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EDUCATING THE HEALTH PROFESSIONS FOR HIGH-QUALITY CARE: NURSING EDUCATION*
LORErrA C. FoRDu, R.N., Ed.D. Dean, School of Nursing Director of Nursing University of Rochester Rochester, N. Y.
F the 4 million workers in the health-care system, nursing personnel represent the largest single group, numbering about 2.5 million workers. Registered nurses comprise approximately 8oo,ooo of these workers; more than 400,ooo are licensed practical or vocational nurses, and another 8ooooo are aides and orderlies. The nursing work force is not only large but comprises a wide range of training, making for complexity within the various occupational roles. Further, 70% of all nonphysician health workers are women and women occupy the majority of jobs within nursing. Preparation for the variety of roles ranges from a few weeks or months of job orientation to postdoctoral education. In the past most registered nurses were trained in diploma or hospital schools of nursing, where emphasis was placed on care of the sick, hospitalized patient. Today tremendous, rapid shifts are being made in the nursing education provided by both professional and vocational institutions, with emphasis on several levels of care. This paper will address those factors which have fostered changes and will raise issues related to educating nursing personnel in the delivery of quality health care. In addition, some methods which have evolved in nursing care will be discussed.
TRENDS IN NURSING EDUCATION Trends in nursing education cannot be separated from the concurrent social influences and cultural demands of the period in which they occur. The recent expansion of the concept of human rights to include the right to health care is of particular importance to this discussion. *Presented in a panel, Educating the Health Professions for High-Quality Care, as part of the 1975 Annual Health Conference of the New York Academy of Medicine, The Professional Responsibility for the Quality of Health Care, held April 24
and 25, 1975.
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This concept has brought into focus issues related to inequities and deprivations of identifiable societal groups. Demands for the expansion of health care to encompass a broad range of services-including prevention and promotion of health, rehabilitation, primary care, long-term care, and acute care-has required uis to reevaluate the health needs, in addition to the medical needs, of defined populations. These demands, in the light of our health-manpower deficits, have prompted a review of priorities in the organization of institutional resources; our goal is to educate health personnel to deliver humane, efficient, effective, and economical care. As providers of care, nurses have taken patients' rights seriously; they have guarded against violations of these rights by demonstrated accountability. Interestingly, today nurses, most of whom are women, also are demanding some rights of their own as professional persons. As nurses, women are taking their rightful places in society and in the health-care system. By enhancing the quality of life for every citizen, they increase the nation's capability to meet its commitment to democratic ideals. Today, many alterations in nursing education are accommodating these new social values. The major changes are in institutional control of nursing education, accreditation standards, recruitment of students, and innovations in curricula. These alterations have influenced significantly our course in developing high quality nursing care. CHANGES IN INSTITUTIONAL SUPPORT ANI) CONTROL In i955 hospital-based programs leading to diplomas enrolled 84% of the students who were preparing to be registered nurses.' By I974 this figure dropped to 260 .- This rapid decline in enrollments and the phenomenal growth of associate degree and baccalaureate programs places the locus of control of nursing programs in educational institutions. Many of these newer educational programs are supported primarily by public funds. In Johnson's words:-" The main stimulus for accelerating the trend toward decline of the diploma school has been the emergence of the two-year associate degree program in nursing that is anchored in the community college environment. . .. In i958, there were fewer than 1,ooo students admitted to 38 associate degree programs; only ten years later (i968), the number of admissions to 33o associate Bull. N. Y. Acad. Med.
