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Education for entry into practice: An ethical perspective
Education for Entry Into Practice: An Ethical Perspective JOANNED. HESS,MSN, RN*
Educational preparation for entry into nursing practice is an issue that has been the subject of intense debate among nursing educators and leaders, but it has yet to be resolved. This issue is surrounded by practice, licensure, and education dilemmas that are examined from an ethical perspective. The ethical principles of justice, fidelity, and utility are informed by an ethic of care and are used to analyze the implications of this issue and its associated dilemmas for the nursing student and graduate, the client and society, and the profession. Moral questions are raised that must be answered by nursing educators because the status quo in nursing practice, licensure, and education is morally unacceptable. (Index words: Education; Entry into practice; Ethics) J ProfNurs 12:289296, 1996. Copyright © 1996 by W.B. Saunders Company
URSES' ENTRY into practice begs for examina-
tion from an ethical perspective. From the N beginning this issue has presented education and
practice dilemmas that have provoked intense debate and division in the profession. These dilemmas arise not from bad intentions on the part of individuals or groups. Rather, the complexity of nursing education, practice, and licensure, plus the competing claims and needs of educators, employers, clients and society, and the profession, have contributed to the dilemmas surrounding this issue. Examining such dilemmas from an ethical perspective can aid in answering the question that ethical study universally addresses: "What is the right thing to do?" The moral course of conduct must be worked out in light of accepted ethical values and principles and a thoughtful investigation of facts relevant to the issue. At present, multiple educational tracts (diploma, associate degree, baccalaureate, entry-level master's, and entry-level doctorate) are used to prepare nurses for licensure and practice. With few exceptions, *Associate Professor, Department of Nursing, New Mexico State University,Las Cruces,NM. Address correspondenceand reprint requests to Ms Hess: 712 StagecoachDr, Las Cruces,NM 88011. Copyright © 1996 by W.B. SaundersCompany
8755-7223/96/1205-0008503.00/0
licensure laws and regulations have not changed nor has practice been differentiated to accommodate nurses with different types of education for different levels of practice. This article couples traditional ethical principles with an ethic of care to illuminate a key aspect of the entry into practice issue--education--from an ethical perspective. Such a perspective will not resolve this issue and its associated dilemmas, but it might provide insight into broader and ongoing decision making. There is rarely a simple choice between right and wrong in any issue but rather a balancing of legitimate claims and needs. In cases where not all parties in the decision-making process will get their way, ethical reflection must include using moral imagination to consider all those who are affected by the outcome. In the case of educational preparation for entry into practice, it is the student and graduate of different types of basic nursing education programs, the client and society, and the nursing profession that are affected and must be considered in resolving this issue. Background
Differentiation of nursing education and practice resulted from two recommendations made by Brown in 1948: (1) professionalize nursing by moving education from hospital-based programs into institutions of higher learning and (2) recognize that nurses can be categorized into professional and practical groups. In response to Brown's recommendations and the critical post-World War II nursing shortage, Montag (1951) proposed an experiment: differentiate between "technical" and "professional" nursing education and practice. The technical nurse, whose functions were conceived as falling in the intermediate range of a continuum from simple to complex, would be educated in associate degree nursing (ADN) programs in community colleges, and the professional nurse would be prepared in baccalaureate (BSN) programs in 4-year colleges and universities for practice at the higher end of the continuum. In 1965, the American Nurses Association's (ANA)
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position paper on education formally endorsed Montag's conceptualization of nursing education and practice by recommending the implementation of these levels of technical and professional education and practice. The association later set 1985 as the deadline for implementation. Twenty years after the 1965 position paper, delegates to the 1985 meeting of the ANA adopted a set of resolutions specifying legal titles and requesting changes in licensure requirements to accommodate the technical and professional categories of nursing education and practice (Lewis, 1985). Issue Dilemmas PRACTICE
In spite of Montag's (1951) plan and the ANA directives (1965), practice patterns have changed little to accommodate the two categories of education and practice. Although severaldifferentiated practice model experiments currently are being conducted in various parts of the country, the majority of these models use an assessment-based, not education-based, approach to hiring for different roles (Goertzen, 1991). In a review of studies done between 1966 and 1988 on differences between baccalaureate and associate degree nurses, Davis-Martin (1990) noted that service settings infrequendy used graduates of ADN and BSN programs differently. Yet, both Davis-Martin's review and Johnson's (1988) meta-analysis of research on differences in the performance of baccalaureate, associate degree, and diploma nurses have identified that baccalaureate nurses are better prepared for a broader range of nursing competencies and perform better in the professional role. It appears that Montag's (1951) original intent of ADN education--the preparation of nurses for the intermediate range of the continuum of nursing practice--is not being fulfilled because of marked differences between the intended role and current utilization of the ADN graduate. Nursing service administrators cannot be faulted for using ADN and BSN graduates interchangeably; in most professions education and licensure are responsive to the needs of employers and consumers, not vice versa, as is the case with nursing. Administrators must deal with the reality that the majority of the nursing work force consists of ADN and diploma graduates. As of March 1992, in every area of the country, on average approximately two thirds of working registered nurses had as their highest level of nursing education an ADN or a certificate from a diploma program (range, 44.1 per cent to 76.7 per cent), and
one third had at least the baccalaureate degree (range, 17.8 per cent to 41 per cent) (US Department of Health and Human Services, Public Health Service, 1992). LICENSURE
Current licensure laws and regulations also do not reflect ANA's (1965) and Montag's (1991) call for change. Only North Dakota has amended its nurse practice act to require separate licensure of technical and professional nurses. Maine is considering implementing a supplemental licensure examination for BSN-prepared graduates in 1994. Other attempts at changing nurse practice acts to require the baccalaureate degree as the minimum educational requirement for professional practice have failed (Velsor-Friedrich & Hackbarth, 1990). Forty-eight states still are unable or unsuccessful in addressing the issue of educational requirements for professional nursing practice. Opponents of two categories oflicensure correctly point out that there is no difference in National Council Licensing Examination (NCLEX) performance between ADN and BSN graduates. However, the current NCLEX validates only the technical knowledge of nursing and the minimum knowledge necessary for safe nursing practice (National Council of State Boards of Nursing [NCSBN], 1994).
•.. baccalaureate nurses are better prepared for a broader range of nursing competencies. . .
