- Email: [email protected]
Undergraduate nursing education in the United States
Journal of Medical Colleges of PLA 25 (2010) 44–49
-2851$/2) 0(',&$/ &2//(*(6 2) 3/$ www.elsevier.com/locate/jmcpla
Undergraduate nursing education in the United States Susan A. LaRocco Division of Nursing, Curry College, Milton, Massachusetts 02186, USA Received 22 December 2009; accepted 05 February 2010
Abstract Nursing education in the United States began in the 1870s with hospital training schools modeled after the Nightingale plan. Presently there are three educational paths that students may take to become a registered nurse (RN). baccalaureate degree (BS), the associate degree (AD) and the diploma. people who have a baccalaureate degree in another field. regulated by each of the 50 states.
These are the
Accelerated nursing programs are also available for
Nursing education and nursing practice in the United States is
The focus of nursing education is the preparation of nurses who use critical thinking skills to
provide comprehensive patient-centered care to a variety of clients.
It is expected that nurses will function using evidence-based
practice in a culturally competent, safe manner. Nursing schools must be approved by the state in which they exist.
In addition
to this, most nursing schools are also accredited, a voluntary process that is done by a non-governmental association. graduates take the same licensing exam, a computer adaptive test that is from 75 to 265 items long.
All
In 2008 almost 120,000 US
educated graduates were first time test takers; 85.5% passed the exam. Trends in nursing education include a focus on evidence based practice, an emphasis on safety and quality, patient education and management of chronic conditions, genetics and genomics and the use of simulation in nursing education. Key words: Nursing education; Nurse licensure; United States of America
1. Historical Perspective
course; however, there was no formal class work or textbooks. The subsequent hospital schools that were
Formal nursing education in the United States
established
followed
the
Nightingale
model
began in the 1870s. Linda Richards, the first nurse to
established at St.Thomas’ Hospital in London in 1860.
receive a diploma in nursing (1873), was trained at the
These included Bellevue Training School for Nurses
New England Hospital for Women and Children in
(New York City, 1873); the Connecticut Training
Boston.
School (New Haven, Connecticut, 1873) and the
Lectures were given during the one year
Boston Training School at Massachusetts General E-mail address: slarocco0603@ curry.edu
Hospital (1873).
By 1910 there were more than 1100
45
Susan A.LaRocco / Journal of Medical Colleges of PLA 25 (2010) 44–49
hospital training schools for nurses.
Most of the
hospitals were privately owned and many were under
Nursing education and nursing practice in the
the direction of religious orders. The training schools
United States is regulated by each of the 50 states.
often lacked an educational focus.
The national government does not make any laws
Their primary
purpose was to provide unpaid labor to care for the
regarding nursing.
patients[1].
in more than one state there is no single unduplicated
The first textbook written by a nurse for nurses
Because nurses may hold licenses
list of registered nurses in the United States. Using
was published in 1885 by Clara S. Weeks, titled A
sophisticated
Textbook of Nursing for the Use of Training Schools,
government does provide information about the
Families, and Private Students.
Prior to that, two
number of nurses in the country. As of 2004, there
training schools had published their handbooks. In
were 2.9 million registered nurses (RNs) with active
1896 the Society of Superintendents [of training
licenses, of which 168,000 (5.8%) were men.
schools] distributed a brief list of reference books and
Approximately 2.4 million RNs were employed in
50 textbooks.
nursing [3].
Less than half of the books were
sampling
techniques,
the
national
authored by nurses[2]. Men students were not admitted to most nursing schools.
3. Educational Programs
The first nursing school exclusively for
men was established in New York City in 1886.
There are three major educational paths to
However, it was closed in 1903. In 1888, the Mills
becoming a registered nurse.
These are the
School of Nursing at Bellevue Hospital was founded
baccalaureate degree (BS), the associate degree (AD)
as the second all male nursing school. Three other
and the diploma. All three programs include courses
exclusively male schools followed.
The Alexian
in the biological sciences, nursing theory and practice,
Brothers, a German religious order, founded two of
and clinical experience. The baccalaureate degree is
these, in Chicago in 1898 and St. Louis in 1928, and
typically offered by colleges and universities and
the third was at the Pennsylvania Hospital –
usually takes four years to complete.
Department for Mental and Nervous Diseases, which
extensive liberal arts courses in addition to nursing
was founded in 1914 [2].
courses.