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degree programs exceeded those to baccalaureate programs. In three more years (197I), admissions to associate degree programs finally surpasses admissions to diploma programs, a state of affairs that had never happened before in the history of nursing education. With 39% of nursing students now enrolled in baccalaureate schools and 35% in associate degree programs, 74% of all students who are preparing to be registered nurses are in institutions whose primary mission is education. For example, in New York State in I972 the distribution was as follows: diploma schools, 30.6%; associate degree, 39.9%; baccalaureate degree, 29.6%.4 Although this paper deals mainly with education for the registered nurse, it is noteworthy that the "admission of students to P.N. [practical nursing] schools had been marked by a steady and rather remarkable rate of growth that extends over a twenty year period, from the early 1950S to the early 1970s. An abrupt levelling-off process is now underway, being first noted in 1972."5 The impact of nurses educated in colleges who possess a wide range of health-care knowledge is now being felt beyond the walls of the hospital. These graduates have both academic and professional skills to assume positions in a variety of community settings: ambulatory care services, long-term care, and the traditional acute-care settings. Contrary to common belief, graduates of baccalaureate programs are prepared for and seek participatory clinical roles, not managerial roles, in the provision of care. The movement of nursing programs to colleges also resulted in the improved and expanded training of faculty. Federal legislation in I957 facilitated the development of graduate programs. It aided appreciably in the establishment of new programs through grants for special projects and gave direct financial assistance to students. According to Johnson," "Masters programs have doubled [in number], from 44 in 1958 to 89 in I974, whereas doctoral programs in nursing have risen from 2 in I958 to 8 in 1974." If we enumerate only the doctoral programs in related disciplines which enroll nurses (including the nursing doctorate), the total number rose from eight in i963 to 13 in 1974. In the same year (1974), more than i,ooo nurses held doctoral degrees and 28,ooo held master's degrees. Despite the growth of graduate programs (in I972, i6,ooo registered nurses were enrolled in 355 part-time or full-time Vol. 52, No. 1, January 1976
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education programs),7 the need remains for qualified teachers, expert clinicians, and knowledgeable researchers. However, these deficiencies have not hampered our efforts to elevate educational standards. QUALITY OF NURSING EDUCATION Now that nursing programs are being measured by academic standards, an increasing number have sought approval and public recognition through accreditation by state and national agencies. For instance, the National League for Nursing (NLN) newsletter reported: "This past academic year, the number of baccalaureate and master's degree programs accredited by the National League for Nursing wvas double the number accredited ten years ago, I964-1965." Of the I,373 schools of nursing which have programs culminating in associate degrees, diplomas, or baccalaureate degrees, 63.I% are accredited by the NLN, a voluntary national professional accrediting agency. At the professional level there are 240 accredited baccalaureate programs; at the master's level 65 are accredited.8 In the past IO years 34 programs, or i6.6% of the number requesting initial accreditation, were denied accreditation. Another 31 programs received deferrals, making a total of almost 32% which did not receive accreditation status. STUDENT RECRUIT]MENT The recent change in the composition of the student body of nursing schools also is interesting. While there has been a noticeable increase in the enrollment of all nursing students, there also has been an increase
in the number of men, minority students, and older students enrolled, primarily in associate-degree programs. A report to Congress') recently stated that "More than twice as many black students were graduated in I972, as compared with i963, and the number enrolled over this period of time increased five-fold. . . . [In I972 almost all students entering diploma and baccalaureate programs were wvomen under 20 years of age, single, and white." It is interesting to note that only a slight increase in the number of black students in baccalaureate programs was realized over the past decade. Expanded opportunities for career mobility have increased the number of nursing personnel who shift from vocational to technical levels and on to progressional programs. There are now more than 4,000 licensed practical/vocational nurses enrolled in proBull. N. Y. Acad. Med.
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grams which lead to registered nurse licensure. Increasingly, students who have earned high degrees in other disciplines and who seek fulfillment through a career in nursing are enrolling in baccalaureate nursing programs. Some of these changes have been attributed to the trends among young people to seek college careers and to enter service-oriented fields. Students also desire the assurance of employment following graduation, which the health field has traditionally offered. A longitudinal study of nursing career patterns reveals some interesting data on the academic mobility, social status, responsibilities, and age of students in different programs.'0 For instance, a trend which affects student recruitment is the retention of nurses in the work force. Since I966 there has been an increase in the number of nurses who remain actively engaged in nursing. This trend creates less turnover and a more stable work group. Predictably, the young have remained the most mobile in their search for a variety of work experiences.10 Today there are almost 245,000 students enrolled in programs preparing for registered nurse licensure: 39% in baccalaureate programs, 35%0 in associate-degree programs, and 26% in diploma schools. This phenomenal increase, especially at the lower level of educational preparation, will create hazardous ratios if adequate attention is not given to the preparation of clinical leaders, administrators, educators, and researchers for the field of nursing. Advanced preparation in all these areas greatly influences the development of basic curricula.
