Journal of Advanced Nursing, 1977, 2, 443-460
Curricuium integration in nursing education: a concept or a way ofiifePA study of six courses integrating basic nursing education andiieaitii visiting in a singie course Grace M. Owen M.PhiL B.Sc.(Soc). S.R.N. S.C.M. H.V.Tutor's Cert. R.N.T. Head of Department of Nursing and Community Health Studies, Polytechnic oj the South Bank, London Accepted for publiealion 7 fvhruary
OwiiN G.M. [if)']']) Journal of Advanced Sursing 2, 443-460
Curriculum integration in nursing education: a concept or a vvay of life? A study of six courses integrating basic nursing education and health visiting in a single course The purpose of this study was to record the historical development of'integrated' nursing courses, which were an innovation in nursing education, and also to attempt to identify any differences existing between health visitors who trained on 'integrated' courses and those who had trained on the 3-year SRN courses, with an additional year for health visiting. The 'integrated' courses, first established in 1957, aimed to attract intelhgent candidates to nursing and to oifer a more appropriate method of preparation for health visiting between hospital and university or college, integrating hospital nursing witb health visiting. The original area of investigation was carried out by means of unstructured questionnaires to all health visitors completing tbe 'integrated' courses in 1972, and a comparable group of health visitors completing the i-year course at the same point in time. Certain significant differences were identifiable between the two groups in terms of expectations, values and satisfactions in nursing and health visiting, and differences also emerged between tbe stereotypes of nursing and bealth visiting beld by both groups. A further study carried out among employers revealed some interesting attitudes beld by tlieir professional colleagues towards those trained on 'integrated' courses, and gave some indication of tbe ways in wbich their performance was evaluated by nursing officers and otiiers. The concluding discussion outlines some of the possible impHcations of tliese findings in the context of present day nursing education in the United Kingdom and an integrated bealth
INTRODUCTION At a time when 'integration' has become a generally accepted concept in the health and social services in tlie United Kingdom, it is an appropriate point to 443
444
G- ^- Owen
look back over the last twenty years at an experiment in nursing education, the significance of which tends to be overlooked in the light of subsequent developments in nursing education. The aim of this study was to record the historical development of the six courses which integrated basic nursing education and health visiting in a single course, and to attempt to identify the diiferences, if any, which existed between health visitors who trained on these courses and those who had followed the traditional 3-year SRN course, with an additional year for health visiting. The 'integrated' courses, first established in 1957, aimed to attract intelligent candidates to nursing and to offer a more appropriate form of preparation for health visiting between hospital and university or college, and integration of clinical nursing with health visiting. When the study was commenced in 1969 there were only the six courses whieh had been established on an experimental basis. Two have achieved degree status and two have been associated with degree development, and a number of modifications have since been made. They were jointly organized at that time between the following establishments: 1 2 3 4 5 6
Southampton University and St, Thomas' Hospital. Surrey University and Hamtnersmith Hospital. Manchester University and Crumpsall Hospital. Croydon Technical College and King's College Hospital. Chiswick Polytechnic and Hillingdon & West Middlesex Hospitals. Newcastle-upon-Tync Polyteclmic and Newcastle University Hospitals.
The stimuli whieh motivated this study originated during my association with one of these courses as organizing tutor. It was a commonly expressed experience of those involved in teaching these students that they were 'different' from students trained on the conventional nursing and health visiting courses. Similar comments came from experienced nurses and health visitors who worked with them after they were qualified. The nature of the differences w^as difficult to identify clearly, although comments frequently heard related to their ability to take a more total approach to patient care throughout the course, or their ability to take a longterm view of things, or assess a situation quickly, also that they lacked confidence. It was apparent too that they were able to take a broader perspective on patient care, registering the need in relation to the family, or seeking for the cause of problems in order to prevent reoccurrences where possible. This kind of difference could, however, quite easily have been attributed to intelligence or higher academic attainment on entry and thus bear no relationship to the kind of course. One particular difference was intriguing—they appeared to retain their curiosity, their inquiring approach and their 'openness' to new ideas and progressive thitiking in a way that was not apparent in other students of comparable educational achievement, or trained in the same nursing schools. Thus, one of the main questions which arose was whether these students had certain different attributes on selection, or whether the courses were so organized that there were identifiable differences in the end product.
Curriculum integration in nursing education
445
Another motivating force for the study was that such courses are complex, difficult to organize and expensive in the use of scarce resourecs, and it appeared important to attempt some kind of general evaluation to complement the work done by Reinkemeyer (1968), Bryden (1969) and Singh (1970). RESEARCH M E T H O D O L O G Y A N D DESIGN Two very obvious difficulties to consider were the wide range of variables and the lack of suitable criteria available for evaluating the attributes under review. All six courses had been planned on an experimental basis over a period of about ten years, were based in different kinds of educational establishments and differently planned, although aims and objectives were remarkably similar. Thc one common and key feature was that in all courses the student was introduced to community nursing very early in the course—at the latest the second term of the first year, and in five courses were introduced to health visiting practice and the remaining one to studies in health visiting in the first year, hi all courses some method of integration of studies was used. It became evident that it was important to document the development of these courses in thc historical and professional context, and their aims, objectives and plans, in order to identify their similarities and differences and compare them with the orthodox courses. Although most of the organizing establishments had kept some kind of reeord of progress and ehanges, there was no uniformity in these and most of them were ofa descriptive nature, apart from factual material relating to applications, interviews, wastage and examination success. Singh (1970) had included these six courses in his study o£ Student nurses on experimental courses,
but had classified two of them with undergraduate courses and four of them as 'intcsrated courses' and thus, while there was a considerable amount of data on the courses, it was not available in a form whieh could be utihzed because of this difference in classification. Reinkemeyer (1968) had studied three ofthe courses in some detail, but in a different context. So while there was a 'scatter' of information available it was difficult to extract material in a form that was useful. A survey of relevant Uterature revealed that there were no properly validated tests for assessing the kind of differences of interest here, particularly in relation to attitudes towards total patient care. Consideration was given to preparing a form of assessment for this purpose, but a pilot scheme revealed that it would be too complex a task and the validity would be somewhat dubious so the idea was abandoned. In the proeess of searching through the records and the descriptive material available, some common factors gained significance and other areas of interest assumed importance, with the result tliat a sociological 'model' emerged giving a conceptual framework within which the variables could be systematically examined and an attempt made to search for relationships between them.
