If you hate accessible nursing education, say it…

I want to start this post with a disclaimer that I am a second-generation community, college-educated nurse. My mother and I attended the same Community College to become registered nurses, albeit many years apart. This topic is very personal for me. Unlike many people in my ancestral line before me, I had the option to pursue a university education. Still, I intentionally chose a community college associate degree in nursing (ADN) program for several reasons. The words to follow come from a place of years of personal frustration, disappointment, and rage. If you aren’t ready for that or wish to find a piece of neutral writing, you may want to move along. This is personal; however, I will always have receipts for you to see that I’m not just grasping at realities that aren’t there.

A New Hampshire state house representative, Linda Tanner, made some MALICIOUS and EXPLICITLY FALSE statements about community college-educated nurses. This discussion called into question the qualifications and skill of these nurses to provide care in a “technical situation” (whatever that means) and their ability to function as school nurses. See her “apology” here.

Note: Let me clarify some things for y’all. Registered Nurses who are educated via diploma and associate degree programs and Licensed Practical/Vocational Nurses receive education and clinical training to care for individuals across the lifespan from pediatric to geriatric populations respective to their level of education and licensure. Registered Nurses Prepared at the Associate Degree and Diploma level and working pediatrics (inpatient or outpatient)are also eligible to become board certified pediatric nurses through the American Nurses Credentialing Center (ANCC), the Pediatric Nursing Certification Board (PCNB), and the Board of Certification for Emergency Nursing (BCEN), just as their Baccalaureate-prepared colleagues.

An aside, because I like asides and want to provide some context and define critical terms. If you are familiar with nursing education acronyms and programs, please feel free to skip this section.

• By Community College (CC)Nursing Education, I am primarily referring to the associate degree in nursing (ADN) that leads to licensure as Registered Nurse (RN) and practical nursing diploma programs that lead to licensure as a Licensed Practical Nurse (LPN) (Also referred to as a licensed vocational nurse or LVN, in some states. LPN and LVN are essentially equivalent).
• The ADN is a category of degree. The particular degree may have slightly different letters, such as AAS (Associate of Applied Science in Nursing) or ASN (Associate of Science in Nursing).
• Both the AAS and ASN are categorically equivalent with few differences. Both types of associate degrees lead to licensure as an RN and fall under the larger umbrella term, associate degree in nursing (ADN).
• Associate Degree and Practical Nursing Diploma These educational qualifications are frequently often offered by, but not limited to, community colleges. Various Technical and Vocational Schools may also provide this level of nursing education, such as universities (see below). However, community colleges have historically been the most commons sites of ADN and PN nursing education.
• Several universities also offer associate degrees in nursing. Gardener-Webb University in North Carolina is unique in that it offers nearly all levels of undergraduate RN education. Gardner-Webb offers an Associate of Science in Nursing (ASN), Traditional Pre-licensure Bachelor of Science in Nursing (BSN), an Accelerated BSN (aka ABSN: for folks who have a Bachelors or higher in a non-nursing field and wish to get a Bachelors in nursing a bit more expeditiously), and an RN to BSN degree completion program (for folks who already have an ADN/RN Diploma and an RN license). Interestingly, according to their website, Louisiana Technical University only offers an Associate degree in nursing and no BSN option or beyond (as of the original date of this post).

For a more thorough overview of the various nursing education programs, check out this post on my blog, The Nursing Education Master Post. Warning, nursing education programs and structure can be dizzyingly overwhelming. Many nurses themselves have a hard time keeping everything straight. I tried to keep the post as concise as possible, but it’s still a lot.

OK, back to my point.

As much as I’d like to say that Representative Tanner’s comments were a singular example of efforts to minimize the education of community college-educated nurses, I can’t because it’s pretty standard behavior, sadly. Among the WORST offenders for insulting ADN/Diploma/and LPN education and practice are, prepare yourself, OTHER NURSES, followed by institutions that educate them or employ them. SHOCKER!!!