CURRICULA DEVELOPMENTS New philosophies and approaches to the education of professional nurses, specifically at the baccalaureate degree and higher levels, have appreciably influenced the graduates of these programs. The focus on the study of man in health and illness, emphasis on obtaining a general educational base preparatory to professional education, the identification of the nurse's accountability to client, patient or family, and society, and the development of a science of nursing all have influenced greatly the process, content, and outcome of nursing education. Innovations in curricula-including self-pacing, open curricula, independent study, and specialized elective study which includes sophisticated assessment skills-are all part of the new pedagogical trends. At the University of Nebraska, for instance, a conceptual frameVol. 52, No. 1, January 1976
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work has guided the inauguration of an articulated program, building from the associate degree to the baccalaureate and master's degrees. Crucial to this innovation in curriculum is the identification of varying clinical skills among the graduates. A number of schools are experimenting with modular curricula which provide students with progressive upward mobility and self-pacing. At Northeastern University a concept of credit allotments provides for upwardly mobile licensed practical nurses to take a battery of tests-including readmission, diagnostic, and, finally, qualifying tests-for which they may earn 29 quarter credit
hours.1' Further, the preparation of nurses for new roles at the continuing educational, baccalaureate, and graduate levels (such as the nurse practitioner, the clinical nursing specialists, and the nurse researcher) is effectively influencing patterns of practice and is changing our system of health-care delivery. A recent report to Congress declared:'!2 Expanded roles are being defined, developed and demonstrated through specialized nursing practitioner programs in various clinical areas, including pediatrics, geriatics, family health service, community or public health, nurse-midwifery, nursing care of medical patients, and care of patients in physicians' offices. In this area of expanded roles, the emphasis is on decisive, independent practitioner action and teaching of patients. Preparing nurses for expanded roles in child care as pediatric nurse practitioners originated at the University of Colorado as a postbaccalaureate demonstration project."3 It quickly caught the imagination of nurses and physicians in educational institutions and service agencies. Short-tenn programs proliferated with little or no certification standards. Today there is a trend not only to introduce into the baccalaureate and master's curricula the processes and content taken from nursingpractitioner programs, but also to certify programs and their graduates to insure the provision of quality care to society. Changes in curriculum at the graduate (master's degree) level and higher levels have occurred to prepare nurses to fill advanced clinical roles as both generalists and specialists in nursing. Most graduate programs prepare nurses to give expert nursing care; to teach patients, family, and staff members; to provide consultation; to investigate nursing problems scientifically; and to influence the nursing and health-care Bull. N. Y. Acad. Med.