The model The model sets the student at one end and the patient or client receiving care at
446
G. M. Owen The potential student nurse
Environmental and social background Individual variables Student
Preparation for nursing and health visiting Type of course— plan and content Socialization processes Patient need and demand
Delivery of care, professional and nursing skills, individual need, expectations and values
The patient FIGURE 1 A tnodelfor stndyiiig nursing and health visiting education and training
the other end, both in the context of a social system with similar cultural influences, the same social institutions and social structure, A number of variables can influence the kind of person the student is on entering the course and her potential for development. Inevitably, a 'product' of family background and subcultural influences, the student is affected by parental influences and educational background, social class factors, peer group influences, social pressures and social
Curriculum integration in nursing education
447
change. Thc student has certain 'personal' variables and attributes, abilities, intelligence, values, attitudes and motivations, and individual needs for satisfaction, fulfilment, recognition, acceptance and belonging, all of which affect the 'input' into any course. The patient or client on the receiving end is also affected by a similar set of social and cultural factors, needs, demands and expectations, which can be thc same as the student's or quite different. For example, the student may see her role as helping the patient to regain independence as part of the recovery process, while the patient's expectations of the nurse may be based on a dependency type of relationship and he expects a different kind of'care' from that received because of differences in his own subculture. His 'demands' may be different from his 'needs' as seen by the professional nurse. In between the 'raw' student, however, and the delivery of care to the patient or client by the qualified nurse or health visitor, is the socializing process of the nurse's professional training and education. Whichever kind of course is followed the professional preparation produces a number of variables common to both. The student is influenced by the kind of course—the hospital experience and its institutionalization effect, the tutorial influences, the professional role and expectations of colleagues and patients, and the general public. The availability of resources and social pressures, the educational setting and plan and content ofthe course and nature of experience, are all relevant. The nature of this process gives certain professional skills by the time of qualification. It endows confidence and competence and a range of technical expertise, with other skills in the area of teaching, management and interpersonal relationships. Attitudes and values may also have been modified or changed by preparation, as will expectations of people and ofthe satisfactions to be found in the profession. All of this will influence the kind and quality of care, the ability to handle situations in hospital or community, and to establish relationships and promote health within the community. This model was used subsequently as a framework, the literature being reviewed in terms ofthe three main areas (i) the student, {2) the course, and {3) the qualified nurse health visitor. In structuring the research design, therefore, it was necessary to recognize the constraints of investigating in an area where previously little work had been done, and there were virtually no criteria for assessing the variables of primary interest. There was, however, some interesting documentary material available which was of considerable value historically and could well be incorporated into the study. The structure, which was ultimately decided upon, was as follows:— 1 An historical account of professional developments contributing to the establishment ofthese courses and a review of relevant literature. 2 An account of the development of the courses in terms of aims, objectives, plans and modifications. 3 The research project consisting of: a A survey ofthe current opinion of tutors and students on the courses.
448
G. M. Owen
b A questionnaire to all students completing the six courses iti 1972, with a matched control group completing a i-year course in health visiting at the same point in time. The questionnaire was to include relevant background material and the use of Rosenberg's (1957) ten item questionnaire on values and expectations, also the occupational stereotype tests as used by Singh and MacGuire (1971). This was found to be the most effective method of covering the entire student population at any one point in time. c A questionnaire to all chief nursing officers in the commutiity to attempt to discover their views on the 'end product' of these courses. THE H I S T O R I C A L B A C K G R O U N D & RELEVANT LITERATURE Historical background The account of the development of these courses, set in the historical and social context, is interesting and relevant to diis study, particularly when seen in the context ofthe development of nursing in the higher education establishments both in the United States and Canada, as well as the United Kingdom. Two significant features call for specific comment, the first relating to the difficulties associated with getting nursing courses established in universities. Across the Adantic, as in the United Kingdom, Henderson & Simons (1964) note that the 'way in' to the academic setting appears to have come through public health nurses and their courses and the efforts to link the preventive and curative aspects of nursing on one course. They also ask 'Can there bc a plan of nursing education that etiables students to progress from one stage of training to the next without repetition, waste of time or imposed hardship?' Brown (1948) suggested the 'professional nurse will be one who recognizes and understands the fundamental health needs of a person sick or well and who knows how these needs can be met'. The placing of public health nursing courses in the universities had preceded the degree programmes and played a part in their evolution, according to Jean Leask (1970). The second similar feature related to the public 'image' of the nurse and the difficulties associated with detaching the nursing image from that of the 'floor nurse' (Davis 1966) in the United States, or the hospital ward in Britain. These, then, were strong social constraints relating to establishing nursing education away from hospitals. Some ofthe innovators ofthe integrated courses in the United Kingdom had travelled across the Atlantic and may well have been influenced by some ofthe events there, but, as Reinkemeyer (1968) noted, nurses in the United Kingdom were not anxious for what universities had to give, neither did diey wish to be controlled by universities. Fortunately for us Reinkemeyer's predictions were not fulfilled and nursing in higher education developed in its own way and time, but much more rapidly than she had anticipated and not necessarily on the same lines as in the United States. Three of the first courses to be associated with the higher education field in the
Curriculum integration in nursing education late 1950s were integrated courses (included in diis study) and were jointly planned and organized between the hospital, community and educational establishment. The fourth, at Edinburgh University, was pioneered in a unit led by a health visitor, so once again in the United Kingdom the entry into higher education was initiated where the growth points already existed with health visitor tutors in post and opportunities for integrated courses available. As others followed, this pattern was repeated in several instances and it is quite apparent that the integrated courses gave impetus to nursing in higher edueation. The Report of the Committee on Nursing (Department of Health and Social Security 1972) also referred to the dififieulty of losing the image ofthe nurse in a hospital setting. These two points are worth observation as they are relevant to some of the resistance to these courses and students associated with them. The relevant literature This was reviewed in the context ofthe model (Figure i) and a few points that emerge were ultimately incorporated in the fmal study. The student. It was possible to observe from the few existing studies (Bryden 1969, Singh 1970, Reinkemeyer 1968) that students in 'integrated' courses generally come from a wider social class background than those on other experimental courses and also were likely to have been educated in an ordinary grammar school rather than privately, as in some teaching hospitals. They were more highly involved in comnumity work than other students on entry to the course. They tended to be 'early deciders', that is they made up their minds to nurse quite early in life (at 12 or 13 years old). These points were reinforced in my own study, and this has implications for lougterm career satisfaction as 'early deciders' tend to stay longer and be more satisfied (MacGuire 1969). No personality differences emerged between these and other general students and no general profile was available. Work done in related fields on personality profiles, occupational choice, roles, values aud expectations, suggested a useful starting point and Rosenberg's (1957) well validated test on occupations and values offered an opportunity for comparing students on 'integrated' courses with health visitor students as these tests had been used in other contexts by Singh & MacGuire (1971) on qualified health visitors and general nurses. The course. The only relevant factor to emerge here was the importance of hnking theory with practice within a period of 3-6 months for maximum value (Bendall 1971). The search revealed nothing in the way of tools suitable for assessing the effects ofthe socialization and educative processes during the course. There were, however, quite considerable records on the details of these courses, their plans and modifications, at the educational establishments. The qualified niurse/health visitor. The main areas of interest here were again in terms of role, role conflict and job satisfaction, and there were no criteria for
449
450
G. M. Owen
nieasuremetit of quality of eare, or even attitudes towards care (at that time). The most relevatit studies were those done by Singh & MaeGuire (1971) which included general nurses and health visitors and actually used Rosenberg's (T957) occupational values and an adapted version of Cohen's (1970) occupational stereotypes. Ultimately it was decided to use these same tests, as they were the most suitable validated tests available and already used to assess any differences betweeti these students. The documentation of the courses Tutors on all six courses were visited and material in the form of early documents, reports atid papers was put at my disposal. A stnall questionnaire, seeking up-todate factual information and opinions of staff, was also completed. As a result it was possible to document these courses in some detail and to classify details as follows: 1 Course aims, objectives and philosophy. 2 Plan structure and content. 3 Modifications as a result of evaluation. 4 Tutorial arrangements, teachitig tnethods and assessment. 5 Recruitment, selection and withdrawal. 6 Finance and administration. 7 Evaluation. It is impossible to go into detail on interesting differences and similarities that emerged. One or two points however stand out:— 1 The role of organizing tutor in the clinical field is a vital one for student satisfaction. 2 Performance of skills on the clinical field was slow at first, students lacking conftdence, but ultimately they caught up and more than equalled other students iti clinical practice. 3 The emphasis in each course was on integration of studies, early introduction to community experience and the concept of total care. 4 Recruitment was good and, contrary to general opinion, the 'wastage' rates, seen in terms of failure to complete State Registration, was low (approximately
Student comments Perhaps the most interesting, if not the most scientific, section of the report on the courses came from the classification of students' opinions. It was based on a personal collection of articles, letters, tapes, reports, press correspondence, seminars etc., which had been collected over the years since these courses began. They were studied carefully and classified and any type of comment made more than three times was recorded verbatim, or quoted exactly, favourable or otherwise. They fell into fairly obvious groupings and it was possible to classify them as follows; I Reasons for entering the course.