Except, it’s not a shocker at all. If you follow any of my social media accounts, I spend a lot of time waxing poetic about this topic; see my July 2020 Twitter thread and a more recent December 2020 thread. Beyond this, efforts and sentiments aimed at delegitimizing the community college nursing education pathways, like ADN and PN programs, have existed since the inception of these programs in the late 50s for the ADN (Mahaffey, 2002). The vast majority of these efforts have been rooted in ELITISM, CLASSISM, and RACISM, hiding behind the guise of “the advancement of our profession.” I’m calling the BULL right now because it’s that “advancement of the profession” guise that is part of the reason why we have misinformed State Representatives spouting harmful and inaccurate information about CC-educated nurses. Let’s get into it.

Note: When I mention my critique of nurses and institutions using “for the advancement of our profession” as the basis of their argument against ADN and LPN programs, many choose to believe I’m somehow “Anti-Education.” However, this is lazy, as I’ve devoted my professional and personal time to talking about making nursing education more accessible to more people. It is my commitment to helping change nursing education that makes me passionate about this topic. This topic, among many others, is part of the reason why I continued my education beyond my ADN to a BSN and Master of Science in Nursing, focusing on nursing education. I am committed to uplifting nursing and nursing education. Still, I have the lived experience of understanding that conversations about “advancing our profession” often lack CRITICAL context.

So often, the literature and online conversations about ADN and LPN education and practice lack understanding informed by critical race theory or an educational justice framework. We can’t afford to “advance the profession” in a way that leaves folks who are dependent on increased diversity in nursing and nursing education out of the picture. We can’t afford to cut off access to a nursing career path that can SIGNIFICANTLY change the life circumstances of potential nurses, but also the lives of those who have been significantly victimized by a system that wasn’t designed to support them.

So I am not anti-education. Instead, I’m ABSOLUTELY against educational designs and innovations that continue to harm and exclude those in our communities who are in the most need of support, PERIOD. The only ETHICAL way forward in nursing education and practice is in solidarity with the folks who are consumers of nursing work and those who could improve and expand what nursing work is and what it can be, yet who’ve been historically excluded and left behind.

WE SHOULD BE ABLE TO HAVE CONVERSATIONS ABOUT ADVANCING NURSING EDUCATION WITHOUT DENIGRATING NURSES WHO DEPEND ON ACCESSING SAID EDUCATION VIA COMMUNITY COLLEGES/ADN & RN DIPLOMA PROGRAMS/& LPN DIPLOMA PROGRAMS.

Unfortunately, that has not been the case. No matter how often organizations like the American Association of Colleges of Nursing (AACN) say, “it is not our intention to dismiss the importance of our ADN and LPN colleagues,” the fact is that is EXACTLY what they continue to do. The reality is that they say one thing and do another. Organizations like AACN have a history of weaponizing data about BSN outcomes to continue perpetuating needless and unhelpful hierarchies in nursing, such as insisting that “Professional Nursing” starts at the BSN. Many others have already asked us to inquire into what we mean by “professional” or “Professionalism” because often, what is meant is proximity to whiteness and affluence.

Another ADN critique from the academy is that BSN-prepared nurses are “more” prepared to act as leaders. I question this because we know that academic qualifications and coursework alone do NOT qualify one as a leader. We could ask that if one having a baccalaureate degree alone prepared one to be a better leader, we need to evaluate what we consider leadership because we have nurses, such as Dawn Wooten, LPN, who showed extraordinary leadership qualities in calling out the harm happening to immigrant women at an ICE detention center.