It includes
The associate degree is offered in
The first collegiate nursing program began in
community and junior colleges and can be completed
1909 at the State University of Minnesota[1]. Prior
in two to three years. Diploma programs are offered
to that, Teachers’ College at Columbia University in
by hospitals and are completed in three years. As of
New York City offered a one year course in hospital
2006 there were 709 baccalaureate programs, 850
economics for nurses beginning in 1907 [1].
associate degree programs and about 70 diploma
The
first autonomous nursing school within a university was established at Yale University in Connecticut in 1923 with Annie W. Goodrich as the first dean [1].
programs[4]. For people with a baccalaureate degree in other fields of study, there are accelerated programs which lead to a BS degree in nursing. These typically take
2. Regulation of Nursing Education
12 to 18 months, but may require additional time prior
46
Susan A.LaRocco / Journal of Medical Colleges of PLA 25 (2010)44-49
to entering the program to complete basic science courses if they were not included in the original baccalaureate degree program.
The focus of nursing education is the preparation
As of 2008 there
of nurses who use critical thinking skills to provide
were more than 200 of these programs available, with
comprehensive patient-centered care to a variety of
almost 40 additional ones in the planning stages.
clients. It is expected that nurses will function using
Most of these programs have been started within the
evidence-based practice in a culturally competent, safe
last 15 years[5].
manner.
In 2004, 31% of all licensed nurses obtained their initial nursing education in a BS program.
Anatomy and physiology, microbiology and
In contrast,
chemistry as well as social sciences such as
in 1980 only 17% of all nurses had completed a BS
psychology and sociology are typically required in all
degree as their entry into practice. Nurses obtaining
nursing programs.
their initial nurses education in diploma programs had
fundamentals of nursing practice, adult medical
declined from 64% in 1980 to 26% in 2004.
surgical nursing, pediatrics, mental health nursing, and
This has
Clinical nursing courses include
resulted from the closure of many of the hospital based
maternity nursing.
diploma programs during the 1970s and 1980s.
include community health nursing where students
Associate degree programs began in the 1950s and
provide care for patients in their homes.
continued to increase in number throughout the 1980s
assessment may be a separate course or it may be
and 1990s.
included in the fundamentals course.
In 1980 only 19% of RNs had been
Baccalaureate programs usually Health Also in
educated at the associate degree level while in 2004
baccalaureate programs there will be an emphasis on
43% had been educated in that type of program.
The
nursing research including statistics and pharmacology
decline of the diploma programs can also be seen in
and pathophysiology may be separate courses. In the
the number of graduates each year. In the five year
shorter associate degree programs this material may be
period from 2004 to 2008 diploma graduates ranged
included in other courses and covered in a more
from 3.63% to less than 3% of all nursing graduates,
superficial manner. Care of older adults may be a
with a consistent decline each consecutive year.
separate course or it may be included in adult health.
Many nurses who are educated in associate degree or
With an aging population there is a trend to include
diploma programs continue their education at the
more content about care of elders.
baccalaureate level [3]. The American Nurses
Additional courses may include nursing ethics,
Association has advocated for the baccalaureate
nursing history, contemporary topics in nursing,
degree to be the entry level into practice since the
leadership, and human growth and development.
1960s.
Some states (especially New York and New
Courses in communication are frequently included in
Jersey) are currently considering laws that would
the curriculum. In all programs there will be clinical
require all nurses to complete the BS degree within 10
hours spent in a variety of settings. Graduates of all
years of initial licensure.
three types of programs are expected to be prepared
initiatives is still uncertain [6].
The outcome of these
for direct patient care. Graduates of the BS programs have the greatest opportunity for advancing in the
4. Curriculum
profession and often continue their education to
47
Susan A.LaRocco / Journal of Medical Colleges of PLA 25 (2010) 44–49
become administrators, nurse researchers, clinical
degree programs in public schools may have a total
specialists, or nurse practitioners.
cost as low as $5000 while the cost of a four year baccalaureate degree in a private school may be as
5. Accreditation
high as $120,000.
This does not include living
expenses, books and uniforms. Nursing schools must be approved by the state in which they exist.
In contrast to state approval,
Many students
receive tuition assistance in the form of loans and scholarships to help pay for their education.
accreditation is a voluntary process that is done by a non-governmental
association.