Curriculum integration in nursing education 2 3 4 5 6
The role ofthe tutor. The educational experience. Fieldwork experience—community and hospital. The course—structure and problems. The course in retrospect. Over seventy comments were recorded representing comments from students and qualified staff from each ofthe six courses. Problems revealed related to the need for constant change and adjustment to new areas of work, also misunderstanding and resentment encountered from both colleagues and staff, feelings of lack of confidence and competence, but with recognition that these feelings went as skills grew. The educational establishment and community experience were thoroughly enjoyed, while some were highly critical ofthe learning situations in the clinical field but tended to show msight into die reasons. Once again the importance of tutorial support needed in the clinical field stood out. One said 'You could get lost in hospital without a good tutor'. One feature which stands out was their ability to be self-critical and take an objective view of situations and problems. Comments from students when qualified staff* showed a greater appreciation ofthe eourse in retrospect, many noting their appreciation ofa 'total approach' to patient care and understanding of the role of other members of the team. It is fitting to quote a final comment as a summary. 'The nursing profession in this country is in danger of omitting an increasingly great part of its responsibility to the patient. There is a tendency to treat patients in bits, caring for one aspect only of their health. The integrated course has not been primarily an academic course, but the means of translating the concept of caring for the whole patient from theory to practice. It has given me greater self-knowledge, and appreciation of others' needs and circumstances than I feel I could have gained any other way. I am utterly convinced that nurse training of the future should be based on courses such as this.' (For obvious reasons the origins of these comments were referred to simply as 'letters', 'articles' or 'taped' interviews).
THE S T U D E N T ' S
QUESTIONNAIRE
After a pilot survey, die student's questionnaire was completed by 57 ofthe 60 students completing the six courses in the summer of 1972. A control group was obtained of 63 students completing the i-year health visitors course at the same time. They were matched as nearly as feasible, using the same educational establishments where possible and obtaining a similar group in terms of age and academic qualifications. The main group of 'integrated' course students was, however, slightly younger and slightly better qualified academically in terms of 'A' levels than the control group. More ofthe control group were married. Most ofthe background information gained from this questionnaire substantiated what had been noted in the literature.
45 ^
452
G. M. Owcit
The occupational values inventory This provided a very interesting aspect of the survey. The ten items used were identical with those developed and validated by Rosenberg (1957) and used hy Singh & MacGuire (1971). The students were asked to rate the items on a 5-point scale, ranging from high to low in terms of satisfaction, given in response to thc following three statements; 1 I think the ideal joh would . . . 2 I think nursing will . . . 3 I think health visiting will. . . The items were as follows: 1 Give me an opportunity to be helpful to others. 2 Provide an opportunity to use my special abilities. 3 Provide a chance to earn good money. 4 Permit me to be creative and original. 5 Give me soeial status and prestige. 6 Give me an opportunity to work with people rather than tilings. 7 Enable me to look forward to a stable, secure future. 8 Leave me relatively free ofthe supervision of others. 9 Give me a ehance to exercise leadership. 10 Provide me with adventure. Obviously the whole range of actual numbers obtained was used to compute the x^ values. For the sake of simplicity and interest in presentation, thc percentages rating the values high and low have been abstracted here, hut the significant differences for x^ calculated on the basis ofthe actual figures in high, medium and low categories. (The medium ratings have not been included in these tables.) Table T shows how thc main or Integrated Course of Nursing Education (ICNE) group compared with the control group in terms of their expectations of an ideal job. Notice the highly significant diffcrenee in relation to social prestige (o-ooi) and difference significant at the 0-05 level for Items i and 10, the main group being more anxious to be helpful and slightly more concerned with gaining adventure. In the latter case the ICNE group showed a very 'high' medium rating and the control group a high 'low' rating. Both groups score relatively high in Items i and 6, which is in keeping with Rosenberg's (1957) 'people orientated' value cluster characteristic of certain other groups, such as teachers. Item 6 was consistently high in every count, there being no significant difference whatsoever between the groups in any of the results. When asked to rate their values in terms of'I think nursing would provide . . .' and '1 think health visiting would provide . . . ' there was no significant difference at all between the two groups on their views on nursing and only one at the 5% level (Item 2) on how they saw health visiting. Thus, we ean conclude that there were some significant differences between the two groups in terms of their expectations of an ideal job, but no differences in their expectations of nursing and only one between their expectations of health visiting. This could be due to
Curriculum integration in nursing education TABLE I
453
Occupational values showing di£erences in expectations In the idea! joh
Main group—ICNll High Low Item
/ (/»'nt the ideal joh tvould . . .
1
Give me an opportunity to help others Provide an opportunity to use my special abilities Provide a chance to earn good money Permit me to be creative and original Give me social status and prestige Give me au opportunity to work with people rather than things Enable me to look forward to a stable secure future Leave me relatively free of the supervision of others Give me a chance to exercise leadership Provide me with adventure
2
3 4 5
7 8 0
10
0-1%
0/
/o
0/ ,0
84-0
Control Group High Low 7 7
Y"
667
*
3-2
70-0
1-8
57-2
15-8
T2-3
31-7
15-9
52-7
3'5
34-9
9-5
7-0
33'3
46-0
4-8
90-4
3-2
96-0 34-0
8-7
39'6
175
54-5
8-6
55-6
12-7
22-8
15-8 24-5
19-9 17-5
22-2
17-3
47-6
t
*
: significant at .s";', level (0-05), t5(;^ — significant at 1%level (o-oi), t 5(^ = significant at level (o-ooi)
their public image ofnursing and health visiting or the socialization processes ofthe course. Table 2 shows how nursing differs from the expectations they had of an ideal job, showing both groups are unsatisfied on at least five items, in terms of their expectations. By contrast, Table 3 shows health visiting significantly different from their expectations in the ideal job on only one item for the ICNE group and two items for the main group. This could account for thc fact that many of the ICNE group actually end up in health visiting. Notice they were not very concerned with earning good money, although at the time the study was carried out many thought that they entered health visiting because of thc better pay. In fact it could have been because they find the job more in line with their ideals. Table 4 is added to show where the difference between nursing and health visiting expectations occur—the two groups being relatively similar, but an interesting picture of differences between their expectations of the two roles.
Occupational stereotypes The two groups were also asked to picture, as far as possible, a typical nurse in a general hospital and a typical health visitor, and again to rate them on a 5-point
G. M. Owen
454
s h^ ^ ^
5
u ^ w
-g ^
I
a. o
•73
o 0 -13 ro
CL,
I
n
0 *-*
Ul i j
-g
0
0 CJ
CJ
rH
0
u
CJ
0
0
0
-^
>^
£
fni
0
S-.
tun
:ivc
i? o
0 C
esti
•5
I
-o
0
%
^
0 l^ ^ c
_c 0
73 •>
o
o
w
c
Curriculum integration in nursing education
455
UJ
2
3
u
1-5
O
ire
so
O
co
a,
bo
3
o
dve
-VPI
-c LJ
o
-d
2 OH
>
> 0 \^
> O
•6
6
G. M. Owen
-T3
§
^ ^ ^
g
o a. o
*3 G u Wl
c ^^ 0
-C w
c 0 -73
'C o
o o
-D C
i M
5 C
o
O
IM
0 a.
c
o 0
u u
re u
•? bc
'S CJ
o
I.'
