The baccalaureate degree in nursing as an entry-level requirement for professional nursing practice

The Baccalaureate Degree in Nursing As an Entry-Level Requirement for Professional Nursing Practice LINDAA. JACOBS, MS, RN,* MARYJANEK. D I M A T T I O , MSN, RN,t T viMI L. BISHOP,MSN, RN,$ AND SHELDOND. FIELDS,MS, RN~

The education of professional nurses must take place in institutions of higher learning with a bachelor of science in nursing degree required for beginning professional practice. Nurses educated in these academic settings should be socialized as professionals with a philosophical and value system that is compatible with this role. This education should be flexible, diverse, and directed toward providing the nurse with a solid base for general, professional nursing practice. Nursing as a profession is a social institution and must present itself as a strong, unified profession to survive the inevitable changes occurring on the health care front. By tracing the evolution of the entry-intopractice dilemma, a systems archetype and two mental models that currently drive nursing and jeopardize its potential to meet the demands of the emerging health care market are identified. The authors offer a high-leverage solution to the entry-into-practice dilemma that they believe will strengthen the nursing profession. (Index words: Entry into practice; Highleverage action; Mental models; Systems archetype) J Prof Nurs 14:225-233, 1998. Copyright © 1998 by W.B. Saunders Company

*Doctoral Student, School of Nursing, University of Pennsylvania, Philadelphia, PA. ~Doctoral Student, School of Nursing, University of Pennsylvania, Philadelphia, PA. #Doctoral Student, School of Nursing, University of Pennsylvania, Philadelphia, PA. ~Doctoral Student, School of Nursing, University of Pennsylvania, Philadelphia, PA. Address and reprint requests correspondence to Ms Jacobs: 133 Valley Rd, Ardmore, PA 19003-1510. Copyright © 1998 byW.B. Saunders Company 8755-7223198/1404-0010503.00/0

verse, and directed toward providing the nurse with a solid base for general, professional nursing practice. Nursing leaders who have resisted change have overlooked the fact that nursing as a profession is a social institution, and social institutions, many of long standing, crumble and change as a result of a society's reordering of priorities and values (Aydelotte, 1972). Nursing must present itself as a strong, unified profession to survive the inevitable changes on the health care front. In this way we will help to ensure that patients and their families receive quality care from licensed, certified, knowledgeable nursing professionals. This would require that nursing leaders and educators come together as professionals and dispel many of the philosophical barriers to standardizing the entrylevel educational requirements. The philosophical differences that exist within the profession have blocked unity in nursing and have served as obstacles to nursing's advancement as a profession. Aydelotte (1972) warned that if nursing fails to restructure social relationships to meet society's needs, "society will surely place the charge they have given us elsewhere" (p. 23). Peter Senge (1990) predicted that the most successful organizations of the future would be learning organizations. Learning organizations are those wherein "people continually expand their capacity to create the results that they desire" (p. 3). These organizations are cocreated by leaders who tap people's commitment and capacity to learn at all levels of the organization. The authors believe that nursing must become a learning organization to meet society's needs both in the near and distant future. As a learning organization, nursing must master what Senge (1990) refers to as "the five learning disciplines." This article will focus on two of the five: systems thinking and mental models. Systems thinking, which is the cornerstone of the five disciplines, allows the organization to identify the patterns that drive current situations thereby freeing the organization from forces that were previously unseen. Repeti-

Journal ofProfessionalNursing,Vo114, No 4 (July-August),

1998: pp 225-233

ANY PROBLEMS that plague nursing are a M result of nursing s failure as a profession to set standards at the entry level. The education of professional nurses must take place in institutions of higher learning with a bachelor of science in nursing (BSN) degree required for beginning professional practice. Nurses educated in these academic settings should be socialized as professionals with a philosophic and value system that is compatible with this role (Aydelotte, 1991). This education should be flexible, di-