Accreditation
provides recognition to programs that meet or exceed standards for educational quality. two accrediting bodies. Nursing
Accrediting
7.
Licensing
of
Nurses–The
NCLEX-RN
Examination
In the US there are
The National League for Commission
(NLNAC)
is
Graduates of all types of RN programs take the same
licensing
exam,
called
the
NCLEX-RN
authorized to accredit all types of basic nursing and
examination.
graduate level programs.
The Commission on
from 75 to 265 items long. The length of the exam is
Collegiate Nursing Education (CCNE) accredits
determined by the answers that the test taker selects
baccalaureate and graduate level programs.
for each question.
Most
It is a computer adaptive test that is
A maximum of six hours is
nursing programs in the US are accredited by one of
allowed for taking the exam. In addition to multiple
these agencies.
choice questions there are items that are described as
Accreditation is received for a
specific period of time, typically ranging from five to
alternate format.
These include multiple response
ten years.
In addition to a lengthy report that
where all of the correct responses must be selected for
provides details about the nursing program, each
a question to be scored as correct, fill in the blank, and
school is visited by a team of nursing educators who
hot spots where the test taker must place the cursor
review records and meet with students and faculty to
over a specific spot on a diagram indicating the correct
determine if the school meets the high standards
placement of the desired spot such as placement of a
required by accreditation.
stethoscope. Because the exam is individualized for each candidate and is completely administered on the
6. Cost of Nursing Education
computer, graduates make an appointment for their exam date at a local designated test center [7].
The cost to be educated as a nurse varies widely
Prior to 1994 the examination was given in paper
depending on the type of program and whether the
and pencil format using multiple choice test items.
school is public or private. Typically public schools
At that time the exam was administered twice a year at
are administered by individual states and lower tuition
testing centers throughout the country with all
rates are applied to students who have established
candidates arriving at the same time and seated in
residency in that state. Associate degree programs
large rooms. Because nursing is viewed as an art and
are less expensive, both because of lower tuition rates
a science that involves critical thinking the test items
and because they are shorter in length.
are written at the application level according to
Associate
48
Susan A.LaRocco / Journal of Medical Colleges of PLA 25 (2010)44-49
Bloom’s Taxonomy of cognitive domains. The test
which allows a nurse licensed by one state to practice
plan is organized into four major client needs
in another state provided that she or he adheres to the
categories: safe and effective care; health promotion
nurse practice act of that state.
and
compact is to “remove regulatory barriers to increase
maintenance;
psychosocial
integrity;
and
physiological integrity [7].
The purpose of the
access to safe nursing care” [9].
While the licensing exam is created and administered by the National Council of State Boards
8. Trends in nursing education
of Nursing, each of the 50 states determines eligibility Typically eligible candidates
Nursing education is increasingly focused on
must have graduated from a state approved nursing
evidence based practice with an emphasis on safety
program and be of good moral character. The board
and quality in patient care. Changing demographics
of nursing in each state also establishes standards for
in the United States, including longer life spans with
approval of nursing programs within that state.
more people living with chronic diseases, has created
for taking the exam.
In 2007 almost 120,000 US educated graduates
an
increased
focus
on
patient
education
and
took the NCLEX-RN for the first time; 85.5% passed
management of chronic conditions.
the exam.
Test takers who do not pass the exam on
of genetics and genomics has also been recognized,
the first attempt are allowed to retake the exam at a
with subsequent focus on integrating these two topics
later date [8].
into nursing curriculum.
Nurses who are educated in a foreign country are
The importance
In the educational setting,
simulation has become an important aspect of a
eligible to take the exam after their candidacy has been
student’s pre-clinical experience.
approved by the state where they are applying for their
especially through on-line courses, has altered the
license.
educational setting for many students.
In 2007 almost 34,000 foreign educated
and
the
A focus on
nurses took the NCLEX-RN exam for the first time.
lifelong
Of these, more than 21,000 (64%) were nurses from
interdisciplinary patient care has also caused some
the Philippines.
curricular changes.
Indian nurses accounted for 5370
learning
Distance learning,
importance
of
(16%) of all foreign educated first time test takers. Completing the list of the top five countries
9. Conclusion
represented by test takers were South Korea (1906); The percent of all
Nursing education in the United States has
internationally educated candidates who passed the
historically been based on the Nightingale model first
exam in 2007 was 52% [8].
utilized in England.