DH
'^ C
0
C'
rn
>
re.
a.
LJ
-T3
o
CL,.5 0 ^
c
o
o
457
Curricitluni integration iti nnrsing education TABLE 5 Occupational stereotypes: the main group {ICNE) {To show comparison between their stereotype ofnursing {SRN) and health visiting {HV) are expressed in percentages gii'ing left and right hand ratings for attributes) How they view
Ho\i> they view Left-hand attribute
SRN
Humble Sober Toughminded
8-6 i0'4 24-6
Practical
75 "4 26-3
Easygoing Conservative Relaxed Conforming Soft Talkative Cultured Subjective Intelligent Stable Mobile Puts hospital first CompetitiveConfident Academically excellent
33-3
28-0 79-0 "23 52-6 14-0 38-6 34-7 38-7 20-0 42-1 8-6 42-1 T2-I
HV 7-0
22-9 IO'6 24-9 33-3 24-6 58-2 21-0 17-5 54-4 54-4 10-6 65-0 65-0 34-7 I.VS 10-6 59-7 47-4
Right-hand attribute
SRN
HV X'
Assertive
47-4 22-8 26-2
63-5 24-6 24-6
5-3
34-9 r8
Happy go lucky Tender Imaginative Aggressive Liberal Tense Individualistic Hard Quiet Uncultured Objective Unintelligent Changeable Settled Puts profession first Cooperative Worrying Academically poor
1^ calculated from actual means, *x^ significant at 5 at o-i°(, level
17-5 15-8 21-0 3-5 31-3 7-0 17-5 22'9 10-7 15-7
2(ri 14-0 61-5 10-6 14-0
45-5 5-3 54-4 3-5 8-9
o-o 40-4 1-8 8-6 42-4 58-4 52-8
t * t t
t t
t t t t *
8-6 0-0
significant at 1%, t/^ significant
scale indicating to what extent the adjectives given described them. This was Cohen's (1970) scale as adapted and used by Singh & MacGuire {1971). As thc tables are rather complicated to present visually just one table will be given here and comments on other findings (see Table 5). There were only two significant differences between thc groups in how they viewed a typical nurse and only two in their views ofa typical health visitor, so it could be assumed that either they retained the images ofthe nurse and health visitor they had acquired in their social background, or they had been subjected to similar socialization processes. The main group, however, showed a more cautious tendency in their ratings yet demonstrated significant differences in their view of the nurse and the health visitor on thirteen items, while the control group showed eleven differences (several less ofthese being highly significant ones). A close scrutiny of thc tables yields many points of interest, but the most relevant one is that the ICNE group do tend to show a more clearly differentiated view ofthe nurse and health visitor, which is interesting in view ofthe fact that it is often feared they will confuse their roles and not have a clearly defined awareness ofthe separate identities. This ties up also with the employer's comments, which suggest they are very aware ofthe subtle differences. Table 5 is included to show
G.M. Owen where the ICNE group saw significant differences between nursing and health visiting. Consumer satisfaction The final questionnaire was an attempt to find out what employers tliougiu about health visitors trained this way. Although such a questionnaire could be too subjective to be of value, a pilot exploration produced a good response and a surprisingly interesting pattern and it was decided to proceed. In 1973, 153 Chief Nursing Officers were invited to complete questionnaires, or ask their staff to do so, and 149 replies were received with only six refusing to participate. Fifty-five said they had not employed any staff trained on ICNE courses, and 116 completed forms were received altogether. The comments made were based on experience of 477 'evaluations' as some staff must have been evaluated several times, or by different employers where they had moved jobs. The most interesting aspect of this survey was the response to the request to rate these staff" on a 5-point scale, in comparison with other young, recently qualified health visitors. The 31 items finally listed after a pilot run were under the four headings of: r General ability—leadership, confidence, teaching etc. 2 Relationships—cooperation etc. 3 Handling situations—applications of theory to practice. 4 Professional awareness. An approximate summary of thc replies shows that about two-thirds of the respondents rated ICNE health visitors higher than the average young health visitor on the following items: 1 Initiative. 2 Aptitude for Healtli Education. 3 Cooperation with colleagues. 4 Cooperation with other workers. 5 Readiness to use teaching opportunities. 6 An intelligent approach to the job. 7 Tendency to use initiative and new ideas. 8 Awareness ofthe needs ofthe profession. The most frequent low ratings were in terms of: 1 Practical ability. 2 Confidence in their ability. 3 Ability to assess their own assets. 4 Assuming leadership. 5 Readiness to seek advice. 6 Tolerating frustration. In actual fact less than a quarter ofthe respondents gave low ratings. There were a few built-in check questions and these, with the comments asked for, revealed a great deal of ambiguity. For example, many who rated these health visitors high in terms of confidence, later commented that they lacked
Curriculum integration in nursing edttcation
459
confidence, or rated tlicin high in taking initiative and in leadership skills and later said they lacked willingness to assume leadership. Many rated them high on practical ability and commented later on their lack of experience in practical situations. Their low score in assuming leadership could be related to the lack of confidence these health visitors experience on the part of their colleagues who appear to expect them to be less skilful in the practical situation. The additional comments made by employers reinforced those made by tutors and the students' assessments of themselves. CONCLUSION The value of a study of this kind probably lies more in the fact that it brings together, in a documented and classified form, the information available on an experimental form of nursing education and throws into relief some ofthe significant characteristics. Several things emerge with some clarity: 1 The remarkable similarity in the aims, objectives, structure and content ofthe courses and the fact that students are introduced to community care very early in the course. 2 The fact that these courses have provided some of the first links between hospital and the higher education system. 3 It is possible to produce a kind of profile of these students as being well motivated to nurse, with a strongly 'people orientated' tendency, anxious to use their special abilities and be creative, and not too concerned with money or social prestige and status. They may be slow starters on the course but learn quickly, grasping principles and applying them well. In spite of good reports they lack confidence in practical situations, but have a keen insight into their own reactions. They are sensitive to criticism and often experience stress in the face of resentment, knowing that their colleagues have high expectations of their performance wliile they themselves fear they will not perform adequately. They express a keen desire to be proved good nurses and demonstrate their ability to take a total view on patient care and understand the different roles of colleagues, clearly. It is possible that there is much to be learned from the early introduction of community care integrated into the basic nursing education programme, from these courses, in terms of attitudes to total patient care. They are welcomed by employers and regarded with considerable esteem, yet much ambiguity exists within the profession in assessing their qualities. On the basis of the statistical data one can say that there are some differences between these students and others upon qualifying and the differences can be identified, but it is not possible here to demonstrate the extent to which the differences existed on entry to the course, or occurred as a result ofthe socialization and educational processes occurring during the course. One would like to see criteria for assessing and evaluating courses like this more fully developed and utihzed, particularly with the increased expansion of nursing in higher education. One other area, which would be fruitful for future research, would be in
46o
G. M. Owen
relation to all the ambiguities thro'wn up relating to the expectations of the professioti, such as the assutnption that these students lack conftdence therefore lack skill. Finally, it is possible to conclude that the pioneers who initiated these courses have in fact achieved many of their aims and much can be learned from these experiments, 'which is valuable in preparing nurses for an integrated health service. References BENDALL E. (1971) The iitirsiiig process in student nurses. Occasional papers. Niirsiti^ Times 67, 173-175BROWN E.L. {1948) Nursing for the Future. Russell Sage, New York. BRYDEN E. (1969) Integrated Course of Nursing Educathti. Queen's Institute of District Nursing, London. COHEN (1970) Occupational values and stereotypes in a group of engineers. British Journal of Industrial Relation