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tive patterns that appear in organizations are called systems archetypes. When an organization is able to identify which archetypes are operational, the organization can employ high-leverage actions. Senge states that high-leverage actions are well-focused and produce significant and enduring improvements. Highleverage actions, however, will not succeed if they are in conflict with the tacit assumptions that drive the organization's thinking. The learning discipline described as mental models allows the organization to acknowledge unspoken assumptions that must be modified or abolished. By tracing the evolution of the entry-into-practice dilemma, the authors identified a systems archetype and two mental models that currently drive nursing and jeopardize its potential to meet the demands of the emerging health care market. In this article, the authors recommend a high-leverage solution that they believe will strengthen the organization of nursing. Evolution of the Issue HISTORICAL OVERVIEW OF THE ISSUE

The move to university education for most professions occurred in the early decades of the 20th century. The first official school of nursing in a university was established in 1909 at the University of Minnesota, and by 1920, 180 schools of nursing reported having college affiliations. Sigma Theta Tan, nursing's honor society, was founded at Indiana University with the expectation that the baccalaureate degree was to be required for entry into practice (McBride, 1996). In 1910, the Carnegie Foundation funded a study of medical education in this country that revealed the existence of substandard schools of medicine and resulted in the closing of inferior schools. This study came to be known as the Flexner report and resulted in the standardization of medical education in this country (Doering, 1992). At that time, nursing leaders proposed a similar study in nursing. The Rockefeller Foundation funded this study, which came to be known as the Goldmark report (1922). The study examined the problems facing the profession and the establishment of recommendations for minimum educational standards. This study was viewed as an opportunity (1) to bring nursing out of a wasteful apprenticeship-type training into an ordered, systematic, and dignified educational system comparable to that of the other professions and (2) to establish sound minimal educational standards. Two other committees developed in the 1920s issued reports on problems that they projected would con-

cern nursing for the remainder of the 20th century. The standardization of nursing education was one of these issues (McBride, 1996). However, nursing leaders did not respond to these reports in the same way that medicine responded to the Flexner report, and nursing education was not standardized. In 1948, the Brown report, considered nursing's equivalent of the Flexner report in medicine, urged that only college graduates be regarded as truly professional. At the same time, the Committee on the Function of Nursing recommended the upgrading of requirement standards for the licensed practical nurse (LPN) to an associate degree in nursing (ADN) and for the registered nurse to a BSN degree (McBride, 1996). Neither of these recommendations were acted on. The early part of the 20th century was the time for nursing to move into the university with other professions. However, this move was opposed by hospitals, physicians, and nurses. Baer (1992) stated that she believes the conflicts in nursing education arose because nursing got caught in a time warp. Nursing as a profession developed in the 19th century when women stayed home, and self-sacrifice drew admiration. As the 20th century ends, self-sacrifice is passS, women can do whatever they want to do, the number of men in nursing has increased, science is society's authoritative source, and medical miracles happen every day. Nursing, however, seemingly frozen in time in the 1930s, dings to old ways while a new world rushes past. It is time to get nursing ready for the 21st century (Baer, 1992).

In 1948, the Brown report.., urged that only college graduates be regarded as truly professional

Associate-degree nursing education was proposed in

1951 by Mildred Montag, a nurse educator. At that time it was thought that technical nurses, educated in the rapidly expanding community colleges of the nation, would replace the diploma school nurses. In turn, the baccalaureate nursing graduates would be accountable for patient care and direct the work of these nurse technicians (Lynaugh, 1992). ADN programs have largely replaced diploma programs in the last 40 years, but they became another means of acquiring the registered nurse (RN) credential (McBride, 1996). Diploma schools, associate-degree pro-