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delivery systems. Cooperation with other health workers often is cited as valuable; however, although some efforts have been made to function collaboratively-particularly with physicians-there are serious problems with these efforts. The diverse curriculum models, educational backgrounds, and maturational stages of students, plus the fact that few nursing and medical school faculties themselves function cooperativelyall are deterrants to cooperative explorations for interdisciplinary collaboration. At the upper end of the educational continuum the number of doctoral programs in nursing also is increasing; these programs can be expected to develop leaders with statesman-like potential. New programs which focus on the theory and science of nursing are expected to affect competencies in clinical research. Postdoctoral education in nursing has yet to be developed. However, continuing education is advancing and valued; professional nurses themselves are demanding continuing educational opportunities to increase their abilities and to meet society's demands for evidence of professional skill. Within the profession, repeated calls for individuals to demonstrate the ability to maintain their licenses to practice also are fueling these demands. Patterns of practice in nursing have been affected by the educational system.'4 Nursing is moving away from the inpatient setting and into the community with emphasis on primary care. Nurses are placing increasing emphasis on early detection of disease, and on efforts to predict and help control conditions that increase susceptability to disease. They are moving to expand their responsibility for counseling people in sound health practices and prevention of illness and fostering follow-up and administration to the health needs of the family and community as well as the individual.... It is predicted that "Nurses will have a markedly different philosophy regarding their roles in the health care system; that is, caring not only for the sick but for the well. They will be a vital part of the interdisciplinary health team, assessing the needs of patients, administering to some of these needs, and referring patients to other health professionals for other needs." IMPACT
CHANGES OF PRACTICE AND EDUCATION Changes are also occurring, albeit slowly, in the role of nursing Vol. 52, No. 1, January 1976
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faculty members. Separations between nursing practice and nursing education are under scrutiny. In some institutions changes are occurring through new organizational patterns. At the University of Rochester School of Nursing a unification model of service, education, and research is being developed. Interdisciplinary cooperation between the schools of nursing and medicine on the university's medical center campus and in the surrounding community and region is fostering the growth of all professional groups at Rochester. Special projects in primary care, sponsored by the Robert Wood Johnson Foundation and a grant from the Divisions of Nursing of the U.S. Department of Health, Education, and Welfare which provides for the retraining of nursing faculty members, will help these leaders to assume clinical roles and to become models in the provision of quality care for students and staff. These projects also will encourage research to improve clinical nursing practice. At the University of Rochester's School of Nursing, careeroriented students, both undergraduate and graduate, are learning how to improve nursing care through the study of patient-care problems. This approach precludes any preconceived method of dealing with patient-care problems since each situation is viewed as unique, wherein the needs of the patients dictate the specifics of care. This type of educational program breaks with the past technique of teaching nursing by formula. The dynamism and excitement of the patient-centered approach to nursing creates a learning climate in which human values and compassion have priority. It therefore attracts a special kind of person who is committed to these values. Advocacy of the rights of patients to know, to choose, and to become equal and respected partners in the process of health care are encouraging signs of professional growth in nursing. As the number of nurses who are educated in these professional roles increases, so does the prospect that they will have satisfying and intellectually challenging careers which do not hinder the development of other societal roles. Further, an involvement with society in general enables the professional nurse to share in an influential power base. Through the judicious use of this power, health-care delivery systems can be changed, thereby giving nurses control over their growth, development, and destiny. Standards for practice, education, certification of practitioners, and accreditation of programs through nursing organizations such as the American Nurses Association and the National League Bull. N. Y. Acad. Med.