Curricuium integration in nursing education: a concept or a way ofiifePA study of six courses integrating basic nursing education andiieaitii visiting in a singie course Grace M. Owen M.PhiL B.Sc.(Soc). S.R.N. S.C.M. H.V.Tutor's Cert. R.N.T. Head of Department of Nursing and Community Health Studies, Polytechnic oj the South Bank, London Accepted for publiealion 7 fvhruary
OwiiN G.M. [if)']']) Journal of Advanced Sursing 2, 443-460
Curriculum integration in nursing education: a concept or a vvay of life? A study of six courses integrating basic nursing education and health visiting in a single course The purpose of this study was to record the historical development of'integrated' nursing courses, which were an innovation in nursing education, and also to attempt to identify any differences existing between health visitors who trained on 'integrated' courses and those who had trained on the 3-year SRN courses, with an additional year for health visiting. The 'integrated' courses, first established in 1957, aimed to attract intelhgent candidates to nursing and to oifer a more appropriate method of preparation for health visiting between hospital and university or college, integrating hospital nursing witb health visiting. The original area of investigation was carried out by means of unstructured questionnaires to all health visitors completing tbe 'integrated' courses in 1972, and a comparable group of health visitors completing the i-year course at the same point in time. Certain significant differences were identifiable between the two groups in terms of expectations, values and satisfactions in nursing and health visiting, and differences also emerged between tbe stereotypes of nursing and bealth visiting beld by both groups. A further study carried out among employers revealed some interesting attitudes beld by tlieir professional colleagues towards those trained on 'integrated' courses, and gave some indication of tbe ways in wbich their performance was evaluated by nursing officers and otiiers. The concluding discussion outlines some of the possible impHcations of tliese findings in the context of present day nursing education in the United Kingdom and an integrated bealth
INTRODUCTION At a time when 'integration' has become a generally accepted concept in the health and social services in tlie United Kingdom, it is an appropriate point to 443
444
G- ^- Owen
look back over the last twenty years at an experiment in nursing education, the significance of which tends to be overlooked in the light of subsequent developments in nursing education. The aim of this study was to record the historical development of the six courses which integrated basic nursing education and health visiting in a single course, and to attempt to identify the diiferences, if any, which existed between health visitors who trained on these courses and those who had followed the traditional 3-year SRN course, with an additional year for health visiting. The 'integrated' courses, first established in 1957, aimed to attract intelligent candidates to nursing and to offer a more appropriate form of preparation for health visiting between hospital and university or college, and integration of clinical nursing with health visiting. When the study was commenced in 1969 there were only the six courses whieh had been established on an experimental basis. Two have achieved degree status and two have been associated with degree development, and a number of modifications have since been made. They were jointly organized at that time between the following establishments: 1 2 3 4 5 6
Southampton University and St, Thomas' Hospital. Surrey University and Hamtnersmith Hospital. Manchester University and Crumpsall Hospital. Croydon Technical College and King's College Hospital. Chiswick Polytechnic and Hillingdon & West Middlesex Hospitals. Newcastle-upon-Tync Polyteclmic and Newcastle University Hospitals.
The stimuli whieh motivated this study originated during my association with one of these courses as organizing tutor. It was a commonly expressed experience of those involved in teaching these students that they were 'different' from students trained on the conventional nursing and health visiting courses. Similar comments came from experienced nurses and health visitors who worked with them after they were qualified. The nature of the differences w^as difficult to identify clearly, although comments frequently heard related to their ability to take a more total approach to patient care throughout the course, or their ability to take a longterm view of things, or assess a situation quickly, also that they lacked confidence. It was apparent too that they were able to take a broader perspective on patient care, registering the need in relation to the family, or seeking for the cause of problems in order to prevent reoccurrences where possible. This kind of difference could, however, quite easily have been attributed to intelligence or higher academic attainment on entry and thus bear no relationship to the kind of course. One particular difference was intriguing—they appeared to retain their curiosity, their inquiring approach and their 'openness' to new ideas and progressive thitiking in a way that was not apparent in other students of comparable educational achievement, or trained in the same nursing schools. Thus, one of the main questions which arose was whether these students had certain different attributes on selection, or whether the courses were so organized that there were identifiable differences in the end product.
Curriculum integration in nursing education
445
Another motivating force for the study was that such courses are complex, difficult to organize and expensive in the use of scarce resourecs, and it appeared important to attempt some kind of general evaluation to complement the work done by Reinkemeyer (1968), Bryden (1969) and Singh (1970). RESEARCH M E T H O D O L O G Y A N D DESIGN Two very obvious difficulties to consider were the wide range of variables and the lack of suitable criteria available for evaluating the attributes under review. All six courses had been planned on an experimental basis over a period of about ten years, were based in different kinds of educational establishments and differently planned, although aims and objectives were remarkably similar. Thc one common and key feature was that in all courses the student was introduced to community nursing very early in the course—at the latest the second term of the first year, and in five courses were introduced to health visiting practice and the remaining one to studies in health visiting in the first year, hi all courses some method of integration of studies was used. It became evident that it was important to document the development of these courses in thc historical and professional context, and their aims, objectives and plans, in order to identify their similarities and differences and compare them with the orthodox courses. Although most of the organizing establishments had kept some kind of reeord of progress and ehanges, there was no uniformity in these and most of them were ofa descriptive nature, apart from factual material relating to applications, interviews, wastage and examination success. Singh (1970) had included these six courses in his study o£ Student nurses on experimental courses,
but had classified two of them with undergraduate courses and four of them as 'intcsrated courses' and thus, while there was a considerable amount of data on the courses, it was not available in a form whieh could be utihzed because of this difference in classification. Reinkemeyer (1968) had studied three ofthe courses in some detail, but in a different context. So while there was a 'scatter' of information available it was difficult to extract material in a form that was useful. A survey of relevant Uterature revealed that there were no properly validated tests for assessing the kind of differences of interest here, particularly in relation to attitudes towards total patient care. Consideration was given to preparing a form of assessment for this purpose, but a pilot scheme revealed that it would be too complex a task and the validity would be somewhat dubious so the idea was abandoned. In the proeess of searching through the records and the descriptive material available, some common factors gained significance and other areas of interest assumed importance, with the result tliat a sociological 'model' emerged giving a conceptual framework within which the variables could be systematically examined and an attempt made to search for relationships between them.
