Nursing didn’t switch from diploma to degree programs in a single moment. The shift unfolded over decades, beginning in the late 1940s and accelerating after 1965, when the American Nurses Association formally called for all nursing education to move into colleges and universities. That 1965 position paper is the closest thing to an official turning point, but the transition it called for is still playing out today.
How Nurses Were Trained Before Degrees
For most of nursing’s modern history, the standard path was a hospital-based diploma program. These were typically three-year programs run by hospitals themselves, not colleges. Students learned on the job, spending most of their time caring for patients on hospital wards. The model worked well enough to staff hospitals through two World Wars, but by the late 1940s, critics were raising serious concerns about the quality and consistency of this training.
The problems were real. Hospital-based programs varied wildly. Some offered rigorous classroom instruction alongside clinical experience; others used student nurses primarily as cheap labor. There was no standardized curriculum, and graduates had no college credential to show for their years of work. As medicine grew more complex after World War II, the gap between what nurses needed to know and what diploma programs were teaching became harder to ignore.
The 1950s: A New Option Emerges
In 1952, a nursing educator named Mildred Montag proposed something entirely new: a two-year Associate Degree in Nursing (ADN) based in community colleges. Her idea grew out of practical reality. After the war ended in 1945, advances in medicine, wider insurance availability, and a growing elderly population had driven hospital use sharply upward. Nursing functions were increasing in number and complexity, and the profession faced a shortage that seemed impossible to solve with the existing diploma pipeline alone.
Montag envisioned a “technical nurse” who could be trained more efficiently in a college setting, gaining both practical skills and a broader education. The associate degree was never meant to replace the four-year bachelor’s degree. It was designed as a faster path to produce competent bedside nurses while bachelor’s-prepared nurses took on more complex professional roles. Community colleges across the country adopted the model quickly, and ADN programs became a major new entry point into nursing within a decade.
1965: The ANA Draws a Line
The most significant policy moment came in 1965, when the American Nurses Association’s Committee on Nursing Education released its first formal position on nursing education. The recommendations were clear and specific. All nursing education, both technical and professional, should take place in colleges or universities rather than hospitals. The minimum preparation for “beginning professional nursing practice” should be a bachelor’s degree. The minimum for “technical nursing practice” should be an associate degree from a community or junior college.
The committee envisioned an orderly transition to a two-tier system. Associate degree nurses would handle technical practice. Bachelor’s-prepared nurses would fill professional roles requiring more advanced judgment and leadership. The position paper also recommended that associate degree programs eventually replace practical nursing (LPN/LVN) programs altogether.
This was a watershed moment on paper, but implementing it proved far more difficult. Hospital-based diploma programs had deep institutional roots, and tens of thousands of working nurses had earned their credentials through those programs. The backlash was significant, and no state immediately moved to require a bachelor’s degree for licensure.
The Slow Decline of Diploma Programs
Despite the controversy, the trend away from diploma programs was already underway by the time the 1965 position paper was published. Through the 1960s and 1970s, the number of hospital-based diploma programs dropped steadily as community college ADN programs and university BSN programs expanded. By the early 1980s, associate degree graduates had overtaken diploma graduates as the largest group of new nurses entering the workforce.
The shift wasn’t driven by any single law or mandate. It happened because colleges could offer more standardized curricula, because students increasingly wanted a transferable college credential, and because hospitals found it cheaper to close their own schools and hire graduates from nearby colleges instead. Diploma programs didn’t vanish entirely. A small number still exist today, mostly in the northeastern United States, but they produce a tiny fraction of new nurses compared to their mid-20th-century peak.
Why the Bachelor’s Degree Gained Ground
The push for bachelor’s-level education picked up momentum in the 2000s and 2010s, fueled in large part by research linking nurse education levels to patient outcomes. A landmark study by researcher Linda Aiken found that for every 10% increase in the proportion of nurses holding a bachelor’s degree at a hospital, the odds of a patient dying dropped by roughly 4%. That finding held true regardless of staffing levels or the hospital’s work environment, and it gave degree advocates a powerful argument grounded in patient safety rather than professional politics.
In 2010, the Institute of Medicine (now the National Academy of Medicine) published a widely cited report recommending that 80% of the nursing workforce hold a bachelor’s degree by 2020. Many hospitals responded by requiring new hires to have a BSN or by offering tuition support for existing nurses to complete their bachelor’s degrees. Magnet-designated hospitals, considered the gold standard for nursing excellence, increasingly made the BSN a hiring preference or requirement.
New York’s “BSN in 10” Law
New York became the most prominent state to put degree requirements into law. Its “BSN in 10” legislation requires newly licensed registered nurses to earn a bachelor’s degree within 10 years of their initial licensure. The law maintains multiple entry points into nursing: you can still start with a diploma or associate degree and pass the licensing exam, but you must complete a BSN within that 10-year window to continue practicing as an RN in the state.
The law includes a grandfather clause protecting nurses who already held an associate degree license at the time of enactment, as well as students who were enrolled or waitlisted in associate degree programs. It also established a special commission to evaluate barriers to nursing education and recommend ways to increase accessibility. The intent was not to shut down ADN programs but to ensure that all professional RNs eventually reach the bachelor’s level, while still keeping the door open for people who need a shorter, less expensive path into the profession initially.
Where Things Stand Now
Today, the associate degree remains the most common entry point into registered nursing. ADN programs are shorter (typically two to three years), less expensive, and widely available at community colleges, making them the most accessible route for many students. Bachelor’s programs take four years and cost more, but they include coursework in research, public health, leadership, and community nursing that associate programs generally don’t cover.
Both pathways lead to the same licensing exam (the NCLEX-RN), and both produce registered nurses who are legally authorized to practice. The practical difference shows up in career options. Many hospitals, especially large academic medical centers, now prefer or require a BSN for hiring. Roles in management, education, public health, and advanced practice all require at least a bachelor’s degree, and most require a master’s or doctorate. Nurses who start with an associate degree increasingly complete RN-to-BSN bridge programs, which are widely available online and typically take one to two years.
The transition the ANA called for in 1965 is still incomplete nearly six decades later. Diploma programs have largely disappeared, but the profession remains split between associate and bachelor’s degree holders, with ongoing debate about whether a single standard will ever take hold nationwide.