Canada (888) and Cuba (673).
Today, pre-licensure nursing
Each state has a board of nursing regulation that
education is a rigorous process, conducted in a variety
is responsible for protecting the public by assuring the
of settings, including colleges and universities,
competence of nurses in that state. Prior to 2000 a
community colleges and hospitals.
nurse needed to obtain a license in each state in which
the states, not the national government. Trends in
she or he practiced. Since that time almost half of the
nursing education include an increased focus on
50 states have entered into a Nurse Licensure Compact
evidenced based practice and critical thinking skills.
It is regulated by
49
Susan A.LaRocco / Journal of Medical Colleges of PLA 25 (2010) 44–49
Simulation
has
also
changed
the
educational
experience for students as they learn to manage
bis.gov/oco/ocos083.htm. 5.
increasingly complex situations.
American Association of Colleges of Nursing. Accelerated programs: The fast-track to careers in nursing. [2008-11-19]. http://www. aacn.nche.edu/
Acknowledgement
Publications/issues/Aug02.htm. 6.
The
author
gratefully
acknowledges
the
Boyd
T.
N.Y.
and
N.
J.
consider
BSN
requirement.Nurse Spectrum/Nurse Week,2009-09-07.
assistance of Dr. Hong Tao.
[2009-11-19].http://news.nurse.com/article/20090907/ NATIONAL02/309070028.
References
7.
National Council of State Boards of Nursing. 2010 NCLEX-RN Detailed Test Plan. Candidate Version.
1.
JA. Nursing in society: A historical
Prepared by Wendt A,Kenny L,Schultz L.[2009-11-19].
perspective. Philadelphia: W. B. Saunders Company,
https://www.ncsbn.org/2010_NCLEX_RN_TestPlan.pdf.
Dolan
8.
1978. 2.
3.
MM. American nursing: History and
Nurse Licensee Volume and NCLEX® Examination
interpretation. New York: The Macmillan Company,
Statistics. (Research Brief Vol. 35). Kenward K,Woo A,
1954.
Gross L,et al. Chicago:National Council of State Boards
Health Resources & Services Administration(2006).
of Nursing,Inc. 2009. [2009-11-19]. https:// www.
The registered nurse population: Findings from the
ncsbn.org/WEB_08_2007LicExamRB_Vol35_CS3.pdf .
Roberts
March 2004 National Sample Survey of Registered Nurses. 4.
National Council of State Boards of Nursing. 2007
[2009-11-19].
ftp://ftp.hrsa.gov/bhpr/
9.
National Council of State Boards of Nursing . Background information about the RN and LPN/VN
workforce/0306rnss.pdf
Nurse Licensure Compact . [2009-11-19] . https://www.
Bureau of Labor Statistics, United States Department
ncsbn.org/156.htm
of Labor. Occupational Outlook Handbook, 2008-2009 edition, Registered Nurses. [2009-11-19]. http://www.
(Editor Lu Renmin)
-2851$/2) 0(',&$/ &2//(*(6 2) 3/$ www.elsevier.com/locate/jmcpla
Undergraduate nursing education in the United States Susan A. LaRocco Division of Nursing, Curry College, Milton, Massachusetts 02186, USA Received 22 December 2009; accepted 05 February 2010
Abstract Nursing education in the United States began in the 1870s with hospital training schools modeled after the Nightingale plan. Presently there are three educational paths that students may take to become a registered nurse (RN). baccalaureate degree (BS), the associate degree (AD) and the diploma. people who have a baccalaureate degree in another field. regulated by each of the 50 states.
These are the
Accelerated nursing programs are also available for
Nursing education and nursing practice in the United States is
The focus of nursing education is the preparation of nurses who use critical thinking skills to
provide comprehensive patient-centered care to a variety of clients.
It is expected that nurses will function using evidence-based
practice in a culturally competent, safe manner. Nursing schools must be approved by the state in which they exist.
In addition
to this, most nursing schools are also accredited, a voluntary process that is done by a non-governmental association. graduates take the same licensing exam, a computer adaptive test that is from 75 to 265 items long.