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grams, and baccalaureate programs are still preparing individuals to sit for the same examination, which, if passed, authorizes them to practice as professional nurses and permits them all to use the RN title (Aydelotte, 1991). This inability to differentiate levels of nursing practice responsibilities on the basis of educational preparation or any other abstract standard was identified by Lynaugh (1992) as one of the most intractable problems of 20th-century nursing. In 1964, the Comprehensive Nurse Training Act was signed into law, and it was within this framework that the American Nurses Association (ANA) undertook the study and examination of nursing education, the nature and characteristics of nursing practice, and the scope of preparation and responsibilities of nurses. As a result of this study, in 1965, the ANA Committee on Education prepared the association's first position paper on education for nursing. The committee identified that nursing practice had become complex, would continue to do so, and that nursing education, like that of any other profession, should be determined by the structure of society and its prevailing values. The committee proposed that education for those who work in nursing take place in institutions of learning within the general system of education (ANA, 1965). The position paper compared nursing with science, engineering, architecture, business, and medicine, professions that had already recognized the important contributions that could be made by the technician. The position paper stated that the professional nurse could not master all of the measures necessary for the care of patients, and it proposed that the nurse educated in associate-degree, 2-year programs would be the nurse technician (ANA, 1965). Leaders of this movement believed that these changes would insure that nursing would exercise its rightful voice and influence in the health care of the future. These proposals were met with tremendous controversy within the nursing community and after years of debate and revisions, the recommendations outlined in the position paper were not adopted by the profession. Once again groups of nurses acted against each other out of fear rather than working together to find solutions acceptable to all (Baer, 1992). The ANA has battled the entry-into-practice issue for more than 30 years. In 1985, the ANA issued a policy/position statement that urged state nurses' associations (SNAs) (1) to establish the baccalaureate degree in nursing as the minimum educational requirement for licensure to practice professional nursing, (2) to retain the legal title of registered nurse for professional nurses and the associate degree in nursing as the

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educational requirement for licensure to practice technical nursing, and (3) to go on record as supporting the legal title of associate nurse for the technical level of nursing (ANA, 1995). In Nursing's Social Policy Statement, issued in 1995, the ANA agreed to declare the baccalaureate degree in nursing as the educational requirement for the registered nurse. The ANA also stated that they would develop and provide resources to assist and support SNAs in their efforts (1) to persuade nurses, educational and health care institutions, legislators, and the public of the importance of adopting this educational standard and (2) to develop and implement strategies to facilitate nurses obtaining baccalaureate preparation in nursing to enhance their marketability in a highly competitive, restructuring health care delivery system (ANA, 1995 ). The ANA has maintained its position on entry into practice since the position paper in 1965. However, the ANA has been unable to mandate this requirement because of opposition from the SNAs. Many SNAs require membership in the ANA for nurses belonging to unions, and many of these nurses are graduates of ADN programs. In return, the ANA acts as the collective bargaining unit for these nurses. If the ANA mandated the BSN as entry into practice, they could lose the support of many SNAs. According to Aydelotte (1991), the system of nursing education today is the result of unplanned and undirected evolution, compromise, timidity, and lost opportunity! Today, North Dakota is the only state that has successfully implemented the requirement of a BSN degree for entry into practice as an RN and an ADN for those practicing as LPNs. This policy has been in existence since 1987. The changes were implemented through the North Dakota Board of Nursing by rewriting the regulatory rules. The new regulations include a "grandfather clause" for all practicing RNs and students who entered nursing programs before 1987. This regulation allows these nurses to continue to practice in North Dakota regardless of their educational credentials. The students entering nursing programs after 1987 are required to be BSN prepared to practice as an RN and ADN prepared to practice as an LPN in North Dakota. It is important to emphasize that this action was implemented under the North Dakota Board of Nursing regulatory powers and not through state legislation. However, in 1989, there was a nursing shortage in North Dakota that resulted in this becoming a political issue. At that time, the state established a temporary licensing policy for nurses moving into

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North Dakota. This policy allowed a nurse educated in an ADN program to practice as an RN with a temporary 4-year license if he or she demonstrated that they were currently enrolled in a BSN program (Milburn & Lambeth, 1994). Discussion of the Issue

The entire nursing profession bears the negative consequences of the lack of distinction between graduates from nursing programs. There has been increasing pressure from consumers, employees, legislators, third-party payers, and others to upgrade the educational system for nurses to ensure the quality of nursing care and to clearly differentiate the competencies of different types of nurses. Aydelotte (1991) stated that the diversity of education and lack of a universally accepted minimum content base make it impossible to generalize about a nurse's knowledge and skills. Nursing practice must be based on a set of standards, and these standards cannot be defined unless the profession deals with the issue of educational preparation. The structure of health care in this country is changing, and nurses are needed who can introduce changes in nursing practice and in the organization of this resource-driven system. Nurses must be capable of making contributions to nursing science as well as influencing and shaping national and local policies.