One possible explanation for the reluctance to change licensure laws may be that the defining characteristics of technical and professional practice remain subject to debate. Numerous attempts to identify technical and professional practice competencies have been made, with no nationwide consensus to date (Hickey et al., 1991; Labunski, 1991; National League for Nursing [NLN], 1993a; Primm, 1986). The development of these statements of the role performance expectations of technical and professional nurses has not resolved the issues of differentiated licensure and practice. One single nurse licensure examination serves to perpetuate the belief that there is no difference in the preparation and the competencies of nurses prepared by the various educational programs. The identical licensure of all nurses contributes to the similar use
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and compensation of technically and professionally prepared graduates throughout the health care system, regardless of the needs of the public and the system and the different competencies for which nurses are prepared. EDUCATION
Pressure from employers and the lack of agreement on licensure, combined with the ambiguity of meaning associated with the technical and professional roles, have resulted in a disparity between Montag's (1951) original ADN curriculum design and current ADN programs. For example, ADN nurses theoretically work with the supervision of higher educated nurses. In reality, the ADN graduate is assigned as team leader, charge nurse, and manager. A study by Schank & Stollenwerk (1988) pointed out that nurse executives employed ADN graduates in leadership and management positions using experience, not education, as a criterion for hiring. In response to such employment pressures, 92 per cent of ADN program directors in this study indicated that their curricula included a leadership and management practicum. It is not unusual for ADN programs to provide community health experiences and critical care content as well. Moreover, in recognizing that nursing is a humanistic discipline as well as a scientific one, ADN programs are requiring more courses in the humanities than ever before. The proliferation of content has resulted in many ADN programs requiring five or more semesters for students to complete 70-plus lower division academic credits. As the amount of nursing content being taught in ADN programs is increasing, so is the depth of the content. And the gap between ADN and BSN program content appears to be narrowing as ADN programs develop along lines different from Montag's (1951) original design, resulting in the blurring of professional and technical roles. The nurse caring for the hospitalized patient with congestive heart failure needs the same basic understanding of pathophysiology in order to do an adequate assessment, regardless of educational preparation. The ADN-prepared nurse administering medications to this individual should understand the kinetics, dynamics, and possible adverse reactions to these drugs to the same degree as the BSN graduate. However, the BSN student receives upper division credit, whereas the ADN student earns lower division credit for mastering the same nursing knowledge and skills. The changing health care system of today and the
foreseeable future has further augmented the disparity between the real and the ideal in ADN education. The NLN's vision for nursing education includes a shift in emphasis for all nursing education programs to ensure that all nurses are prepared to function in a communitybased, community-focused health care system (NLN, 1993b). Furthermore, the NLN believes that all programs must prepare students for the macro level of intervention rather than for individual patient situations; for greater authority, responsibility, and accountability; and for management roles. Yet, such competencies have been identified by the NLN as clearly in the realm of the professional, not technical, nurse (NLN, 1993a). This view of the needs of the health care system and the role of nurses within that system is not incongruent with ANA's (1991) agenda for health care reform and other recent conceptualizations of health care. NLN (1993b) acknowledges that "Differentiation among graduates solely on the basis of degrees is being replaced with differentiation on the basis of competencies needed in various patient situations and expected from the graduates of particular programs" (p. 9). It appears that these necessary and expected competencies will continue to dictate increasing depth and breadth of content in ADN programs.
PROPOSED SOLUTIONS
Multiple solutions to this issue and its associated dilemmas have been proposed and considered. Waters (1986, 1989, 1990) has been a thoughtful and vigorous proponent of a multilevel system of education for the foreseeable future because of current and anticipated economic and demographic forces. The NLN is another advocate for technical and professional educational tracts, but it couples that advocacy with a call to employers to "develop position descriptions recognizing distinctions between graduates of each type of program and to select, support and utilize nurses who will provide the most appropriate and cost-effective care" (1993a, p. 3) and a call to educators to make the necessary shifts in curricula noted above (1993b). Others advocate a two-tiered nursing education system but with separate licensure for the ADN and BSN graduate to ensure clear differentiation and appropriate utilization of nurses (Davis-Martin, 1990). Montag (1991), in revisiting her initial vision of nursing education and practice, suggests retaining the present system of examination and licensure for registered nurses for the ADN graduate and create a new title and examination for the baccalaureate-
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prepared nurse, a proposal not inconsistent with her original conceptualization. The NCSBN (1994) also proposes a supplemental examination for the BSN graduate for entry into professional nursing. Fagin and Lynaugh (1992) and Ross (1993), among others, argue that the baccalaureate degree must be the minimum preparation for nursing practice. Still others believe that nursing education should begin at the postbaccalaureate level in order to meet the needs of the health care system, clients and society, and the nursing profession (Parse, 1992; Watson & Phillips, 1992). Styles et al (1991) propose a solution based on a system of national certification and recognition by states of differentiated practice.
We are entering the 21st century without consensus on the appropriate system for conveying nursing knowledge.
We are entering the 21 st century without consensus on the appropriate system for conveying nursing knowledge. The issue of educational preparation for entry into practice is surrounded by dilemmas that must be resolved now. For resolution to take place, these dilemmas need to be considered in light of their impact on the nursing student and graduate, the client and society, and the nursing profession.
