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Nursing’s Civil War

ADN v BSN
Nursing is at war with itself; the conflict is between associates degree nurses

against their siblings with a bachelors degree. The battles are being fought in many

arenas, from the med-surg floors of local hospitals, to the corridors of power in

Washington DC. “What should the entry level be for practice as a registered professional

in the United States?’ “Do BS prepared nurses provide safer care than their ADN

counterparts?”, “Should ADN programs be phased out all together?” These are just a few

of the questions facing nursing today, questions that pit nurse against nurse, and ADN

nurses against the most influential organization representing nursing in the United States,

the American Nurses Association (ANA). The issues in this quarrel have been tearing at

nursing for over forty years, and there is no easy end in sight.

In 1962 the ANA published a position paper that stated that the minimum

educational level for practice into nursing should be the bachelors degree. The ANA’s

position grew out of a need to give nurses a more professional science based education

making it less the apprenticeship based vocation it had mostly been to that point. At the

time of the publication of the position paper 78% of new nursing graduates received their

education from a hospital based diploma program. This schooling lasted three years and

at the end the student received a diploma. Due in large part to the efforts of the ANA by

2000 the number of diploma graduate nurses had been reduced to 29.6% (Nelson,

2002,”Looking Backward” Para 2), by 2010 only 4% of nursing graduates sitting for their

state licensure examination were educated in vocational diploma awarding programs. The

ANA’s glass though was only half full, filling the vacuum left by the vanishing hospital

based programs were schools of nursing based in community and junior colleges that

awarded associates degrees.


In 1950 Dr. Mildred Montag received her Ed.D. from Teachers College,

Columbia University. In her dissertation Dr. Montague made a proposal for a new kind of

nurse to help ease the severe nursing shortage that existed to this time. This nurse was to

be dubbed a “nursing technician” their education was to last two years, and their role was

to be as an assistant to the “professional nurse”. Dr. Montag’s goals in creating these

programs were to “alleviate the critical nursing shortage, to provide a sound educational

base for nursing instruction by placing these programs in junior or community colleges

The programs that Dr Montag and her team were responsible for creating have become

today’s ADN programs. (Haase, 1990, p. 26-27) The first associates degree program in

nursing was started at New Jersey’s Farleigh Dickinson University in 1952 (Ironically,

this program was phased out in 1970, being replaced by a BSN program) This program

and four more pilot programs like it were wildly successful and were quickly copied. 25

years after their introduction there were over 700 schools of nursing in the United States

offering the associates degree, today there are more than 800. These programs graduated

60% of the new nurses sitting for their state’s licensure exam in 2010. As in 1952 these

programs continue to attract a higher percentage of non-traditional students, which

include males, older students and minorities. (Haase, 1990, p.38) Dr Montag reported that

the graduates of her pilot programs were able to pass the state boards and function as staff

nurses (Haase, 1990, p.40) .

Controversy notwithstanding a patient who receives care from a BSN nurse has

better outcomes and is safer than those treated by ADN nurses. It should be inconceivable

that there is such controversy surrounding this issue; BSN equals better, cheaper, safer

care Nursing, nurses the health care community and society as a whole should be
advocating for the BS to be the minimum degree required for entry into practice as a

registered nurse. There are however several factors which have kept this from happening.

In 2010, 60% of nurses graduating from nursing school in the United States received

associates degrees. Projections are that there will be a shortage of approximately

1,016,900 by 2020 (US: Supply versus Demand Projections for FTE Registered Nurses,

Source: Data from the Bureau of Health Professions. (2004)) The current output from all

nursing schools BS, ADN and diploma now in existence would have to be increased 90%

in order to meet this projected shortfall. In addition to the nursing shortage there is

currently no political will to change the Nurse Practice act to make the bachelors degree

the minimum degree required for entry into practice. North Dakota was the only state in

the union to have this requirement, but this was subsequently overturned in 2003 when a

group which included nurses, long term care facilities and community colleges

successfully lobbied to have this requirement repealed. These factors plus the shortage of

nursing faculty, the lack of funding for associates nurses to return to school etc make the

quest to raise the educational requirement difficult for the foreseeable future.

There are currently 18 states that have legislation pending that would require

nurses who currently hold associates degrees to return to school and obtain their BSN

within 10 years of graduating from nursing school. In New York this requirement would

be incumbent on nurses who graduate from nursing school after 2012. The same powerful

forces that aligned against the legislation in North Dakota are coming out again to lobby

for this bills defeat. This time though there are equally important forces united in an

attempt to see these bills through to passage, and they have some powerful

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