The entire nursing profession bears the negative consequences of the lack of distinction between graduates from nursing programs.

In addition, nursing must begin to pay closer attention to how the image of nursing plays a role in determining who will enter the profession. The results of a 1989 study by Kaler, Levy, and Schall underscore the need for increased public awareness that nurses are scholars and leaders. The research findings showed that the public perceives the nurse as having academic preparation similar to that of a therapist or librarian. They were seen as less logical, less intelligent, more extroverted, and less of a leader than physicians. These researchers identified that their findings were consistent with the earlier research of Kalisch and Kalisch (1987), who conducted extensive research on the image of nurses in the media. A change in the public

image of nursing requires better educated nurses and a change in nursing's image of itself. It is the responsibility of nursing professionals to change this image. Much of nursing's future is at stake in the changing health care environment. Aydelotte (1991) wrote that the impact of nursing education on future nursing services in this country and worldwide are not to be underestimated. Nursing education is the foundation on which the quality of nursing care rests and from which the knowledge base for practice evolves. As nursing moves through the 1990s, the nursing profession continues to debate problems that have their origins in nursing's history and culture and the society in which nursing finds itself (Aydelotte, 1991). THE CURRENT HEALTH CARE MARKET

There have been significant changes in the health care market during the last 10 years that impact nursing and influence the entry-into-practice debate. Some of these market changes include (1) the impact of managed care, (2) the nursing work force supply, (3) the downsizing, closing, and restructuring of hospitals, and (4) the shift of care to the community and other nonhospital settings. MANAGED CARE

Managed care is a major force in health care delivery today. The first integrated health plans, Kaiser Permanente in California and the Health Insurance Plan of New York, were developed 50 years ago. Such plans have steadily grown since that time, and similar plans have been developed all over the country (Friedman, 1996). The terminology of health maintenance organizations (HMOs) emerged in the late 1960s when rising health care costs continued the growing interest in prepaid health care models. The passage of the 1973 HMO Act provided loans and grants to further support the development of HMOs (Drew, 1990). Since the passage of this act, managed care organizations (independent practitioner associations, preferred provider organizations, networks, group practice) have continued to grow. In 1980, there were 150 different organizations enrolling 8 million people, and by 1988 there were 653 organizations enrolling more than 30 million people (Drew, 1990; Wunderlich, Sloan, & Davis, 1996). Today, more than 50 million people are enrolled in managed care plans (West, Hicks, Balas, & West, 1996). The net increase in HMO enrollment between 1988 and 1993 was 38 per cent, and 20 of the largest HMOs have captured 59 per cent of that enrollment (Wunderlich et al.).

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Even the federal government, through Medicare and Medicaid, is awarding contracts to managed care companies in an attempt to control the escalating costs of health care. The roles of the professional nurse in managed care organizations are becoming more and more complex. Professional nurses are engaged in case management, quality assurance, health teaching, primary care interventions, utilization review, and long-range planning (Drew, 1990). These roles require education and knowledge not rendered in ADN and diploma programs. Administrators of managed care organizations are demanding highly skilled, educated nursing professionals to assume key leadership roles (Drew, 1990). There are a growing number of opportunities for advanced practice nurses in these managed care organizations, and these positions require graduation education. Nursing must address the needs of managed care organizations by providing nurses prepared at adequate educational levels for the changing market. THE NURSING WORK FORCE