Ethical Perspective As a philosophical mode of inquiry that assists in understanding the moral dimensions of human behavior, ethics attempts to identify that which is good or desirable for human beings, that which is moral. A principle-based ethic to guide and justify moral decision making and choices has dominated western approaches to ethics and morality, including bioethics and nursing ethics. Principles such as autonomy, justice, fidelity, and beneficence have been used as tools by which decision-makers seek to ensure consistent standards and universal actions in dealing with moral dilemmas. In the recent past we have heard a growing chorus of those calling for the departure from exclusive reliance on the traditional principle-based ethics in nursing (Bishop & Scudder, 1990; Yeo, 1989). These voices have been joined by those crying out for a nursing ethic embodied in the caring ideal to provide
moral guidance in nursing--an ethic of care (Brody, 1988; Cooper, 1989, 1990; Davis, 1986; Fry, 1989; Watson & Ray, 1988). Such an ethic is founded on beliefs that the moral concern is with competing needs and corresponding responsibilities and that moral deliberations are contextual and relational (Gilligan, 1982; Noddings, 1984). An ethic of care can provide the profession and its educational institutions with a perspective from which to proceed in deliberating about the dilemmas generated by the entry into practice issue. Our moral concern is with the needs of the ones cared for (nursing students and graduates, clients and society, and the profession) and our corresponding responsibilities as they arise in the discipline's and profession's relationship with them. This concern will serve to inform a more traditional principle-based ethical consideration of the issue that follows. STUDENT AND GRADUATE
In preparing the ADN graduate to sit for the same licensure examination and to meet the same job expectations as the BSN graduate, is nursing education conducting itself morally? An ethic of care asks us to consider nursing education's responsibilities in meeting the needs of ADN and BSN students and graduates vis-~t-vis their preparation for licensure and practice. This consideration is congruent with the ethical principle of justice as identified by Rawls (1971) to apply to situations where individuals exert power or influence over others. In such situations, these individuals are in a position to make decisions and to execute them in a way that affects others' interests and well-being. The justice principle suggests that those with such power or influence over others are obligated to treat them fairly. Mill (1974) earlier described this principle in terms of rights and duties: giving a person what the individual deserves or is owed. Is the current ADN education fair to the student and graduate? Is this education giving graduates of both ADN and BSN programs what they deserve and what they need? According to a justice-based and a caring ethic, nursing education is responsible for providing at least two things to the ADN student. First, the student has the right and needs to be prepared adequately to meet the requisites of clients, employers, and the health care system. Employers continue to use ADN and BSN graduates interchangeably as a result of the lack of bilevel licensure and consensus on well-defined technical and professional competencies. The increasing
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demands of the health care system also have contributed to the blurring of roles. The ADN graduate was intended to care for patients with common, welldefined problems (as opposed to those with complex and interacting problems). Through cost-containment measures, such as diagnosis-related groups and early discharge, and through technological advances, the health care system has made the second category of patient the one the nurse is most likely to encounter in hospital practice. The family of that patient is as much the nurse's focus of care as the individual because of the increased need for discharge planning and health care coordination. Many ADN graduates practice in home health care and other community-based environments. It is only just that the ADN student be adequately prepared to meet these needs of employers and the health care system. Second, the ADN graduate has the right to the appropriate credential for the amount of learning that is required by the educational program. The number of credit hours and semesters, the amount of content, and the depth of that content need to be examined in relation to the expectations of programs other than nursing that confer associate degrees. The question of whether it is feasible to educate a nurse in fewer than five semesters and 70 credits to meet licensure and practice demands must be addressed. Educators are requiring too much education for what the ADN nurse originally was intended but are not giving them enough formal recognition for what is learned. Is the associate degree the appropriate credential for the nurse who has undergone the rigors of ADN education? In requiring increasing breadth and depth of content of the ADN student to prepare him or her for increasing responsibilities in the current and anticipated health care system, are we reducing the student to the "moral status of object" (Gadow, 1985; Watson, 1990)? The patient who is relegated to the moral status of object by a highly technological health care system is treated as a clinical object, an abstract body, free of the subjective experiences and meanings of life. Is the ADN student an object created to respond to system needs while the impact of these demands on the student physically, emotionally, and psychologically are ignored? Moreover, we have a commitment under an ethic of care to ease the other's vulnerability (Gadow, 1988). The student entering nursing education who only knows "I want to be a nurse" assumes that any program that prepares students for licensure must be an appropriate educational track. That student is exceedingly vulnerable to the consequences of the
profession's ambivalent decision making about what is truly appropriate education for nursing practice. This student is in the position of assuming that the amount of content he or she is learning is appropriate for the associate degree credential, licensure, and practice. BSN programs generally require eight semesters and a minimum of 120 credits for graduation. Except in certain instances where the BSN degree is required for public health and school nursing practice and in those rare instances where models of differentiated practice are being tested, the BSN student is being educated for the same job expectations and often the same salary as the ADN graduate. Is it just and fair to require of the BSN student such a tuition and time commitment differential for the same ends? Beyond the questions of whether ADN and BSN students and graduates are receiving what they deserve and need, what is nursing education modeling to them in its approach to the aforementioned dilemmas? We must model what we expect of the graduate in our relationship with the student to be philosophically and morally consistent. Education for entry into practice becomes part of what Bevis and Watson (1989) term the "hidden" curriculum what we teach by the hidden messages we send. If, as Noddings (1984) points out, we learn caring from being cared for, our approach to educating future ones who care should mirror caring. And, if we accept caring as the substantive base of nursing that informs not only its moral stance but its philosophy, praxis, and epistemology as well (Watson, 1985, 1988, 1990), and if we wish students and graduates to live that base, we only can deal with this issue in a caring manner.
CLIENT AND SOCIETY
Fidelity is a traditional ethical principle to be considered in examining the implications of the issue of education for entry into practice for the client-including individual patients, families, groups, and communities--and society. Fidelity is an ethical duty implicit in the nurse-patient relationship. It presupposes that the profession has a special knowledge and will use it to benefit the patient or client (Quinn & Smith, 1987). Fidelity further implies a commitment by the profession to ensure the competence of its members. For Gadow (1988), care is the ethical principle or standard by which nursing interventions are measured. The nurse's covenant of care with the patient is that nurse's commitment to alleviating that patient's vulnerability. Both fidelity and the moral covenant of
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care are viewed as ethical duties implicit in the nurse-client relationship. Is current nursing educational preparation the best model for meeting the needs of clients and society as measured against the yardsticks of fidelity and the covenant of care? For nursing to keep its professional commitment, there should be an adequate number of nurses to meet the needs of the client and the health care system. Yet, cyclical nurse shortages have occurred throughout this century. The effect of restructuring on these cycles is yet to be determined. As pointed out earlier, the majority of nursing students are enrolled in ADN and diploma programs. Although many BSN programs report rising enrollments, 77 per cent of the programs are turning away qualified applicants because of faculty, clinical, and classroom limitations (BSN schools, 1992).
There are those who believe that even 4 years are inadequate.., for educating a humanities-based professional n u r s e . . .
Just as the number of nurses must be adequate to meet demand, the profession's commitment to ensure the competence of its members also must be demonstrated. This commitment can be carried out only if nursing education is responsive to the needs of clients and society. There are those who believe that even 4 years are inadequate to provide the liberal arts and sciences necessary for educating a humanities-based professional nurse (Bevis & Watson, 1989; Parse, 1992). Moreover, by focusing on the technical in nursing to the exclusion of the intersubjective aspects of the nurse-dient relationship, we may be reducing the person, family, group, or community to the moral status of object. NURSING PROFESSION
The history of nurses' entry into practice issue has been fraught with bitter wrangling and division among educators, nursing service administrators, and nursing leaders. The experience of Illinois in unsuccessfully attempting to standardize nursing education in 1987 showed that there are many individuals, groups, and agencies who do not accept the BSN as the minimum educational requirement for licensure as professional nurses (Labunski, 1991; Velsor-Friedrich & Hackbarth, 1990). Testimony at hearings before North Dakota's Board of Nursing to change the state's
rules and regulations to standardize educational requirements for two entry levels of practice was consistently thoughtful and valid (Warner, Ross, & Clark, 1988). The divisiveness, anger, and hurt generated by this debate cannot be overemphasized or ignored. How are these sentiments affecting the nursing profession? From the traditional perspective of utilitarian theory, the value of this turmoil must be considered in terms of its cost. Utilitarian theory asks that one conscientiously attempt to determine the morally favorable course of action according to what produces the greatest possible balance of value over disvalue for all persons affected (Beauchamp & Childress, 1979). State legislators and policymakers deliberating changes in licensure laws and regulations view nurses as a divided constituency that is unclear on what is good public policy (Velsor-Friedrich & Hackbarth, 1990). Lack of consensus about educational preparation for nursing practice both within and among professional organizations undermines their strength and influence. Furthermore, a profession suffers when its members do not have clearly defined roles and educational paths to achieve those roles. Utilitarian theory urges that these costs to the profession be weighed against the benefits of resolving the issue in one way or another. Because of its inherently reciprocal nature, caring is reflected back on the one caring, who also gains from the caring encounter. In using an ethic of care to deliberate the consequences of the status quo and proposed solutions on students, graduates, clients, and society, the nursing profession can only gain. If caring is focused on the growth and self-actualization of the other, as Milton Mayeroff (1971) claims, then the nursing profession will benefit as an ethic of care toward students, graduates, dients, and society is mirrored back on itself. If caring is nursing's ontology, our profession can reflect that ontology only if it is embedded in our approach to this issue. To the uninitiated, caring may seem self-sacrificing. However, with the focus of caring reflected back on the profession, it becomes the ultimate self-serving device for nursing's survival. Moreover, from both a utilitarian and caring perspective, the cost to the nursing profession of not resolving this issue ethically might be a moral community of uncaring.