The model The model sets the student at one end and the patient or client receiving care at
446
G. M. Owen The potential student nurse
Environmental and social background Individual variables Student
Preparation for nursing and health visiting Type of course— plan and content Socialization processes Patient need and demand
Delivery of care, professional and nursing skills, individual need, expectations and values
The patient FIGURE 1 A tnodelfor stndyiiig nursing and health visiting education and training
the other end, both in the context of a social system with similar cultural influences, the same social institutions and social structure, A number of variables can influence the kind of person the student is on entering the course and her potential for development. Inevitably, a 'product' of family background and subcultural influences, the student is affected by parental influences and educational background, social class factors, peer group influences, social pressures and social
Curriculum integration in nursing education
447
change. Thc student has certain 'personal' variables and attributes, abilities, intelligence, values, attitudes and motivations, and individual needs for satisfaction, fulfilment, recognition, acceptance and belonging, all of which affect the 'input' into any course. The patient or client on the receiving end is also affected by a similar set of social and cultural factors, needs, demands and expectations, which can be thc same as the student's or quite different. For example, the student may see her role as helping the patient to regain independence as part of the recovery process, while the patient's expectations of the nurse may be based on a dependency type of relationship and he expects a different kind of'care' from that received because of differences in his own subculture. His 'demands' may be different from his 'needs' as seen by the professional nurse. In between the 'raw' student, however, and the delivery of care to the patient or client by the qualified nurse or health visitor, is the socializing process of the nurse's professional training and education. Whichever kind of course is followed the professional preparation produces a number of variables common to both. The student is influenced by the kind of course—the hospital experience and its institutionalization effect, the tutorial influences, the professional role and expectations of colleagues and patients, and the general public. The availability of resources and social pressures, the educational setting and plan and content ofthe course and nature of experience, are all relevant. The nature of this process gives certain professional skills by the time of qualification. It endows confidence and competence and a range of technical expertise, with other skills in the area of teaching, management and interpersonal relationships. Attitudes and values may also have been modified or changed by preparation, as will expectations of people and ofthe satisfactions to be found in the profession. All of this will influence the kind and quality of care, the ability to handle situations in hospital or community, and to establish relationships and promote health within the community. This model was used subsequently as a framework, the literature being reviewed in terms ofthe three main areas (i) the student, {2) the course, and {3) the qualified nurse health visitor. In structuring the research design, therefore, it was necessary to recognize the constraints of investigating in an area where previously little work had been done, and there were virtually no criteria for assessing the variables of primary interest. There was, however, some interesting documentary material available which was of considerable value historically and could well be incorporated into the study. The structure, which was ultimately decided upon, was as follows:— 1 An historical account of professional developments contributing to the establishment ofthese courses and a review of relevant literature. 2 An account of the development of the courses in terms of aims, objectives, plans and modifications. 3 The research project consisting of: a A survey ofthe current opinion of tutors and students on the courses.
448
G. M. Owen
b A questionnaire to all students completing the six courses iti 1972, with a matched control group completing a i-year course in health visiting at the same point in time. The questionnaire was to include relevant background material and the use of Rosenberg's (1957) ten item questionnaire on values and expectations, also the occupational stereotype tests as used by Singh and MacGuire (1971). This was found to be the most effective method of covering the entire student population at any one point in time. c A questionnaire to all chief nursing officers in the commutiity to attempt to discover their views on the 'end product' of these courses. THE H I S T O R I C A L B A C K G R O U N D & RELEVANT LITERATURE Historical background The account of the development of these courses, set in the historical and social context, is interesting and relevant to diis study, particularly when seen in the context ofthe development of nursing in the higher education establishments both in the United States and Canada, as well as the United Kingdom. Two significant features call for specific comment, the first relating to the difficulties associated with getting nursing courses established in universities. Across the Adantic, as in the United Kingdom, Henderson & Simons (1964) note that the 'way in' to the academic setting appears to have come through public health nurses and their courses and the efforts to link the preventive and curative aspects of nursing on one course. They also ask 'Can there bc a plan of nursing education that etiables students to progress from one stage of training to the next without repetition, waste of time or imposed hardship?' Brown (1948) suggested the 'professional nurse will be one who recognizes and understands the fundamental health needs of a person sick or well and who knows how these needs can be met'. The placing of public health nursing courses in the universities had preceded the degree programmes and played a part in their evolution, according to Jean Leask (1970). The second similar feature related to the public 'image' of the nurse and the difficulties associated with detaching the nursing image from that of the 'floor nurse' (Davis 1966) in the United States, or the hospital ward in Britain. These, then, were strong social constraints relating to establishing nursing education away from hospitals. Some ofthe innovators ofthe integrated courses in the United Kingdom had travelled across the Atlantic and may well have been influenced by some ofthe events there, but, as Reinkemeyer (1968) noted, nurses in the United Kingdom were not anxious for what universities had to give, neither did diey wish to be controlled by universities. Fortunately for us Reinkemeyer's predictions were not fulfilled and nursing in higher education developed in its own way and time, but much more rapidly than she had anticipated and not necessarily on the same lines as in the United States. Three of the first courses to be associated with the higher education field in the
Curriculum integration in nursing education late 1950s were integrated courses (included in diis study) and were jointly planned and organized between the hospital, community and educational establishment. The fourth, at Edinburgh University, was pioneered in a unit led by a health visitor, so once again in the United Kingdom the entry into higher education was initiated where the growth points already existed with health visitor tutors in post and opportunities for integrated courses available. As others followed, this pattern was repeated in several instances and it is quite apparent that the integrated courses gave impetus to nursing in higher edueation. The Report of the Committee on Nursing (Department of Health and Social Security 1972) also referred to the dififieulty of losing the image ofthe nurse in a hospital setting. These two points are worth observation as they are relevant to some of the resistance to these courses and students associated with them. The relevant literature This was reviewed in the context ofthe model (Figure i) and a few points that emerge were ultimately incorporated in the fmal study. The student. It was possible to observe from the few existing studies (Bryden 1969, Singh 1970, Reinkemeyer 1968) that students in 'integrated' courses generally come from a wider social class background than those on other experimental courses and also were likely to have been educated in an ordinary grammar school rather than privately, as in some teaching hospitals. They were more highly involved in comnumity work than other students on entry to the course. They tended to be 'early deciders', that is they made up their minds to nurse quite early in life (at 12 or 13 years old). These points were reinforced in my own study, and this has implications for lougterm career satisfaction as 'early deciders' tend to stay longer and be more satisfied (MacGuire 1969). No personality differences emerged between these and other general students and no general profile was available. Work done in related fields on personality profiles, occupational choice, roles, values aud expectations, suggested a useful starting point and Rosenberg's (1957) well validated test on occupations and values offered an opportunity for comparing students on 'integrated' courses with health visitor students as these tests had been used in other contexts by Singh & MacGuire (1971) on qualified health visitors and general nurses. The course. The only relevant factor to emerge here was the importance of hnking theory with practice within a period of 3-6 months for maximum value (Bendall 1971). The search revealed nothing in the way of tools suitable for assessing the effects ofthe socialization and educative processes during the course. There were, however, quite considerable records on the details of these courses, their plans and modifications, at the educational establishments. The qualified niurse/health visitor. The main areas of interest here were again in terms of role, role conflict and job satisfaction, and there were no criteria for
449
450
G. M. Owen
nieasuremetit of quality of eare, or even attitudes towards care (at that time). The most relevatit studies were those done by Singh & MaeGuire (1971) which included general nurses and health visitors and actually used Rosenberg's (T957) occupational values and an adapted version of Cohen's (1970) occupational stereotypes. Ultimately it was decided to use these same tests, as they were the most suitable validated tests available and already used to assess any differences betweeti these students. The documentation of the courses Tutors on all six courses were visited and material in the form of early documents, reports atid papers was put at my disposal. A stnall questionnaire, seeking up-todate factual information and opinions of staff, was also completed. As a result it was possible to document these courses in some detail and to classify details as follows: 1 Course aims, objectives and philosophy. 2 Plan structure and content. 3 Modifications as a result of evaluation. 4 Tutorial arrangements, teachitig tnethods and assessment. 5 Recruitment, selection and withdrawal. 6 Finance and administration. 7 Evaluation. It is impossible to go into detail on interesting differences and similarities that emerged. One or two points however stand out:— 1 The role of organizing tutor in the clinical field is a vital one for student satisfaction. 2 Performance of skills on the clinical field was slow at first, students lacking conftdence, but ultimately they caught up and more than equalled other students iti clinical practice. 3 The emphasis in each course was on integration of studies, early introduction to community experience and the concept of total care. 4 Recruitment was good and, contrary to general opinion, the 'wastage' rates, seen in terms of failure to complete State Registration, was low (approximately
Student comments Perhaps the most interesting, if not the most scientific, section of the report on the courses came from the classification of students' opinions. It was based on a personal collection of articles, letters, tapes, reports, press correspondence, seminars etc., which had been collected over the years since these courses began. They were studied carefully and classified and any type of comment made more than three times was recorded verbatim, or quoted exactly, favourable or otherwise. They fell into fairly obvious groupings and it was possible to classify them as follows; I Reasons for entering the course.