Nurses constitute the largest number of health care workers. More than 50,000 nurses have been added annually to the job market in the last 10 years. Today, there are more than 2.2 million registered nurses in this country, and more than 80 per cent are actively employed in the profession. There is one nurse for every 142 people, and nurses leave the profession for other careers at a rate of less than 5 per cent (Aiken, 1994; Aiken & Salmon, 1994). The aggregate number of nurses is adequate for the country's needs at this time. However, nursing must examine the educational level and mix of these nurses. There are more than 800 associate-degree nursing programs that currently produce 65 per cent of all nursing graduates and more than 140 diploma programs that produce 8 per cent of graduates (Aiken, 1994; Aiken & Salmon, 1994). The US Department of Health and Human Services (1994) estimates that by the year 2000, there will be a 400,000-plus deficiency of baccalaureate and higherdegree nurses and a 150,000-plus surplus of the minimally educated nurses. HOSPITALS AND COMMUNITY SHIFT OF CARE

More then 500 hospitals have dosed in the last decade. Many others have consolidated and/or joined multifacility networks (Wunderlich et al., 1996). This has resulted in the downsizing of nursing staffs and layoffs in certain areas. However, the overall employment of nurses in hospitals has continued to grow

despite the decline, by more then 50 million, in the number of inpatient days nationwide (Aiken & Salmon, 1994). Hospitals in the current market have entered various restructuring phases that have shifted care to outpatient and community settings, and nurse employment within hospitals has had its greatest growth in outpatient departments. Today, more than 80 per cent of community hospitals have established outpatient departments compared with only 50 per cent in 1985 (Wunderlich et al., 1996). The number of outpatient surgical procedures has increased, and half of all surgery today is done on an outpatient basis. The number of hospitals offering in-house-sponsored home health services increased to more than 40 per cent in 1993 from only 29 per cent in 1985 (Wunderlich et al., 1996). Blancett and Flarey (1995) stated that hospitals as we know them today will soon be extinct, and the largest delivery system will be home health care agencies. Hospitals function as primary triage centers with the goal of rapid diagnosis and stabilization. Most inpatient units are critical status, and the average length of stay is approaching 3 days. At the same time, the number of specialty care units in hospitals doubled between 1983 and 1993 (Wunderlich et al., 1996). These units target AIDS, cancer, transplant, and other patient populations. The increased use of technology and the high acuity of patients in hospital settings demand professional, theory-based nursing practice.

Proposal Having outlined the evolution of the entry-intopractice issue and the resulting costs to the profession, the authors submit that the "shifting-the-burden" systems archetype (Senge, 1990, p. 104) is operational in nursing. The shifting-the-burden archetype often occurs when the necessary or fundamental solution to a problem is particularly difficult for an organization to accept. Short-term solutions seem to fix the problem by ameliorating its symptoms while the actual problem becomes worse over time. As the underlying problem continues to go unsolved, reinforcing processes from the short-term solution further erode the organization's ability to implement the fundamental solution. Organizations often have difficulty accepting fundamental solutions because such solutions usually involve some degree of delay before results can be recognized. The results of fundamental solutions, however, are lasting and act to strengthen the organization.

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It is clear that entry into practice is an emotionally and politically charged issue that has been difficult for the profession to address directly. Society requires nurses who will be prepared to meet the challenges of the evolving health care system. The fundamental solution is to declare the baccalaureate degree as the minimal requirement for entry into the profession and to discontinue recognition of the associate degree. Nursing, however, has chosen a complex short-term response, which is to implement only half of the fundamental response. Nursing has declared the baccalaureate degree as the minimal requirement for entry into the profession but continues to recognize the associate degree as a terminal degree. This recognition comes in many forms. The most obvious, of course, is the continued eligibility of associate-degree graduates to take the registered nurse licensing examination. Recognition also comes in the form of baccalaureate completion programs and current articulation models, which accept credit for courses taken in associatedegree programs. Furthermore, the authors believe that proposals for differentiated practice (Koerner, 1992; Levi, Montgomery, & Hurd, 1994; McClure, 1991; Styles et al., 1991) would inadvertently serve to continue recognition of the associate degree as a terminal degree because it would be exceedingly difficult to enforce differentiated practice in the work place without differentiated licensure. Continued recognition of associate-degree education relegates the baccalaureate degree to the realm of choice and results in increased dependence on the short-term solution, which is to continue to recognize associate-degree education. A reinforcing process of the short-term response that erodes the professions ability to implement the fundamental response is the proliferation of associate-degree programs, which edu-