Conclusion
The current state of affairs in nursing education in regard to the entry into practice issue is ethically dubious. Consideration of this issue begs for an ethical
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perspective that softens the language of rights-andduties, fidelity, and costs-and-benefits with the notion of caring that involves context, intersubjectivity, covenant, and the easing of vulnerability. This dual perspective raises moral questions that must be addressed by nursing: • Is nursing education and the profession meeting the needs of its students and graduates? • Is the ADN student being prepared for the needs of clients, employers, the health care system, and the nursing profession in a just, fair, and caring manner? • Is the ADN graduate receiving just reward for the nursing educational program requirements? • Is BSN education just, fair, and caring to the student when the cost of that education is weighed against its value? • How might nursing education best keep its moral commitment to provide clients and society with an adequate number of competent nurses? • What are costs to the nursing profession in relation to the benefits of resolving this issue in one way or another? • What type of moral community are we creating by our inability to resolve this issue? • What type of moral community will we create with our proposed solution to this issue? Although moral judgments are judgments and not guarantees of moral correctness, the answers to each of
these questions should be considered in arriving at a solution to the issue of educational preparation for entry into practice. To answer the questions raised, nurses first must recognize that significant value tensions exist in this issue that demand resolution. Educators must examine the values guiding their choices and reach a consensus on what these values are. Such values should address beliefs about what comprises nursing's substance, nurses' roles and functions in the current and near-future health care system, and the professions commitment to its members and society. Only after identifying these values can an appropriate model for nursing education--one responsive to the needs of students, graduates, clients, society, and the profess i o n - b e formulated. To borrow the words of Watson (1990), "My plea is for informed passion, passion that is informed by thought, reflection, and contemplation, giving rise to moral landscapes and contexts of human and nature relational concerns" (p. 18). Our moral landscape and context must be exemplified in how we educate nurses for entry into practice. Ethics does not purport to provide a solution to this issue. Rather, it serves as a moral guide to decision-making. However the issue of educational preparation for entry into practice is resolved, nurses are morally obligated to consider the educational process and its outcomes in light of their moral implications for nursing students and graduates, clients, society, and the nursing profession. To continue to prepare nurses in both technical and professional programs for the licensure and practice status quo is morally unacceptable.
References
American Nurses Association. (1965). A position paper: Educational preparation for nurse practitioners and assistants to nurses. New York: Author. American Nurses Association. (1991). Nursing} agenda for health care reform. Kansas City, MO: Author. Beauchamp, T. L., & Childress, J. E (1979). Principles of biomedical ethics. New York: Oxford University Press. Bevis, E. O., & \Vatson, J. (1989). Toward a earing curriculum: A new pedagogyfor nursing. New York: National League for Nursing. Bishop, A. H., & Scudder, J. R. (1990). The practical, moral, and personal sense of nursing: A phenomenological philosophy of practice. Albany, NY: State University of New York Press. Brody, J. K. (1988). Virtue ethics, caring, and nursing. Scholarly Inquiry for Nursing Practice, 2, 87-96.
Brown, E. L. (1948). Nursing for the future. New York: Russell Sage Foundation. BSN schools see graduations gaining, more men choosing nursing careers. (1992). American Journal of Nursing, 92(6), 84, 88. Department of Health and Human Services, Public Health Service. (1992). The registered nurse population. Findings from the national sample survey of registered nurses. Rockville, MD: Author. Cooper, M. C. (1989). Gilligan's different voice: A perspective for nursing. Journal of Professional Nursing, 5, 10-16. Cooper, M. C. (1990). Reconceptualizing nursing ethics. ScholarlyInquiry for Nursing Practice, 4, 209-218. Davis, D. S. (1986). Nursing: An ethic of caring. Humane Medicine, 2(1), 19-25. Davis-Martin, S. (1990). Research on the differences
296 between baccalaureate and associate degree nurses. In G. M. Clayton & P. A. Baj (Eds.), Review of research in nursing education (Vol. 3; pp. 109-145). New York: National League for Nursing. Fagin, C., & Lynaugh, J. E. (1992). Reaping the rewards of radical change: A new agenda for nursing education. Nursing Outlook, 40, 213-220. Fry, S. T. (1989). Toward a theory of nursing ethics. Advances in Nursing Science, ••(4), 9-22. Gadow, S. (1985). Nurse and patient: The caring relationship. In A. H. Bishop & J. R. Scudder (Eds.), Caring, curing, coping: Nurse, physician, patient relationships (pp. 31-43). Tuscaloosa, AL: University of Alabama Press. Gadow, S. (1988). Covenant without cure: Letting go and holding on in chronic illness. In J. Watson & M. Ray (Eds.), The ethics of care and the ethics of cure: Synthesis in chronicity (pp. 5-14). New York: National League for Nursing. Gilligan, C. (1982). In a different voice. Cambridge, MA: Harvard University Press. Goertzen, I. E. (Ed.). (1991). Differentiating nursing practice: Selectedpapers from the 18th Annual Meeting and 1990 Conferenceof the American Academy ofNursing. Kansas City, MO: American Academy of Nursing. Hickey, M., Billings, D. M., Disch, J., Eagleton, B., Farrell, M. C., Turzan, L., & Vitello, J. M. (1991). Competence statements for differentiated nursing practice in critical care. Focuson Critical Care, 18, 286-293. Johnson, J. H. (1988). Differences in the performance of baccalaureate, associate degree, and diploma nurses: A meta-analysis. Researchin Nursing and Health, 11, 183-197. Labunski, A. J. (1991). Behavioral competencies for nursing practice. Nursing Outlook, 39, 174-177. Lewis, E. (1985). Taking care of business: The ANA house of delegates, 1985. Nursing Outlook, 33, 239-243. Mayeroff, M. (1971). On caring. New York: Harper and Row. Mill, J. S. (1974). Collected works. Toronto, Canada: Toronto University Press. Montag, M. (1951). The education of nursing technicians. New York: G. P. Putnam. Montag, M. (1991). Nursing, then and now. Advancing Clinical Care, 6(4), 12-15. National Council of State Boards of Nursing. (1994). Where are we now and where are we headed? In Proceedings of the 1994 Concurrent Educational Sessions of the National Council of&ate Boards of Nursing (pp. 113-165). Chicago: Author. National League for Nursing. (1993a). Differentiated competencies of new graduates: A draft report of the committee on competencies. New York: Author. National League for Nursing. (1993b). A vision for nursing education. New York: Author.