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for Nursing all attest to this emerging professionalization of nurses. Another factor which has an impact on changes in education is the type of financial support for nursing education required to maintain the number and kinds of nurses necessary to serve the burgeoning health needs of the nation. Insurance companies, concerned about the cost of care, are questioning the expense incurred by health agencies for educational programs. This raises the issue of adequate societal support: it simply must be forthcoming! Indeed, appropriate utilization, distribution, and reimbursement for services rendered by nurses are related to cost factors. Disuse, misuse, and abuse of nursing talent has wasted the potential of nurses to deliver high-quality health care. Often nurses are underutilized. Rather than examining the health-care needs of people, we have concentrated on the roles that professionals will play. Geographical and specialty distribution, too, have been problems. Today, although there is no demonstrable market overflow, we have evidence of a pending oversupply of nursing personnel at the lower level; yet the need for those with advanced preparation remains overwhelming. The issue of reimbursement for nursing services must also be addressed if comprehensive, quality health care is to be delivered to 2 12 million people within the next decade. At present, prospects for federal support for nursing education is uncertain. It is to be hoped that the Congress will address health needs rather than medical needs alone; these include preparing nurses for teaching, clinical specialization, and research. Regardless of the problems surrounding issues of financial support and their tenuous solutions, however, nursing's concerns, interest, and efforts will remain focused on searching for new methods of delivering quality care and on evolving new ways to evaluate the results of that care. Three tools to measure the quality of nursing care have been described by Maria C. Phaneuf in an excellent overview of recent developments in the field;15 In nursing, concern for measurement of quality of care provided to patients is not new, but acknowledgment that quantitative measurement of quality is possible is relatively recent. Three examples of instruments for appraising the quality of care are the Slater Nursing Competency Grading Scale, which measures the competencies displayed by a nurse under observation Vol. 52, No. 1, January 1976
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in nurse-patient interaction; the Quality Patient Care Scale, for measuring the quality of nursing care being received by the patient while care is ongoing; and the Nursing Audit, for measuring the quality of nursing care received by a patient. All three methods and others that are now evolving use a conceptual framework of evaluation which generally reflects the nursing process, focuses on the functional potential of the patient, and may account for one or all of the major aspects of quality assurance: structure, process, and outcome. Probably the most commonly used method to assure quality is the nursing audit. This audit is a retrospective, systematic, recorded appraisal of the completed process of nursing care which is made on discharge of the patient from a nursing service. "The process of nursing," says Phaneuf,16 "encompasses all major steps taken in the care of the patient with attention to the nature and purpose of the steps, their sequence, and the degree to which they help the patient reach specific and attainable therapeutic goals. Tasks and activities are considered in the context of practice." Concurrent with the development of these methods, there is a movement in nursing to identify the patient's responses to the processes of health and illness, and to define and classify these in a universal manner. Efforts to develop a classification system for nursing diagnosis-to identify systems, signs, and the effectiveness of nursing-are underway at St. Louis University School of Nursing and Allied Health Professionals. The stated mission of this investigation is a monumental task: to describe "the entire domain of nursing."117 As Kristine Gebbie and Mary Ann Lavin interpret it,"8 This does not mean the identification of all of the tasks performed by nurses or of all the things that nurses have ever done in any situation or under any circumstances. It is the identification of those patient problems or concerns most frequently identified by nurses, problems which are usually identified by nurses before they are recognized by other health care workers, and problems which are amenable to some intervention which is available in the present or potential scope of nursing practice. These diagnoses focus mainly on the broad health needs of people. The interpretation and identification of these needs can only be addressed by nurses. Some nurses, organized in a national conference format, have begun to gather data and classify them for nursing diagnoses.19 Bull. N. Y. Acad. Med.
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At the first conference in St. Louis nurses provided a tentative list of nursing diagnoses, including estimations of alterations and relations in self-concept and faith, anxiety, levels of comfort, impairment of digestion, family adjustment, level of consciousness, malnutrition, impaired mobility, pain, sensory disturbances, ineffective sleep and rest patterns, and impairment of verbal communication. These diagnoses are early labels which require explication through stated characteristics (signs and symptoms). The subsequent effective nursing interactions should be followed by evaluation of outcomes which will result in greater usefulness and predictability. After the first conference a task force on miodus operandi was established and charged with responsibility for identifying and executing "any activities which could further the goals of the conferences, namely, the identification of