All
In 2008 almost 120,000 US
educated graduates were first time test takers; 85.5% passed the exam. Trends in nursing education include a focus on evidence based practice, an emphasis on safety and quality, patient education and management of chronic conditions, genetics and genomics and the use of simulation in nursing education. Key words: Nursing education; Nurse licensure; United States of America
1. Historical Perspective
course; however, there was no formal class work or textbooks. The subsequent hospital schools that were
Formal nursing education in the United States
established
followed
the
Nightingale
model
began in the 1870s. Linda Richards, the first nurse to
established at St.Thomas’ Hospital in London in 1860.
receive a diploma in nursing (1873), was trained at the
These included Bellevue Training School for Nurses
New England Hospital for Women and Children in
(New York City, 1873); the Connecticut Training
Boston.
School (New Haven, Connecticut, 1873) and the
Lectures were given during the one year
Boston Training School at Massachusetts General E-mail address: slarocco0603@ curry.edu
Hospital (1873).
By 1910 there were more than 1100
45
Susan A.LaRocco / Journal of Medical Colleges of PLA 25 (2010) 44–49
hospital training schools for nurses.
Most of the
hospitals were privately owned and many were under
Nursing education and nursing practice in the
the direction of religious orders. The training schools
United States is regulated by each of the 50 states.
often lacked an educational focus.
The national government does not make any laws
Their primary
purpose was to provide unpaid labor to care for the
regarding nursing.
patients[1].
in more than one state there is no single unduplicated
The first textbook written by a nurse for nurses
Because nurses may hold licenses
list of registered nurses in the United States. Using
was published in 1885 by Clara S. Weeks, titled A
sophisticated
Textbook of Nursing for the Use of Training Schools,
government does provide information about the
Families, and Private Students.
Prior to that, two
number of nurses in the country. As of 2004, there
training schools had published their handbooks. In
were 2.9 million registered nurses (RNs) with active
1896 the Society of Superintendents [of training
licenses, of which 168,000 (5.8%) were men.
schools] distributed a brief list of reference books and
Approximately 2.4 million RNs were employed in
50 textbooks.
nursing [3].
Less than half of the books were
sampling
techniques,
the
national
authored by nurses[2]. Men students were not admitted to most nursing schools.
3. Educational Programs
The first nursing school exclusively for
men was established in New York City in 1886.
There are three major educational paths to
However, it was closed in 1903. In 1888, the Mills
becoming a registered nurse.
These are the
School of Nursing at Bellevue Hospital was founded
baccalaureate degree (BS), the associate degree (AD)
as the second all male nursing school. Three other
and the diploma. All three programs include courses
exclusively male schools followed.
The Alexian
in the biological sciences, nursing theory and practice,
Brothers, a German religious order, founded two of
and clinical experience. The baccalaureate degree is
these, in Chicago in 1898 and St. Louis in 1928, and
typically offered by colleges and universities and
the third was at the Pennsylvania Hospital –
usually takes four years to complete.
Department for Mental and Nervous Diseases, which
extensive liberal arts courses in addition to nursing
was founded in 1914 [2].
courses.
It includes
The associate degree is offered in
The first collegiate nursing program began in
community and junior colleges and can be completed
1909 at the State University of Minnesota[1]. Prior
in two to three years. Diploma programs are offered
to that, Teachers’ College at Columbia University in
by hospitals and are completed in three years. As of
New York City offered a one year course in hospital
2006 there were 709 baccalaureate programs, 850
economics for nurses beginning in 1907 [1].
associate degree programs and about 70 diploma
The
first autonomous nursing school within a university was established at Yale University in Connecticut in 1923 with Annie W. Goodrich as the first dean [1].
programs[4]. For people with a baccalaureate degree in other fields of study, there are accelerated programs which lead to a BS degree in nursing. These typically take
2. Regulation of Nursing Education
12 to 18 months, but may require additional time prior
46
Susan A.LaRocco / Journal of Medical Colleges of PLA 25 (2010)44-49
to entering the program to complete basic science courses if they were not included in the original baccalaureate degree program.
The focus of nursing education is the preparation
As of 2008 there
of nurses who use critical thinking skills to provide
were more than 200 of these programs available, with
comprehensive patient-centered care to a variety of
almost 40 additional ones in the planning stages.
clients. It is expected that nurses will function using
Most of these programs have been started within the
evidence-based practice in a culturally competent, safe
last 15 years[5].
manner.
In 2004, 31% of all licensed nurses obtained their initial nursing education in a BS program.