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Noddings, N. (1984). Caring: A feminine approach to ethics and moral education. Berkley, CA: University of California Press. Parse, R. R. (1992). Nursing knowledge for the 21st century: An international commitment. Nursing Science Quarterly, 5, 8-12. Primm, P. L. (1986). Entry into practice: Competency statements for BSNs and ADNs. Nursing Outlook, 34, 135-137. Quinn, C. A., & Smith, M. D. (1987). The professional commitment: Issues and ethics in nursing. Philadelphia: Sounders. Rawls, J. (1971). A theory of justice. Cambridge, MA: Harvard University Press. Ross, M. E. (1993). Settling an ongoing debate with one entry level. Nursing Forum, 28(3), 29-32. Schank, M. J., & Stollenwerk, R. (1988). The leadership/ management role: A differentiating factor for ADN/BSN programs? Journal of Nursing Education, 27, 253-257. Styles, M., Allen, S., Armstrong, S., Matsuura, M., Stannard, D., & Stocker-Ordway, J. (1991). Entry: A new approach. Nursing Outlook, 39, 200-203. Velsor-Friedrich, B., & Hackbarth, D. E (1990). A house divided. Nursing Outlook, 38, 129-133. Warner, S. L., Ross, M. C., & Clark, L. (1988). An analysis of entry into practice arguments. Image:Journal of Nuning Scholarship, 20, 212-216. Waters, V. (1986). Restricting the RN license to BSN graduates could cloud nursing's future. Nursing and Health Care, 7, 143-144. Waters, V. (1989). Transforming barriers in nursing education. In Curriculum revolution: Reeonceptualizing nursing education (pp. 91-99). New York: National League for Nursing. Waters, V. (1990). Associate degree nursing and curriculum revolution II. Journal of Nursing Education, 29, 322325. Watson, J. (1985). The philosophy and science of caring. Boulder, CO: Colorado Associated University Press. Watson, J. (1988). Nursing: Human science and human care. New York: National League for Nursing. Watson, J. (1990). Caring knowledge and informed moral passion. Advances in Nursing Science, 13(1), 15-24. Watson, J., & Phillips, S. (1992). A call for educational reform: Colorado nursing doctorate model as exemplar. Nursing Outlook, 40, 20-26. Watson, J., & Ray, M. A. (1988). The ethics of care and the ethics of cure: Synthesis in chronici~ New York: National League for Nursing. Yeo, M, (1989). Integration of nursing theory and nursing ethics. Advances in Nursing Science, 11(3), 33-42.
Educational preparation for entry into nursing practice is an issue that has been the subject of intense debate among nursing educators and leaders, but it has yet to be resolved. This issue is surrounded by practice, licensure, and education dilemmas that are examined from an ethical perspective. The ethical principles of justice, fidelity, and utility are informed by an ethic of care and are used to analyze the implications of this issue and its associated dilemmas for the nursing student and graduate, the client and society, and the profession. Moral questions are raised that must be answered by nursing educators because the status quo in nursing practice, licensure, and education is morally unacceptable. (Index words: Education; Entry into practice; Ethics) J ProfNurs 12:289296, 1996. Copyright © 1996 by W.B. Saunders Company
URSES' ENTRY into practice begs for examina-
tion from an ethical perspective. From the N beginning this issue has presented education and
practice dilemmas that have provoked intense debate and division in the profession. These dilemmas arise not from bad intentions on the part of individuals or groups. Rather, the complexity of nursing education, practice, and licensure, plus the competing claims and needs of educators, employers, clients and society, and the profession, have contributed to the dilemmas surrounding this issue. Examining such dilemmas from an ethical perspective can aid in answering the question that ethical study universally addresses: "What is the right thing to do?" The moral course of conduct must be worked out in light of accepted ethical values and principles and a thoughtful investigation of facts relevant to the issue. At present, multiple educational tracts (diploma, associate degree, baccalaureate, entry-level master's, and entry-level doctorate) are used to prepare nurses for licensure and practice. With few exceptions, *Associate Professor, Department of Nursing, New Mexico State University,Las Cruces,NM. Address correspondenceand reprint requests to Ms Hess: 712 StagecoachDr, Las Cruces,NM 88011. Copyright © 1996 by W.B. SaundersCompany
8755-7223/96/1205-0008503.00/0
licensure laws and regulations have not changed nor has practice been differentiated to accommodate nurses with different types of education for different levels of practice. This article couples traditional ethical principles with an ethic of care to illuminate a key aspect of the entry into practice issue--education--from an ethical perspective. Such a perspective will not resolve this issue and its associated dilemmas, but it might provide insight into broader and ongoing decision making. There is rarely a simple choice between right and wrong in any issue but rather a balancing of legitimate claims and needs. In cases where not all parties in the decision-making process will get their way, ethical reflection must include using moral imagination to consider all those who are affected by the outcome. In the case of educational preparation for entry into practice, it is the student and graduate of different types of basic nursing education programs, the client and society, and the nursing profession that are affected and must be considered in resolving this issue. Background
Differentiation of nursing education and practice resulted from two recommendations made by Brown in 1948: (1) professionalize nursing by moving education from hospital-based programs into institutions of higher learning and (2) recognize that nurses can be categorized into professional and practical groups. In response to Brown's recommendations and the critical post-World War II nursing shortage, Montag (1951) proposed an experiment: differentiate between "technical" and "professional" nursing education and practice. The technical nurse, whose functions were conceived as falling in the intermediate range of a continuum from simple to complex, would be educated in associate degree nursing (ADN) programs in community colleges, and the professional nurse would be prepared in baccalaureate (BSN) programs in 4-year colleges and universities for practice at the higher end of the continuum. In 1965, the American Nurses Association's (ANA)
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position paper on education formally endorsed Montag's conceptualization of nursing education and practice by recommending the implementation of these levels of technical and professional education and practice. The association later set 1985 as the deadline for implementation. Twenty years after the 1965 position paper, delegates to the 1985 meeting of the ANA adopted a set of resolutions specifying legal titles and requesting changes in licensure requirements to accommodate the technical and professional categories of nursing education and practice (Lewis, 1985). Issue Dilemmas PRACTICE