Need for s!ngle

cate nurses who view the baccalaureate degree as a choice and who often resist the fundamental response (Fig 1). The authors, therefore, propose a high-leverage action that will create an organizational climate that eliminates recognition of the associate degree as a terminal degree in nursing. The authors believe that this action will strengthen the fundamental solution to society's need for a new breed of nurses, and they offer the following recommendations: 1. The ANA will change Nursing's Social Policy Statement to read that the baccalaureate degree in nursing is the minimal educational requirement for basic nursing practice and that the associate degree will no longer be recognized (ANA, 1995, p. 13). 2. The ANA will adopt a resolution that beginning January 1, 2001, anyone desiring to enter into the practice of professional nursing will enroll in one of the following educational programs: (1) a baccalaureate nursing program within a college or university or (2) an associate degree program specifically designed to articulate with a baccalaureate nursing program in a 4-year college or university. The associate degree earned by students in this program will not be a nursing degree, but it will allow students to earn a baccalaureate nursing degree after completion of requirements in the 4-year college or university program that articulates with the associate degree program they attend. 3. The National Council of State Boards of Nursing will adopt a resolution that the

Proliferation of AD programs

-

Delay . , ,

/

Shifting-the-burden archetype template. (From THE FIFTH DISCIPLINE by Peter M. Senge. Coypright © 1990 by Peter M. Senge. Used by permission of Doubleday, a division of Bantam Doubleday Dell Publishing Group, Inc.)

Figure 1.

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baccalaureate degree is the minimal educational requirement for eligibility to take state registered nurse licensing examinations. 4. The ANA will support the decision by the American Nurses Credentialing Center to require the baccalaureate degree for nurses to be eligible to take specialty certification examinations. 5. The American Association of Colleges of Nursing will assume responsibility for accrediting basic and graduate nursing education programs. By the year 2001, every associatedegree program will be required to articulate with a baccalaureate-degree program in nursing in a 4-year college or university. 6. The ANA will adopt a resolution that anyone either enrolled in an associate-degree program in nursing or receiving an associate degree in nursing before January I, 2001 will be eligible to practice as a professional nurse for the remainder of her or his career. 7. The ANA will lobby for the redirection of federal funds from diploma and associatedegree nursing programs to baccalaureateand higher-degree nursing programs in the form of student aid, especially for students from disadvantaged socioeconomic backgrounds and for students articulating from associate-degree programs.

RATIONALE

For nursing to secure its position in the new marketplace, nurses must be able to practice autonomously, synthesize vast amounts of knowledge, problem-solve in situations of high uncertainty, supervise the work of others, practice across health care settings, and participate in policy making (Wunderlich et al., 1996, p. 87). Nursing's holistic approach to health, coupled with its 24-hour proximity to the nursing client, has placed nursing in a unique position to coordinate the efforts of multiple health care providers. The current health care environment is creating a demand for such coordinators and planners, and it is time for nursing to formalize its role to meet society's need for less fragmented services. The authors believe, therefore, that the college or university is the only appropriate environment in which to begin the educational process of nurses who will meet the demands of the emerging health care system.