Anatomy and physiology, microbiology and
In contrast,
chemistry as well as social sciences such as
in 1980 only 17% of all nurses had completed a BS
psychology and sociology are typically required in all
degree as their entry into practice. Nurses obtaining
nursing programs.
their initial nurses education in diploma programs had
fundamentals of nursing practice, adult medical
declined from 64% in 1980 to 26% in 2004.
surgical nursing, pediatrics, mental health nursing, and
This has
Clinical nursing courses include
resulted from the closure of many of the hospital based
maternity nursing.
diploma programs during the 1970s and 1980s.
include community health nursing where students
Associate degree programs began in the 1950s and
provide care for patients in their homes.
continued to increase in number throughout the 1980s
assessment may be a separate course or it may be
and 1990s.
included in the fundamentals course.
In 1980 only 19% of RNs had been
Baccalaureate programs usually Health Also in
educated at the associate degree level while in 2004
baccalaureate programs there will be an emphasis on
43% had been educated in that type of program.
The
nursing research including statistics and pharmacology
decline of the diploma programs can also be seen in
and pathophysiology may be separate courses. In the
the number of graduates each year. In the five year
shorter associate degree programs this material may be
period from 2004 to 2008 diploma graduates ranged
included in other courses and covered in a more
from 3.63% to less than 3% of all nursing graduates,
superficial manner. Care of older adults may be a
with a consistent decline each consecutive year.
separate course or it may be included in adult health.
Many nurses who are educated in associate degree or
With an aging population there is a trend to include
diploma programs continue their education at the
more content about care of elders.
baccalaureate level [3]. The American Nurses
Additional courses may include nursing ethics,
Association has advocated for the baccalaureate
nursing history, contemporary topics in nursing,
degree to be the entry level into practice since the
leadership, and human growth and development.
1960s.
Some states (especially New York and New
Courses in communication are frequently included in
Jersey) are currently considering laws that would
the curriculum. In all programs there will be clinical
require all nurses to complete the BS degree within 10
hours spent in a variety of settings. Graduates of all
years of initial licensure.
three types of programs are expected to be prepared
initiatives is still uncertain [6].
The outcome of these
for direct patient care. Graduates of the BS programs have the greatest opportunity for advancing in the
4. Curriculum
profession and often continue their education to
47
Susan A.LaRocco / Journal of Medical Colleges of PLA 25 (2010) 44–49
become administrators, nurse researchers, clinical
degree programs in public schools may have a total
specialists, or nurse practitioners.
cost as low as $5000 while the cost of a four year baccalaureate degree in a private school may be as
5. Accreditation
high as $120,000.
This does not include living
expenses, books and uniforms. Nursing schools must be approved by the state in which they exist.
In contrast to state approval,
Many students
receive tuition assistance in the form of loans and scholarships to help pay for their education.
accreditation is a voluntary process that is done by a non-governmental
association.
Accreditation
provides recognition to programs that meet or exceed standards for educational quality. two accrediting bodies. Nursing
Accrediting
7.
Licensing
of
Nurses–The
NCLEX-RN
Examination
In the US there are
The National League for Commission
(NLNAC)
is
Graduates of all types of RN programs take the same
licensing
exam,
called
the
NCLEX-RN
authorized to accredit all types of basic nursing and
examination.
graduate level programs.
The Commission on
from 75 to 265 items long. The length of the exam is
Collegiate Nursing Education (CCNE) accredits
determined by the answers that the test taker selects
baccalaureate and graduate level programs.
for each question.
Most
It is a computer adaptive test that is
A maximum of six hours is
nursing programs in the US are accredited by one of
allowed for taking the exam. In addition to multiple
these agencies.
choice questions there are items that are described as
Accreditation is received for a
specific period of time, typically ranging from five to
alternate format.
These include multiple response
ten years.
In addition to a lengthy report that
where all of the correct responses must be selected for
provides details about the nursing program, each
a question to be scored as correct, fill in the blank, and
school is visited by a team of nursing educators who
hot spots where the test taker must place the cursor
review records and meet with students and faculty to
over a specific spot on a diagram indicating the correct
determine if the school meets the high standards
placement of the desired spot such as placement of a
required by accreditation.
stethoscope. Because the exam is individualized for each candidate and is completely administered on the
6. Cost of Nursing Education
computer, graduates make an appointment for their exam date at a local designated test center [7].