In spite of Montag's (1951) plan and the ANA directives (1965), practice patterns have changed little to accommodate the two categories of education and practice. Although severaldifferentiated practice model experiments currently are being conducted in various parts of the country, the majority of these models use an assessment-based, not education-based, approach to hiring for different roles (Goertzen, 1991). In a review of studies done between 1966 and 1988 on differences between baccalaureate and associate degree nurses, Davis-Martin (1990) noted that service settings infrequendy used graduates of ADN and BSN programs differently. Yet, both Davis-Martin's review and Johnson's (1988) meta-analysis of research on differences in the performance of baccalaureate, associate degree, and diploma nurses have identified that baccalaureate nurses are better prepared for a broader range of nursing competencies and perform better in the professional role. It appears that Montag's (1951) original intent of ADN education--the preparation of nurses for the intermediate range of the continuum of nursing practice--is not being fulfilled because of marked differences between the intended role and current utilization of the ADN graduate. Nursing service administrators cannot be faulted for using ADN and BSN graduates interchangeably; in most professions education and licensure are responsive to the needs of employers and consumers, not vice versa, as is the case with nursing. Administrators must deal with the reality that the majority of the nursing work force consists of ADN and diploma graduates. As of March 1992, in every area of the country, on average approximately two thirds of working registered nurses had as their highest level of nursing education an ADN or a certificate from a diploma program (range, 44.1 per cent to 76.7 per cent), and
one third had at least the baccalaureate degree (range, 17.8 per cent to 41 per cent) (US Department of Health and Human Services, Public Health Service, 1992). LICENSURE
Current licensure laws and regulations also do not reflect ANA's (1965) and Montag's (1991) call for change. Only North Dakota has amended its nurse practice act to require separate licensure of technical and professional nurses. Maine is considering implementing a supplemental licensure examination for BSN-prepared graduates in 1994. Other attempts at changing nurse practice acts to require the baccalaureate degree as the minimum educational requirement for professional practice have failed (Velsor-Friedrich & Hackbarth, 1990). Forty-eight states still are unable or unsuccessful in addressing the issue of educational requirements for professional nursing practice. Opponents of two categories oflicensure correctly point out that there is no difference in National Council Licensing Examination (NCLEX) performance between ADN and BSN graduates. However, the current NCLEX validates only the technical knowledge of nursing and the minimum knowledge necessary for safe nursing practice (National Council of State Boards of Nursing [NCSBN], 1994).
•.. baccalaureate nurses are better prepared for a broader range of nursing competencies. . .
One possible explanation for the reluctance to change licensure laws may be that the defining characteristics of technical and professional practice remain subject to debate. Numerous attempts to identify technical and professional practice competencies have been made, with no nationwide consensus to date (Hickey et al., 1991; Labunski, 1991; National League for Nursing [NLN], 1993a; Primm, 1986). The development of these statements of the role performance expectations of technical and professional nurses has not resolved the issues of differentiated licensure and practice. One single nurse licensure examination serves to perpetuate the belief that there is no difference in the preparation and the competencies of nurses prepared by the various educational programs. The identical licensure of all nurses contributes to the similar use
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and compensation of technically and professionally prepared graduates throughout the health care system, regardless of the needs of the public and the system and the different competencies for which nurses are prepared. EDUCATION
Pressure from employers and the lack of agreement on licensure, combined with the ambiguity of meaning associated with the technical and professional roles, have resulted in a disparity between Montag's (1951) original ADN curriculum design and current ADN programs. For example, ADN nurses theoretically work with the supervision of higher educated nurses. In reality, the ADN graduate is assigned as team leader, charge nurse, and manager. A study by Schank & Stollenwerk (1988) pointed out that nurse executives employed ADN graduates in leadership and management positions using experience, not education, as a criterion for hiring. In response to such employment pressures, 92 per cent of ADN program directors in this study indicated that their curricula included a leadership and management practicum. It is not unusual for ADN programs to provide community health experiences and critical care content as well. Moreover, in recognizing that nursing is a humanistic discipline as well as a scientific one, ADN programs are requiring more courses in the humanities than ever before. The proliferation of content has resulted in many ADN programs requiring five or more semesters for students to complete 70-plus lower division academic credits. As the amount of nursing content being taught in ADN programs is increasing, so is the depth of the content. And the gap between ADN and BSN program content appears to be narrowing as ADN programs develop along lines different from Montag's (1951) original design, resulting in the blurring of professional and technical roles. The nurse caring for the hospitalized patient with congestive heart failure needs the same basic understanding of pathophysiology in order to do an adequate assessment, regardless of educational preparation. The ADN-prepared nurse administering medications to this individual should understand the kinetics, dynamics, and possible adverse reactions to these drugs to the same degree as the BSN graduate. However, the BSN student receives upper division credit, whereas the ADN student earns lower division credit for mastering the same nursing knowledge and skills. The changing health care system of today and the
foreseeable future has further augmented the disparity between the real and the ideal in ADN education. The NLN's vision for nursing education includes a shift in emphasis for all nursing education programs to ensure that all nurses are prepared to function in a communitybased, community-focused health care system (NLN, 1993b). Furthermore, the NLN believes that all programs must prepare students for the macro level of intervention rather than for individual patient situations; for greater authority, responsibility, and accountability; and for management roles. Yet, such competencies have been identified by the NLN as clearly in the realm of the professional, not technical, nurse (NLN, 1993a). This view of the needs of the health care system and the role of nurses within that system is not incongruent with ANA's (1991) agenda for health care reform and other recent conceptualizations of health care. NLN (1993b) acknowledges that "Differentiation among graduates solely on the basis of degrees is being replaced with differentiation on the basis of competencies needed in various patient situations and expected from the graduates of particular programs" (p. 9). It appears that these necessary and expected competencies will continue to dictate increasing depth and breadth of content in ADN programs.