We constantly hear that BSN-prepared nurses are “more well-rounded” because of their education in the arts and sciences. However, we again must stop these assertions that academic coursework, ALONE, makes one more well-rounded. Now don’t confuse what I’m saying here. There is an UNDENIABLE value in the nursing curriculum, including a thorough exposure to the arts, various sciences, literature, foreign language, and more. However, despite an increase in the number of nurses with BSNs and advanced degrees, issues like racism, ableism, colonialism, and transmisia continue to be MAJOR issues within nursing and society, despite the increasing levels of education. We know that, in addition to education, folks’ intrinsic morality and qualities can accentuate or work against their education. Thus, framing a specific degree level as the PRIMARY determinant for leadership qualities, cultural humility, and empathy creates unrealistic expectations of individuals with said degrees, in this case, a BSN or higher. The danger of the narrative of “well-roundedness” is that it assumes that becoming well-rounded only happens within the confines of higher education. Community College students come from a wide variety of backgrounds and often are adults who bring in varied work and life experiences to their journey to become nurses.

And added thought…

I’ve never been one who is satisfied with reasonings for promoting academic progression in nursing being primarily sourced in external optics. For example, “we need to require more education to keep up with other professions” or “the nurse is the least educated person on the rounding team.” I call this a “keeping up with the Jones” mentality, which is problematic for several reasons. Chiefly, progression based SOLELY or HEAVILY on this line of reasoning fails to recognize nurses’ unique role in healthcare and society. Despite other professions having singular degree entry points at higher degree levels, they still cannot fulfill or replace nurses. Even more, when we focus the energy behind our desire for a more highly educated workforce from a “parity” perspective, we become blind to how we are leaving people behind. Nurses (and many other caregivers) show up for communities in unique ways; because of this, I think it is essential for us to relinquish ourselves from the tiring constant comparisons to other fields, like medicine. Nursing is NOT, nor will it ever be, medicine. As a profession, WE are not, or should not be, beholden to having to exist and grow as the discipline of medicine has. We are allowed to grow and exist as a profession in OUR OWN CREATIVE AND UNIQUE ways that meet the needs of the communities to which we serve and belong. For now, that means having multitiered access points to nursing education and practice (or On and Off ramps, as my friend Jerry Soucy, the Death Nurse, is fond of saying) because we are at a point in time where that is NEEDED. I believe nursing’s greatest advancement will come when we stop letting the confines of what has always been and what “others have done” bind us.

The reality is that the United States of America, for quite some time, has HEAVILY DEPENDED on the labor, expertise, and care that community college-educated nurses, as well as nurses educated in diploma programs. However, in my observations, the overall narrative surrounding the value and abilities of ADN and LPN programs is completed without much context. Much too often, subjective terms like “better” and “more qualified” are used in scholarly and non-scholarly discussions comparing and contrasting BSN and ADN/LPN qualifications. This is disappointing for many reasons, chiefly because many of these conversations fail to include meaningful discussions of the nuances that make such expressions more or less accurate according to the highly diverse socioeconomic circumstances across the United States.

A Little History

Community Colleges were founded on more open access to education, vocational training, and meeting community needs for a skilled workforce or services (Baime & Baum, 2016). The Baime and Baum report highlights that community colleges offer the public the opportunity to transfer to a 4-year university or immediately enter the workforce, often both. One of the most beautiful things about community colleges is that they are for EVERYONE. Regardless of your first language, your academic performance in high school (or even if you didn’t attend/finish high school), or your socioeconomic status, community colleges are open to you (generally speaking). Community colleges are particularly vital in rural areas, and it’s estimated that two-thirds of community colleges serve rural areas in the United States, according to the Rural Community College Association (RCCA). Does this mean that community colleges are perfect? By no means. Community colleges face their own challenges and require more diversity in their faculty and students, and more. However, community colleges give us a glimpse of what open access to higher education should/could look like.

According to Mildred Montag (1980), an interesting fact about the ADN degree is that “it was the FIRST nursing education program to be developed through research, rather than as a result of a historical accident.” Regarding the Associate Degree in Nursing (ADN), there are 1,100 ADN programs in the United States, according to the organization for associate degree nursing (OADN), with an estimated 81,000 nurses being produced from these schools annually. According to the 2017 data collected by the National Council of State Boards of Nursing (NCSBN), the average number of new RNs is approximately 155,000. I’ll let you do that math.

