful in increasing the diversity of nursing within the military. There are also “generic” master’s and doctoral programs that lead to eligibility for RN licensure. These latter programs are for students who already have a baccalaureate degree in a discipline other than nursing. On completion of the program, which may be from 1 to 3 years in length, graduates obtain their initial professional degree in nursing. Graduates of these programs are eligible to take the licensure examination to become an RN and may continue into specialty roles such as nurse practitioner or nurse educator. Although educational preparation varies considerably, all RNs in the United States take the same licensure examination, the National Council Licensure Examination (NCLEX-RN). This examination is administered in each state, and the successful candidate becomes licensed in that particular state, even though the examination is of national origin. To practice nursing in another state, the nurse must receive reciprocal licensure by applying to that state’s board of nursing. Some state legislatures have created a regulatory model called mutual recognition that allows for multistate licensure under one license. Nurses who have received their training in other countries may be granted registration after successfully completing the NCLEX. Both licensure and registration must be renewed regularly in order to remain valid. For additional information about licensure and registration, see Chapter 30 ∞. The legal right to practice nursing requires not only passing the licensing examination, but also verification that the candidate has completed a prescribed course of study in nursing. Some states may have additional requirements. All U.S. nursing programs must be approved by their state board of nursing. In addition to state approval, the Accreditation Commission for Education in Nursing (ACEN) provides accreditation for all levels of nursing programs, and the Commission on Collegiate Nursing Education (CCNE) accredits baccalaureate and higher degree programs. Accreditation is a voluntary, peer review process. Accredited programs meet standard requirements that are evaluated periodically through written self-studies and on-site visitation by peer examiners. ## Types of Education Programs Education programs available for nurses include practical or vocational nursing, registered nursing, graduate nursing, and continuing education. All levels of nursing are needed in healthcare today. Each has a unique scope of practice and by working collaboratively can help meet the often complex needs of clients. ### Licensed Practical (Vocational) Nursing Programs Practical or vocational nursing programs are housed in community colleges, vocational schools, hospitals, or other independent health agencies. These programs generally last 9 to 12 months and include both classroom and clinical experience. At the end of the program, graduates take the NCLEX-PN to obtain licensure as a practical or vocational nurse. Some LPN and LVN programs articulate with associate degree programs. In these ladder programs, the practical or vocational education component constitutes the first year of an associate degree program for registered nursing, and, if successful in passing the NCLEX-PN, students can work while continuing their registered nurse education. Practical nurses work under the supervision of an RN in numerous settings, including hospitals, nursing homes, rehabilitation centers, home health agencies, ambulatory care, and hospice. Although the scope of practice varies by state regulation and agency policy, LPNs usually provide basic direct technical care to clients. Employment of LPNs has shifted away from acute care settings to care of older adults in community-based settings, including long-term care. ### Registered Nursing Programs Currently, three major routes lead to eligibility for RN licensure: completion of a diploma, associate degree, or baccalaureate program. #### Diploma Programs After Florence Nightingale established the Nightingale Training School for Nurses at St. Thomas Hospital in England in 1860, the concept traveled quickly to North America. Hospital administrators welcomed the idea of training schools as a source of free or inexpensive staffing for the hospital. In early years, nursing education largely took the form of apprenticeship programs. With little formal classroom instruction, students learned by doing—that is, by providing direct care to clients. There was no standardization of curriculum and no accreditation. Programs were designed to meet the service needs of the hospital, not the educational needs of the students. Three-year diploma programs were the dominant nursing programs and the major source of nursing graduates from the late 1800s until the mid-1960s. Today's diploma programs are hospital-based educational programs that provide rich clinical experiences for nursing students. These programs often are associated with colleges or universities. Approximately 12% of RNs obtained their initial nursing education in diploma programs in 2017, which is a decrease of 5.4% since 2013 (Smiley et al., 2018, p. S15). #### Associate Degree Programs Associate degree nursing programs, which originated in the early 1950s, were the first and only educational programs for nursing that were systematically developed from planned research and controlled experimentation. Most of these programs take place in community colleges. The graduating student receives an associate degree in nursing (ADN) or an associate of arts (AA), associate of science (AS), or associate in applied science (AAS) degree with a major in nursing. Several trends and events prompted the development of these programs: (a) the Cadet Nurse Corps, (b) the community college movement, (c) earlier nursing studies, and (d) Dr. Mildred Montag's proposal for an associate degree. The Cadet Nurse Corps of the United States was legislated and financed during World War II to provide nurses to meet both military and civilian needs. The corps demonstrated that qualified nurses could be educated in less time