PROPOSED SOLUTIONS
Multiple solutions to this issue and its associated dilemmas have been proposed and considered. Waters (1986, 1989, 1990) has been a thoughtful and vigorous proponent of a multilevel system of education for the foreseeable future because of current and anticipated economic and demographic forces. The NLN is another advocate for technical and professional educational tracts, but it couples that advocacy with a call to employers to "develop position descriptions recognizing distinctions between graduates of each type of program and to select, support and utilize nurses who will provide the most appropriate and cost-effective care" (1993a, p. 3) and a call to educators to make the necessary shifts in curricula noted above (1993b). Others advocate a two-tiered nursing education system but with separate licensure for the ADN and BSN graduate to ensure clear differentiation and appropriate utilization of nurses (Davis-Martin, 1990). Montag (1991), in revisiting her initial vision of nursing education and practice, suggests retaining the present system of examination and licensure for registered nurses for the ADN graduate and create a new title and examination for the baccalaureate-
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prepared nurse, a proposal not inconsistent with her original conceptualization. The NCSBN (1994) also proposes a supplemental examination for the BSN graduate for entry into professional nursing. Fagin and Lynaugh (1992) and Ross (1993), among others, argue that the baccalaureate degree must be the minimum preparation for nursing practice. Still others believe that nursing education should begin at the postbaccalaureate level in order to meet the needs of the health care system, clients and society, and the nursing profession (Parse, 1992; Watson & Phillips, 1992). Styles et al (1991) propose a solution based on a system of national certification and recognition by states of differentiated practice.
We are entering the 21st century without consensus on the appropriate system for conveying nursing knowledge.
We are entering the 21 st century without consensus on the appropriate system for conveying nursing knowledge. The issue of educational preparation for entry into practice is surrounded by dilemmas that must be resolved now. For resolution to take place, these dilemmas need to be considered in light of their impact on the nursing student and graduate, the client and society, and the nursing profession.
Ethical Perspective As a philosophical mode of inquiry that assists in understanding the moral dimensions of human behavior, ethics attempts to identify that which is good or desirable for human beings, that which is moral. A principle-based ethic to guide and justify moral decision making and choices has dominated western approaches to ethics and morality, including bioethics and nursing ethics. Principles such as autonomy, justice, fidelity, and beneficence have been used as tools by which decision-makers seek to ensure consistent standards and universal actions in dealing with moral dilemmas. In the recent past we have heard a growing chorus of those calling for the departure from exclusive reliance on the traditional principle-based ethics in nursing (Bishop & Scudder, 1990; Yeo, 1989). These voices have been joined by those crying out for a nursing ethic embodied in the caring ideal to provide
moral guidance in nursing--an ethic of care (Brody, 1988; Cooper, 1989, 1990; Davis, 1986; Fry, 1989; Watson & Ray, 1988). Such an ethic is founded on beliefs that the moral concern is with competing needs and corresponding responsibilities and that moral deliberations are contextual and relational (Gilligan, 1982; Noddings, 1984). An ethic of care can provide the profession and its educational institutions with a perspective from which to proceed in deliberating about the dilemmas generated by the entry into practice issue. Our moral concern is with the needs of the ones cared for (nursing students and graduates, clients and society, and the profession) and our corresponding responsibilities as they arise in the discipline's and profession's relationship with them. This concern will serve to inform a more traditional principle-based ethical consideration of the issue that follows. STUDENT AND GRADUATE
In preparing the ADN graduate to sit for the same licensure examination and to meet the same job expectations as the BSN graduate, is nursing education conducting itself morally? An ethic of care asks us to consider nursing education's responsibilities in meeting the needs of ADN and BSN students and graduates vis-~t-vis their preparation for licensure and practice. This consideration is congruent with the ethical principle of justice as identified by Rawls (1971) to apply to situations where individuals exert power or influence over others. In such situations, these individuals are in a position to make decisions and to execute them in a way that affects others' interests and well-being. The justice principle suggests that those with such power or influence over others are obligated to treat them fairly. Mill (1974) earlier described this principle in terms of rights and duties: giving a person what the individual deserves or is owed. Is the current ADN education fair to the student and graduate? Is this education giving graduates of both ADN and BSN programs what they deserve and what they need? According to a justice-based and a caring ethic, nursing education is responsible for providing at least two things to the ADN student. First, the student has the right and needs to be prepared adequately to meet the requisites of clients, employers, and the health care system. Employers continue to use ADN and BSN graduates interchangeably as a result of the lack of bilevel licensure and consensus on well-defined technical and professional competencies. The increasing
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demands of the health care system also have contributed to the blurring of roles. The ADN graduate was intended to care for patients with common, welldefined problems (as opposed to those with complex and interacting problems). Through cost-containment measures, such as diagnosis-related groups and early discharge, and through technological advances, the health care system has made the second category of patient the one the nurse is most likely to encounter in hospital practice. The family of that patient is as much the nurse's focus of care as the individual because of the increased need for discharge planning and health care coordination. Many ADN graduates practice in home health care and other community-based environments. It is only just that the ADN student be adequately prepared to meet these needs of employers and the health care system. Second, the ADN graduate has the right to the appropriate credential for the amount of learning that is required by the educational program. The number of credit hours and semesters, the amount of content, and the depth of that content need to be examined in relation to the expectations of programs other than nursing that confer associate degrees. The question of whether it is feasible to educate a nurse in fewer than five semesters and 70 credits to meet licensure and practice demands must be addressed. Educators are requiring too much education for what the ADN nurse originally was intended but are not giving them enough formal recognition for what is learned. Is the associate degree the appropriate credential for the nurse who has undergone the rigors of ADN education? In requiring increasing breadth and depth of content of the ADN student to prepare him or her for increasing responsibilities in the current and anticipated health care system, are we reducing the student to the "moral status of object" (Gadow, 1985; Watson, 1990)? The patient who is relegated to the moral status of object by a highly technological health care system is treated as a clinical object, an abstract body, free of the subjective experiences and meanings of life. Is the ADN student an object created to respond to system needs while the impact of these demands on the student physically, emotionally, and psychologically are ignored? Moreover, we have a commitment under an ethic of care to ease the other's vulnerability (Gadow, 1988). The student entering nursing education who only knows "I want to be a nurse" assumes that any program that prepares students for licensure must be an appropriate educational track. That student is exceedingly vulnerable to the consequences of the
profession's ambivalent decision making about what is truly appropriate education for nursing practice. This student is in the position of assuming that the amount of content he or she is learning is appropriate for the associate degree credential, licensure, and practice. BSN programs generally require eight semesters and a minimum of 120 credits for graduation. Except in certain instances where the BSN degree is required for public health and school nursing practice and in those rare instances where models of differentiated practice are being tested, the BSN student is being educated for the same job expectations and often the same salary as the ADN graduate. Is it just and fair to require of the BSN student such a tuition and time commitment differential for the same ends? Beyond the questions of whether ADN and BSN students and graduates are receiving what they deserve and need, what is nursing education modeling to them in its approach to the aforementioned dilemmas? We must model what we expect of the graduate in our relationship with the student to be philosophically and morally consistent. Education for entry into practice becomes part of what Bevis and Watson (1989) term the "hidden" curriculum what we teach by the hidden messages we send. If, as Noddings (1984) points out, we learn caring from being cared for, our approach to educating future ones who care should mirror caring. And, if we accept caring as the substantive base of nursing that informs not only its moral stance but its philosophy, praxis, and epistemology as well (Watson, 1985, 1988, 1990), and if we wish students and graduates to live that base, we only can deal with this issue in a caring manner.