The cost to be educated as a nurse varies widely
Prior to 1994 the examination was given in paper
depending on the type of program and whether the
and pencil format using multiple choice test items.
school is public or private. Typically public schools
At that time the exam was administered twice a year at
are administered by individual states and lower tuition
testing centers throughout the country with all
rates are applied to students who have established
candidates arriving at the same time and seated in
residency in that state. Associate degree programs
large rooms. Because nursing is viewed as an art and
are less expensive, both because of lower tuition rates
a science that involves critical thinking the test items
and because they are shorter in length.
are written at the application level according to
Associate
48
Susan A.LaRocco / Journal of Medical Colleges of PLA 25 (2010)44-49
Bloom’s Taxonomy of cognitive domains. The test
which allows a nurse licensed by one state to practice
plan is organized into four major client needs
in another state provided that she or he adheres to the
categories: safe and effective care; health promotion
nurse practice act of that state.
and
compact is to “remove regulatory barriers to increase
maintenance;
psychosocial
integrity;
and
physiological integrity [7].
The purpose of the
access to safe nursing care” [9].
While the licensing exam is created and administered by the National Council of State Boards
8. Trends in nursing education
of Nursing, each of the 50 states determines eligibility Typically eligible candidates
Nursing education is increasingly focused on
must have graduated from a state approved nursing
evidence based practice with an emphasis on safety
program and be of good moral character. The board
and quality in patient care. Changing demographics
of nursing in each state also establishes standards for
in the United States, including longer life spans with
approval of nursing programs within that state.
more people living with chronic diseases, has created
for taking the exam.
In 2007 almost 120,000 US educated graduates
an
increased
focus
on
patient
education
and
took the NCLEX-RN for the first time; 85.5% passed
management of chronic conditions.
the exam.
Test takers who do not pass the exam on
of genetics and genomics has also been recognized,
the first attempt are allowed to retake the exam at a
with subsequent focus on integrating these two topics
later date [8].
into nursing curriculum.
Nurses who are educated in a foreign country are
The importance
In the educational setting,
simulation has become an important aspect of a
eligible to take the exam after their candidacy has been
student’s pre-clinical experience.
approved by the state where they are applying for their
especially through on-line courses, has altered the
license.
educational setting for many students.
In 2007 almost 34,000 foreign educated
and
the
A focus on
nurses took the NCLEX-RN exam for the first time.
lifelong
Of these, more than 21,000 (64%) were nurses from
interdisciplinary patient care has also caused some
the Philippines.
curricular changes.
Indian nurses accounted for 5370
learning
Distance learning,
importance
of
(16%) of all foreign educated first time test takers. Completing the list of the top five countries
9. Conclusion
represented by test takers were South Korea (1906); The percent of all
Nursing education in the United States has
internationally educated candidates who passed the
historically been based on the Nightingale model first
exam in 2007 was 52% [8].
utilized in England.
Canada (888) and Cuba (673).
Today, pre-licensure nursing
Each state has a board of nursing regulation that
education is a rigorous process, conducted in a variety
is responsible for protecting the public by assuring the
of settings, including colleges and universities,
competence of nurses in that state. Prior to 2000 a
community colleges and hospitals.
nurse needed to obtain a license in each state in which
the states, not the national government. Trends in
she or he practiced. Since that time almost half of the
nursing education include an increased focus on
50 states have entered into a Nurse Licensure Compact
evidenced based practice and critical thinking skills.
It is regulated by
49
Susan A.LaRocco / Journal of Medical Colleges of PLA 25 (2010) 44–49
Simulation
has
also
changed
the
educational
experience for students as they learn to manage
bis.gov/oco/ocos083.htm. 5.
increasingly complex situations.
American Association of Colleges of Nursing. Accelerated programs: The fast-track to careers in nursing. [2008-11-19]. http://www. aacn.nche.edu/
Acknowledgement
Publications/issues/Aug02.htm. 6.
The
author
gratefully
acknowledges
the
Boyd
T.
N.Y.
and
N.
J.
consider
BSN
requirement.Nurse Spectrum/Nurse Week,2009-09-07.
assistance of Dr. Hong Tao.
[2009-11-19].http://news.nurse.com/article/20090907/ NATIONAL02/309070028.
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7.
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(Editor Lu Renmin)