than the traditional 3 years of most diploma programs. After World War II, the number of community colleges in the United States increased rapidly. The low tuition and open-door admission policy of these colleges, as well as their location in towns and cities lacking 4-year colleges and universities, made higher education accessible to more individuals by offering the first 2 years of a 4-year college program, as well as vocational programs that addressed community needs. Studies of nursing education, such as the Goldmark Report in 1923, the Committee on the Grading of Nursing Schools in 1934, and the Brown Report in 1948, also had a significant influence on the development of 2-year nursing programs. The recommendations in these reports supported the idea of independent schools of nursing in institutions of higher learning separate from hospitals. In the United States, associate degree nursing programs were started after Mildred Montag published her doctoral dissertation, The Education of Nursing Technicians, in 1951. This study proposed a 2-year education program for RNs in community colleges as a solution to the acute shortage of nurses that came about because of World War II. Dr. Montag conceptualized a “nursing technician” or “bedside nurse” able to perform nursing functions broader than those of a practical nurse, but lesser in scope than those of the professional nurse. At the end of the 2 years, the student was to be awarded an ADN and be eligible to take the state board examination for RN licensure. The first ADN program was established at Columbia University Teachers College in 1952 under the direction of Dr. Montag. Currently, 36.3% of all new RNs each year are initially educated in associate degree programs, which is a decrease of 1.9% since 2013 (Smiley et al., 2018, p. S15). Dr. Montag's original idea that these graduates be nursing technicians and that the degree become a terminal one did not last. In 1978, the ANA proposed that associate degree programs no longer be considered terminal, but part of a career upward-mobility plan. Today many students enter an associate degree program with the intention of continuing their education to the baccalaureate or higher level. Many community colleges have articulation agreements with college and university bachelor of science in nursing (BSN) programs to facilitate the upward mobility toward the BSN. RN to master of science in nursing (MSN) programs are also available to the associate degree nurse. #### Baccalaureate Degree Programs The first school of nursing in a university setting was established at the University of Minnesota in 1909. This program's curriculum, however, differed little from that of a 3-year diploma program. It was not until 1919 that the University of Minnesota established its undergraduate baccalaureate degree in nursing. Most of the early baccalaureate programs were 5 years in length. They consisted of the basic 3-year diploma program plus 2 years of liberal arts education. In the 1960s, the number of students enrolled in baccalaureate programs increased markedly. Almost 42% of RNs in the United States are initially educated in baccalaureate programs (Smiley et al., 2018, p. S15). Baccalaureate programs are located in senior colleges and universities and are generally 4 years in length. Programs include courses in the liberal arts, sciences, humanities, and nursing, including nursing leadership, nursing research, and community health nursing. Graduates must complete both the degree requirements of the college or university and the nursing program before being awarded a baccalaureate degree. The usual degree awarded is a BSN. Partially in response to the significant shortage of RNs, some schools have established accelerated BSN programs. These programs may include summer coursework in order to shorten the length of time required to complete the curriculum or may be a modified curriculum designed for students who already have a baccalaureate degree in another field. These “second degree” or “fast track” BSN programs can be completed in as little as 12 to 18 months of study. Many baccalaureate programs also admit RNs who have a diploma or associate degree. These programs typically are referred to as BSN completion, BSN transition, 2 + 2, or RN-BSN programs. Most RN-BSN programs have a special curriculum designed to meet the needs of these students. Many accept transfer credits from other accredited colleges or universities and award academic credit for the nursing coursework completed previously in a diploma or associate degree program. An increasing number of RN-BSN programs are offered online. In the four years between 2007 to 2011, there was an 86% increase in RN to BSN graduates (HRSA, 2013, p. 48). Because of changes in the practice environment, the nurse who holds a baccalaureate degree generally experiences more autonomy, responsibility, participation in institutional decision making, and career advancement than the nurse prepared with a diploma or associate degree. Some employers have different salary scales for nurses with a baccalaureate degree, as opposed to an associate degree or diploma. In addition, the American Nurses Credentialing Center (ANCC) requires a baccalaureate degree for initial basic certification in most nursing specialties, and certification often is rewarded with a salary increase. The Magnet Recognition Program, developed by the ANCC to recognize healthcare organizations that provide nursing excellence, requires that 75% of nurse managers hold at least a baccalaureate degree. Also, the Institute of Medicine’s (IOM) publication The Future of Nursing (2010) recommended that 80% of RNs be baccalaureate prepared by 2020. All of these points provide an incentive for nurses with diplomas and associate degrees to continue their formal preparation in baccalaureate completion programs. This is reflected in the increasing enrollment in RN to BSN programs. ### Graduate Nursing Programs Although graduate nursing programs, typical requirements for admission to a graduate program in nursing include the following: * Licensure