CLIENT AND SOCIETY
Fidelity is a traditional ethical principle to be considered in examining the implications of the issue of education for entry into practice for the client-including individual patients, families, groups, and communities--and society. Fidelity is an ethical duty implicit in the nurse-patient relationship. It presupposes that the profession has a special knowledge and will use it to benefit the patient or client (Quinn & Smith, 1987). Fidelity further implies a commitment by the profession to ensure the competence of its members. For Gadow (1988), care is the ethical principle or standard by which nursing interventions are measured. The nurse's covenant of care with the patient is that nurse's commitment to alleviating that patient's vulnerability. Both fidelity and the moral covenant of
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care are viewed as ethical duties implicit in the nurse-client relationship. Is current nursing educational preparation the best model for meeting the needs of clients and society as measured against the yardsticks of fidelity and the covenant of care? For nursing to keep its professional commitment, there should be an adequate number of nurses to meet the needs of the client and the health care system. Yet, cyclical nurse shortages have occurred throughout this century. The effect of restructuring on these cycles is yet to be determined. As pointed out earlier, the majority of nursing students are enrolled in ADN and diploma programs. Although many BSN programs report rising enrollments, 77 per cent of the programs are turning away qualified applicants because of faculty, clinical, and classroom limitations (BSN schools, 1992).
There are those who believe that even 4 years are inadequate.., for educating a humanities-based professional n u r s e . . .
Just as the number of nurses must be adequate to meet demand, the profession's commitment to ensure the competence of its members also must be demonstrated. This commitment can be carried out only if nursing education is responsive to the needs of clients and society. There are those who believe that even 4 years are inadequate to provide the liberal arts and sciences necessary for educating a humanities-based professional nurse (Bevis & Watson, 1989; Parse, 1992). Moreover, by focusing on the technical in nursing to the exclusion of the intersubjective aspects of the nurse-dient relationship, we may be reducing the person, family, group, or community to the moral status of object. NURSING PROFESSION
The history of nurses' entry into practice issue has been fraught with bitter wrangling and division among educators, nursing service administrators, and nursing leaders. The experience of Illinois in unsuccessfully attempting to standardize nursing education in 1987 showed that there are many individuals, groups, and agencies who do not accept the BSN as the minimum educational requirement for licensure as professional nurses (Labunski, 1991; Velsor-Friedrich & Hackbarth, 1990). Testimony at hearings before North Dakota's Board of Nursing to change the state's
rules and regulations to standardize educational requirements for two entry levels of practice was consistently thoughtful and valid (Warner, Ross, & Clark, 1988). The divisiveness, anger, and hurt generated by this debate cannot be overemphasized or ignored. How are these sentiments affecting the nursing profession? From the traditional perspective of utilitarian theory, the value of this turmoil must be considered in terms of its cost. Utilitarian theory asks that one conscientiously attempt to determine the morally favorable course of action according to what produces the greatest possible balance of value over disvalue for all persons affected (Beauchamp & Childress, 1979). State legislators and policymakers deliberating changes in licensure laws and regulations view nurses as a divided constituency that is unclear on what is good public policy (Velsor-Friedrich & Hackbarth, 1990). Lack of consensus about educational preparation for nursing practice both within and among professional organizations undermines their strength and influence. Furthermore, a profession suffers when its members do not have clearly defined roles and educational paths to achieve those roles. Utilitarian theory urges that these costs to the profession be weighed against the benefits of resolving the issue in one way or another. Because of its inherently reciprocal nature, caring is reflected back on the one caring, who also gains from the caring encounter. In using an ethic of care to deliberate the consequences of the status quo and proposed solutions on students, graduates, clients, and society, the nursing profession can only gain. If caring is focused on the growth and self-actualization of the other, as Milton Mayeroff (1971) claims, then the nursing profession will benefit as an ethic of care toward students, graduates, dients, and society is mirrored back on itself. If caring is nursing's ontology, our profession can reflect that ontology only if it is embedded in our approach to this issue. To the uninitiated, caring may seem self-sacrificing. However, with the focus of caring reflected back on the profession, it becomes the ultimate self-serving device for nursing's survival. Moreover, from both a utilitarian and caring perspective, the cost to the nursing profession of not resolving this issue ethically might be a moral community of uncaring.
Conclusion
The current state of affairs in nursing education in regard to the entry into practice issue is ethically dubious. Consideration of this issue begs for an ethical
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perspective that softens the language of rights-andduties, fidelity, and costs-and-benefits with the notion of caring that involves context, intersubjectivity, covenant, and the easing of vulnerability. This dual perspective raises moral questions that must be addressed by nursing: • Is nursing education and the profession meeting the needs of its students and graduates? • Is the ADN student being prepared for the needs of clients, employers, the health care system, and the nursing profession in a just, fair, and caring manner? • Is the ADN graduate receiving just reward for the nursing educational program requirements? • Is BSN education just, fair, and caring to the student when the cost of that education is weighed against its value? • How might nursing education best keep its moral commitment to provide clients and society with an adequate number of competent nurses? • What are costs to the nursing profession in relation to the benefits of resolving this issue in one way or another? • What type of moral community are we creating by our inability to resolve this issue? • What type of moral community will we create with our proposed solution to this issue? Although moral judgments are judgments and not guarantees of moral correctness, the answers to each of
these questions should be considered in arriving at a solution to the issue of educational preparation for entry into practice. To answer the questions raised, nurses first must recognize that significant value tensions exist in this issue that demand resolution. Educators must examine the values guiding their choices and reach a consensus on what these values are. Such values should address beliefs about what comprises nursing's substance, nurses' roles and functions in the current and near-future health care system, and the professions commitment to its members and society. Only after identifying these values can an appropriate model for nursing education--one responsive to the needs of students, graduates, clients, society, and the profess i o n - b e formulated. To borrow the words of Watson (1990), "My plea is for informed passion, passion that is informed by thought, reflection, and contemplation, giving rise to moral landscapes and contexts of human and nature relational concerns" (p. 18). Our moral landscape and context must be exemplified in how we educate nurses for entry into practice. Ethics does not purport to provide a solution to this issue. Rather, it serves as a moral guide to decision-making. However the issue of educational preparation for entry into practice is resolved, nurses are morally obligated to consider the educational process and its outcomes in light of their moral implications for nursing students and graduates, clients, society, and the nursing profession. To continue to prepare nurses in both technical and professional programs for the licensure and practice status quo is morally unacceptable.
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