Curriculum integration in nursing education 2 3 4 5 6
The role ofthe tutor. The educational experience. Fieldwork experience—community and hospital. The course—structure and problems. The course in retrospect. Over seventy comments were recorded representing comments from students and qualified staff from each ofthe six courses. Problems revealed related to the need for constant change and adjustment to new areas of work, also misunderstanding and resentment encountered from both colleagues and staff, feelings of lack of confidence and competence, but with recognition that these feelings went as skills grew. The educational establishment and community experience were thoroughly enjoyed, while some were highly critical ofthe learning situations in the clinical field but tended to show msight into die reasons. Once again the importance of tutorial support needed in the clinical field stood out. One said 'You could get lost in hospital without a good tutor'. One feature which stands out was their ability to be self-critical and take an objective view of situations and problems. Comments from students when qualified staff* showed a greater appreciation ofthe eourse in retrospect, many noting their appreciation ofa 'total approach' to patient care and understanding of the role of other members of the team. It is fitting to quote a final comment as a summary. 'The nursing profession in this country is in danger of omitting an increasingly great part of its responsibility to the patient. There is a tendency to treat patients in bits, caring for one aspect only of their health. The integrated course has not been primarily an academic course, but the means of translating the concept of caring for the whole patient from theory to practice. It has given me greater self-knowledge, and appreciation of others' needs and circumstances than I feel I could have gained any other way. I am utterly convinced that nurse training of the future should be based on courses such as this.' (For obvious reasons the origins of these comments were referred to simply as 'letters', 'articles' or 'taped' interviews).
THE S T U D E N T ' S
QUESTIONNAIRE
After a pilot survey, die student's questionnaire was completed by 57 ofthe 60 students completing the six courses in the summer of 1972. A control group was obtained of 63 students completing the i-year health visitors course at the same time. They were matched as nearly as feasible, using the same educational establishments where possible and obtaining a similar group in terms of age and academic qualifications. The main group of 'integrated' course students was, however, slightly younger and slightly better qualified academically in terms of 'A' levels than the control group. More ofthe control group were married. Most ofthe background information gained from this questionnaire substantiated what had been noted in the literature.
45 ^
452
G. M. Owcit
The occupational values inventory This provided a very interesting aspect of the survey. The ten items used were identical with those developed and validated by Rosenberg (1957) and used hy Singh & MacGuire (1971). The students were asked to rate the items on a 5-point scale, ranging from high to low in terms of satisfaction, given in response to thc following three statements; 1 I think the ideal joh would . . . 2 I think nursing will . . . 3 I think health visiting will. . . The items were as follows: 1 Give me an opportunity to be helpful to others. 2 Provide an opportunity to use my special abilities. 3 Provide a chance to earn good money. 4 Permit me to be creative and original. 5 Give me soeial status and prestige. 6 Give me an opportunity to work with people rather than tilings. 7 Enable me to look forward to a stable, secure future. 8 Leave me relatively free ofthe supervision of others. 9 Give me a ehance to exercise leadership. 10 Provide me with adventure. Obviously the whole range of actual numbers obtained was used to compute the x^ values. For the sake of simplicity and interest in presentation, thc percentages rating the values high and low have been abstracted here, hut the significant differences for x^ calculated on the basis ofthe actual figures in high, medium and low categories. (The medium ratings have not been included in these tables.) Table T shows how thc main or Integrated Course of Nursing Education (ICNE) group compared with the control group in terms of their expectations of an ideal job. Notice the highly significant diffcrenee in relation to social prestige (o-ooi) and difference significant at the 0-05 level for Items i and 10, the main group being more anxious to be helpful and slightly more concerned with gaining adventure. In the latter case the ICNE group showed a very 'high' medium rating and the control group a high 'low' rating. Both groups score relatively high in Items i and 6, which is in keeping with Rosenberg's (1957) 'people orientated' value cluster characteristic of certain other groups, such as teachers. Item 6 was consistently high in every count, there being no significant difference whatsoever between the groups in any of the results. When asked to rate their values in terms of'I think nursing would provide . . .' and '1 think health visiting would provide . . . ' there was no significant difference at all between the two groups on their views on nursing and only one at the 5% level (Item 2) on how they saw health visiting. Thus, we ean conclude that there were some significant differences between the two groups in terms of their expectations of an ideal job, but no differences in their expectations of nursing and only one between their expectations of health visiting. This could be due to
Curriculum integration in nursing education TABLE I
453
Occupational values showing di£erences in expectations In the idea! joh
Main group—ICNll High Low Item
/ (/»'nt the ideal joh tvould . . .
1
Give me an opportunity to help others Provide an opportunity to use my special abilities Provide a chance to earn good money Permit me to be creative and original Give me social status and prestige Give me au opportunity to work with people rather than things Enable me to look forward to a stable secure future Leave me relatively free of the supervision of others Give me a chance to exercise leadership Provide me with adventure
2
3 4 5
7 8 0
10
0-1%
0/
/o
0/ ,0
84-0
Control Group High Low 7 7
Y"
667
*
3-2
70-0
1-8
57-2
15-8
T2-3
31-7
15-9
52-7
3'5
34-9
9-5
7-0
33'3
46-0
4-8
90-4
3-2
96-0 34-0
8-7
39'6
175
54-5
8-6
55-6
12-7
22-8
15-8 24-5
19-9 17-5
22-2
17-3
47-6
t
*
: significant at .s";', level (0-05), t5(;^ — significant at 1%level (o-oi), t 5(^ = significant at level (o-ooi)
their public image ofnursing and health visiting or the socialization processes ofthe course. Table 2 shows how nursing differs from the expectations they had of an ideal job, showing both groups are unsatisfied on at least five items, in terms of their expectations. By contrast, Table 3 shows health visiting significantly different from their expectations in the ideal job on only one item for the ICNE group and two items for the main group. This could account for thc fact that many of the ICNE group actually end up in health visiting. Notice they were not very concerned with earning good money, although at the time the study was carried out many thought that they entered health visiting because of thc better pay. In fact it could have been because they find the job more in line with their ideals. Table 4 is added to show where the difference between nursing and health visiting expectations occur—the two groups being relatively similar, but an interesting picture of differences between their expectations of the two roles.
Occupational stereotypes The two groups were also asked to picture, as far as possible, a typical nurse in a general hospital and a typical health visitor, and again to rate them on a 5-point
G. M. Owen
454
s h^ ^ ^
5
u ^ w
-g ^
I
a. o
•73
o 0 -13 ro
CL,
I
n
0 *-*
Ul i j
-g
0
0 CJ
CJ
rH
0
u
CJ
0
0
0
-^
>^
£
fni
0
S-.
tun
:ivc
i? o
0 C
esti
•5
I
-o
0
%
^
0 l^ ^ c
_c 0
73 •>
o
o
w
c
Curriculum integration in nursing education
455
UJ
2
3
u
1-5
O
ire
so
O
co
a,
bo
3
o
dve
-VPI
-c LJ
o
-d
2 OH
>
> 0 \^
> O
•6
6
G. M. Owen
-T3
§
^ ^ ^
g
o a. o
*3 G u Wl
c ^^ 0
-C w
c 0 -73
'C o
o o
-D C
i M
5 C
o
O
IM
0 a.
c
o 0
u u
re u
•? bc
'S CJ
o
I.'