Some facts worth remembering:

1. According to the Future of Nursing 2030 report (page 193), as of 2020, ADN programs had the largest population of first-time NCLEX test-takers.
2. We still missed the 2020 deadline for achieving an 80% BSN-Prepared nursing workforce, outlined in the Institute of Medicine’s 2010 recommendations. Currently, the campaign for action estimates that approximately 57%-60% of all RNs in the United States have a BSN.
3. RNs initially prepared via the ADN or Diploma who enroll in and complete RN to BSN programs have made up nearly 50% (45% and more) of all BSN annually since 2015.
4. In many places, such as the state of NC, nurses educated in ADN & Diploma programs and LPNs are more evenly distributed across the state. For example, in NC, ADN and LPN nurses are more likely to be employed in underserved and rural areas. It is unlikely that NC is unique in this trend.
5. Sweeping assumptions that ADN/Diploma-prepared nurses and LPNs aren’t qualified to participate in community and population health ignore the realities of many areas of the country. In NC (my state of residence), RNs working in population health are less likely to hold a BSN, according to Dr. Jacqueline Nikpour (Slide 17). Moreover, Dr. Nikpour identified that 30% of NC RNs work in populational health settings versus 70% of LPNs.
6. Elizabeth Mahaffey highlighted that decisions and assumptions about ADN programs are often made from outdated data or a lack of information.

7. ADN programs often make access to a career in nursing more accessible to historically excluded and disadvantaged populations.

8. According to the American Association of Community Colleges (AACC) in 2020 the national average annual tuition at community colleges was $3,770 annually vs the public university annual national average of $10, 560. When it comes to enrollment, in 2019, community colleges held 41% of all undergraduates, 56% of native/indigenous, 53% of Latinx, and 43% of Black students. So let’s not act like we don’t know what’s going on when folks disparage community college education.

9. Data from the campaign for action shows us that ADN programs are more frequently used by historically excluded groups, including those in the White majority who come from rural areas and from areas with increased poverty. Once licensed, Black Nurses have been found to be more slightly likely to hold Masters or Doctorates in relevant fields, when compared with their white counterparts. ADN/Diploma/and LPN programs act as critical access points and launchpad for the careers of many Black, Brown, First-Generation, Second-Career, and people from impoverished backgrounds.

10. Until the creation of the academic journal, Teaching and Learning in nursing (TELN) there’s no significant evidence of efforts to establish scholarship and literature surrounding and focusing on data about ADN education. There still aren’t many major modern efforts to study RN Diploma and LPN programs, that I’m aware of. There simply isn’t much data or scholarship done on these programs, especially when compared with other types of nursing education programs. For the sake of transparency, I am on the editorial board of TELN Journal and I’m a member of the organization that created the journal, the organization for associate degree nursing (OADN).

We, as a profession, need to deeply interrogate the attitudes and assumptions made when discussing ADN and LPN education and comparison with baccalaureate nursing programs. Mainly when presented with the fact that pre-licensure BSN programs alone don’t produce nearly enough nurses to meet the needs of various geographic areas and the needs of an increasingly diverse population at this moment in time. Furthermore, pre-licensure BSN programs remain disproportionately inaccessible to many for various socioeconomic reasons. In a country that depends on the presence of ADN and LPNs to meet the needs of communities, we cannot afford to perpetuate divisive misconceptions and half-truths that alienate nurses trained in these programs. Any way “forward” that does not include VALUING and SUPPORTING the role that ADN-prepared nurses and LPNs do a disservice to the communities that we ALL serve.

*** Update 12/22/2022: Since the time of the original posting of this blog poat, the American Nurses Association (ANA) released a statement on JUNE 11th, 2022 on reckoning with racism in nursing, in response to the newly formed National Commission for Addressing Racism in Nursing. The statement can be read here and includes an acknowledgment (paragraph #9) about how their support for BSN-entry contributed to racism in nursing.