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Nurses "have one foot high on the crystal tower of knowledge and theory and one foot in the dust and grit of human need" (Shalala, 1992, p. 7). In the college or university, nursing is both taught and learned within the context of a liberal education. The aim of a liberal education is knowledge for the sake of knowledge. The study of arts, sciences, and humanities produces a state of intellect whereby the person is able to undertake the study of any particular discipline with an "ease, a grace, a versatility, and a success to which another is a stranger" (Newman, 185211976, p. 118). A liberal education thus broadens students' view of the world and helps them to see where their professional discipline fits within that world. Conversely, the community college as the sole educational experience perpetuates isolationism and "localism" (Lynaugh, 1992, p. 441), which ultimately result in fragmentation of the profession. Furthermore, a liberal arts education fosters the attitude that learning is a life-long enterprise and prepares the way for master's and doctoral education, which will be increasingly required for nurses to assume the roles required by society. Nurses will need master's degrees for positions as advanced practice nurses and case managers. Nurses who wish to engage in scientific inquiry, theory development, and education will require doctoral degrees. Nursing knowledge is expanding rapidly, and it is no longer realistic to think that the discipline can be adequately mastered within 4 years, let alone 2. Nursing, therefore, must consider the ethics of depriving sectors of society of the full measure of nursing knowledge (Christman, 1991) as well as the ethics of leading students to believe that 2 years constitutes an adequate introduction to the discipline.

• . . it is time for nursing to formalize its role to meet society's need for less fragmented services•

The authors believe that nurses, whose introduction to the discipline and profession of nursing is informed by a liberal education, will be better prepared to think critically, to think creatively, and to lead (McBride, 1996). A liberal education "frees the individual from fear of himself" (Joel, 1972, p. 12). Nursing needs fearless leaders to secure its place in the emerging health care marketplace and to advance its social agendas. In American society, education and earned wealth substitutes for inherited status. Without

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higher education as a requirement, nursing will continue to lack the social authority to be included in the policymaldng that has an impact both on society and the profession (Lynaugh, 1992). The fundamental solution to make the baccalaureate degree the minimal requirement for entry into the profession is hindered by the mental model that has long prevailed in nursing that "a nurse is a nurse." This myth is perpetuated by the fact that graduates of various types of nursing programs are eligible to take the same licensing examination. Nursing faculty have contributed to the problem by failing to articulate different expectations for graduates of baccalaureateand associate-degree programs. For nurses to be able m meet the demands of the health care environment, curricular reform at the baccalaureate level will be warranted. Despite the discipline's orientation toward health, nursing education programs are designed primarily to teach students how to manage illness experiences within the hospital setting. The emphasis must shift toward community-based and home care, managed care, team approaches to care, and costeffective care (Wunderlich et al., 1996). In making this proposal, the authors recognize that community colleges address a societal need, and that is the need for access to affordable education that is both flexible and geographically convenient. The authors, therefore, advocate a new system of articulation programs between community colleges and baccalaureate degree-granting institutions. They suggest a system whereby a student could take basic science or liberal arts courses toward the nursing degree at a community college and then transfer to an affiliated 4-year college or university to complete his or her degree requirements. The 2-year option would provide access to the higher educational system for students who require time to plan for family, work, and financial commitments, but it would in no way constitute a terminal degree for entry into professional status.

Educational systems should be defined by practice, but in nursing the reverse has been true for too long and has contributed to the problems surrounding entry (McClure, 1991). The authors believe that a second mental model that is operational in nursing is that the solution to the problem of entry into practice will come from within the educational system. Any educational system, however, must respond to the needs of society, and the current health care environment is creating a new set of societal needs to which nursing education must respond. The pressure for change, however, must come from outside the academ76

Conclusion

In this article, the authors proposed that as a result of the emerging health care environment, society is confronting nursing with new demands. The authors suggested that nursing position itself as a learning organization to meet these demands and to ensure its future as a profession. Aydelotte (1972) warned that if nursing fails to restructure social relationships to meet society's needs, "society will surely place the charge they have given us elsewhere" (p. 23). The authors identified two of the five learning disciplines that nursing must master to become a learning organization and traced the evolution of the entry-intopractice dilemma to illustrate the systems archetype currently driving nursing. They offered what they believe to be a high-leverage solution that will bring about lasting change and strength to the nursing profession. Finally, the authors identified two mental models that must both be acknowledged and changed for their proposed solution to work.

Acknowledgment The authors thank Dr Margaret Sovie for her guidance and encouragement in the development of the manuscript.

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