DH
'^ C
0
C'
rn
>
re.
a.
LJ
-T3
o
CL,.5 0 ^
c
o
o
457
Curricitluni integration iti nnrsing education TABLE 5 Occupational stereotypes: the main group {ICNE) {To show comparison between their stereotype ofnursing {SRN) and health visiting {HV) are expressed in percentages gii'ing left and right hand ratings for attributes) How they view
Ho\i> they view Left-hand attribute
SRN
Humble Sober Toughminded
8-6 i0'4 24-6
Practical
75 "4 26-3
Easygoing Conservative Relaxed Conforming Soft Talkative Cultured Subjective Intelligent Stable Mobile Puts hospital first CompetitiveConfident Academically excellent
33-3
28-0 79-0 "23 52-6 14-0 38-6 34-7 38-7 20-0 42-1 8-6 42-1 T2-I
HV 7-0
22-9 IO'6 24-9 33-3 24-6 58-2 21-0 17-5 54-4 54-4 10-6 65-0 65-0 34-7 I.VS 10-6 59-7 47-4
Right-hand attribute
SRN
HV X'
Assertive
47-4 22-8 26-2
63-5 24-6 24-6
5-3
34-9 r8
Happy go lucky Tender Imaginative Aggressive Liberal Tense Individualistic Hard Quiet Uncultured Objective Unintelligent Changeable Settled Puts profession first Cooperative Worrying Academically poor
1^ calculated from actual means, *x^ significant at 5 at o-i°(, level
17-5 15-8 21-0 3-5 31-3 7-0 17-5 22'9 10-7 15-7
2(ri 14-0 61-5 10-6 14-0
45-5 5-3 54-4 3-5 8-9
o-o 40-4 1-8 8-6 42-4 58-4 52-8
t * t t
t t
t t t t *
8-6 0-0
significant at 1%, t/^ significant
scale indicating to what extent the adjectives given described them. This was Cohen's (1970) scale as adapted and used by Singh & MacGuire {1971). As thc tables are rather complicated to present visually just one table will be given here and comments on other findings (see Table 5). There were only two significant differences between thc groups in how they viewed a typical nurse and only two in their views ofa typical health visitor, so it could be assumed that either they retained the images ofthe nurse and health visitor they had acquired in their social background, or they had been subjected to similar socialization processes. The main group, however, showed a more cautious tendency in their ratings yet demonstrated significant differences in their view of the nurse and the health visitor on thirteen items, while the control group showed eleven differences (several less ofthese being highly significant ones). A close scrutiny of thc tables yields many points of interest, but the most relevant one is that the ICNE group do tend to show a more clearly differentiated view ofthe nurse and health visitor, which is interesting in view ofthe fact that it is often feared they will confuse their roles and not have a clearly defined awareness ofthe separate identities. This ties up also with the employer's comments, which suggest they are very aware ofthe subtle differences. Table 5 is included to show
G.M. Owen where the ICNE group saw significant differences between nursing and health visiting. Consumer satisfaction The final questionnaire was an attempt to find out what employers tliougiu about health visitors trained this way. Although such a questionnaire could be too subjective to be of value, a pilot exploration produced a good response and a surprisingly interesting pattern and it was decided to proceed. In 1973, 153 Chief Nursing Officers were invited to complete questionnaires, or ask their staff to do so, and 149 replies were received with only six refusing to participate. Fifty-five said they had not employed any staff trained on ICNE courses, and 116 completed forms were received altogether. The comments made were based on experience of 477 'evaluations' as some staff must have been evaluated several times, or by different employers where they had moved jobs. The most interesting aspect of this survey was the response to the request to rate these staff" on a 5-point scale, in comparison with other young, recently qualified health visitors. The 31 items finally listed after a pilot run were under the four headings of: r General ability—leadership, confidence, teaching etc. 2 Relationships—cooperation etc. 3 Handling situations—applications of theory to practice. 4 Professional awareness. An approximate summary of thc replies shows that about two-thirds of the respondents rated ICNE health visitors higher than the average young health visitor on the following items: 1 Initiative. 2 Aptitude for Healtli Education. 3 Cooperation with colleagues. 4 Cooperation with other workers. 5 Readiness to use teaching opportunities. 6 An intelligent approach to the job. 7 Tendency to use initiative and new ideas. 8 Awareness ofthe needs ofthe profession. The most frequent low ratings were in terms of: 1 Practical ability. 2 Confidence in their ability. 3 Ability to assess their own assets. 4 Assuming leadership. 5 Readiness to seek advice. 6 Tolerating frustration. In actual fact less than a quarter ofthe respondents gave low ratings. There were a few built-in check questions and these, with the comments asked for, revealed a great deal of ambiguity. For example, many who rated these health visitors high in terms of confidence, later commented that they lacked
Curriculum integration in nursing edttcation
459
confidence, or rated tlicin high in taking initiative and in leadership skills and later said they lacked willingness to assume leadership. Many rated them high on practical ability and commented later on their lack of experience in practical situations. Their low score in assuming leadership could be related to the lack of confidence these health visitors experience on the part of their colleagues who appear to expect them to be less skilful in the practical situation. The additional comments made by employers reinforced those made by tutors and the students' assessments of themselves. CONCLUSION The value of a study of this kind probably lies more in the fact that it brings together, in a documented and classified form, the information available on an experimental form of nursing education and throws into relief some ofthe significant characteristics. Several things emerge with some clarity: 1 The remarkable similarity in the aims, objectives, structure and content ofthe courses and the fact that students are introduced to community care very early in the course. 2 The fact that these courses have provided some of the first links between hospital and the higher education system. 3 It is possible to produce a kind of profile of these students as being well motivated to nurse, with a strongly 'people orientated' tendency, anxious to use their special abilities and be creative, and not too concerned with money or social prestige and status. They may be slow starters on the course but learn quickly, grasping principles and applying them well. In spite of good reports they lack confidence in practical situations, but have a keen insight into their own reactions. They are sensitive to criticism and often experience stress in the face of resentment, knowing that their colleagues have high expectations of their performance wliile they themselves fear they will not perform adequately. They express a keen desire to be proved good nurses and demonstrate their ability to take a total view on patient care and understand the different roles of colleagues, clearly. It is possible that there is much to be learned from the early introduction of community care integrated into the basic nursing education programme, from these courses, in terms of attitudes to total patient care. They are welcomed by employers and regarded with considerable esteem, yet much ambiguity exists within the profession in assessing their qualities. On the basis of the statistical data one can say that there are some differences between these students and others upon qualifying and the differences can be identified, but it is not possible here to demonstrate the extent to which the differences existed on entry to the course, or occurred as a result ofthe socialization and educational processes occurring during the course. One would like to see criteria for assessing and evaluating courses like this more fully developed and utihzed, particularly with the increased expansion of nursing in higher education. One other area, which would be fruitful for future research, would be in
46o
G. M. Owen
relation to all the ambiguities thro'wn up relating to the expectations of the professioti, such as the assutnption that these students lack conftdence therefore lack skill. Finally, it is possible to conclude that the pioneers who initiated these courses have in fact achieved many of their aims and much can be learned from these experiments, 'which is valuable in preparing nurses for an integrated health service. References BENDALL E. (1971) The iitirsiiig process in student nurses. Occasional papers. Niirsiti^ Times 67, 173-175BROWN E.L. {1948) Nursing for the Future. Russell Sage, New York. BRYDEN E. (1969) Integrated Course of Nursing Educathti. Queen's Institute of District Nursing, London. COHEN (1970) Occupational values and stereotypes in a group of engineers. British Journal of Industrial Relation