those health states diagnosed primarily by nurses, the development of a nomenclature of the labelling problem." Data on 25 patients were requested from 33 institutions during a 3o-day collection period. Analyses of the data are planned during the interim period between conferences; this process will be facilitated by transferring the diagnostic labels, vital statistics, and patients' symptoms to separate cards from which groupings can be made by a panel of nurse experts. If it receives funding, this pilot project will be expanded to a five-year cooperative study and then to a national plan to make explicit nursing diagnoses. The assurance of quality in nursing also has been advanced by the standard of nursing practice published by the Congress on Nursing Practice of the American Nurses Association. These standards, now in their implemental stages, were developed as20 "descriptive statements which reflect the dynamic nature of nursing practice and reflect the best current knowledge available." The individual practitioner of nursing will be assisted by programs of continuing education, peer review, and certification. Nursing education has evolved from a beginning outside of academic control, namely, diploma schools, to become part of institutions of higher education. Through this evolution major progress has been made in the preparation of faculty, the development of curriculum, and the identification of the unique mission of nursing in health care. Throughout these processes there has been a concurrent effort to scrutinize not only the educational process, but also the manner in which care is given and the outcomes which are elicited. The methods deVol. 52, No. 1, January 1976
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scribed in this paper are still in the early stages, but in a very short time they have had a tremendous impact. This impact would not have been possible without nurses wvho were alert in recognizing patients' rights and who responded with a high degree of accountability and unfaltering determination to provide good care. REFERENCES York, January 1975. 1. Scott, M. and Levine, E.: Nursing 9. Report to Conigres .... p- l;. manpo wer analysis: Its past, present, and future. Coiif. onl Currentt liforma- 10. Knopf, L.: From Student to R.N.: A tion oni Heallth Manpower, April 17-18, R~eport of the Nurse's Career Pattern. 1975, T-arrytown, N.Y. Washington, D.C., Govt. Print. Off., 197o. 2. Personal conmaunication with the National League for Nursing. April 1975. 11. Na'ationial Leaigue for Nursing: NLN Vews2..:7, 1974. 3. Joohnson, WN. L.: Trends in nursing education and projectionls of the supply 12. Ibid., 1). 4. of nurses. Cmof. on Currendt Informa- 1:3. Ford, L. C. ;¢and Silver, H. K.: Ihe tionI on Health 31Mnpower, April 17-18, exp)ande(l role of the nurse in ehild (are. Nu.)r.'inq Outlook 1.5-:43-45, 1967. 1975, 'Larrytown, N.Y., 1). 8. 14. 11)1i(., p. :3. 4. Educatiownl Prep(aration for Practical anid Professional Nursing in the State 15. h'lianeuif, M. C.: Quality Assurance: A Nursing View. In: Quality Assurof New York, 1972. University of the aone of Medwicat (aore. Regional MediState of New York, the State Depart(cail Progranis Service. Dept. of eIacilth, ment, Office of Professional Educration, Education, aned \Welfare mionograpihl. Nursing Education, Albany, N.Y., Washington, L).C., Govt. Print. Off., 1973. 1973, 1). :351. 5. Johnson, W. L., op. cit., p. 10. 16. Ihid., 1). :3.52. 6. Ibid. 7. Dept. Public Health Service, Health Re- 17. (Gebbie, K. and 1Lavin, M. A.: Classifving- nursing diagnoses. Amer. J. sources Administration, Division of Nursin( 'i'7;:250, 1974. Nursing, Dept. of Healtlh, Education, and Welfare: Report to the Conrgress- 18. Ibidl., p. 252t. Nurse Training, 1974. DHEW Publica- 19. Gehbie, K. M. (1and Lavin, M. AX., editors: C(la.silicatiOi of Aurshin Diagtion No. (HRA) 7.5-41. Bethesda, Md., nioses. St. Louis, Mosby 1975. p. 10. 8. Memo to Members, Council of Ba(fcca- 20. Activities of the Congress on NYursiig Practice. Kansais City, Mo., Aimer. laureate and Higher Degree Programs. Nurses Assoc., 1975. National League for Nursing, New
Bull. N. Y. Acad. Med.
EDUCATING THE HEALTH PROFESSIONS FOR HIGH-QUALITY CARE: NURSING EDUCATION*
LORErrA C. FoRDu, R.N., Ed.D. Dean, School of Nursing Director of Nursing University of Rochester Rochester, N. Y.
F the 4 million workers in the health-care system, nursing personnel represent the largest single group, numbering about 2.5 million workers. Registered nurses comprise approximately 8oo,ooo of these workers; more than 400,ooo are licensed practical or vocational nurses, and another 8ooooo are aides and orderlies. The nursing work force is not only large but comprises a wide range of training, making for complexity within the various occupational roles. Further, 70% of all nonphysician health workers are women and women occupy the majority of jobs within nursing. Preparation for the variety of roles ranges from a few weeks or months of job orientation to postdoctoral education. In the past most registered nurses were trained in diploma or hospital schools of nursing, where emphasis was placed on care of the sick, hospitalized patient. Today tremendous, rapid shifts are being made in the nursing education provided by both professional and vocational institutions, with emphasis on several levels of care. This paper will address those factors which have fostered changes and will raise issues related to educating nursing personnel in the delivery of quality health care. In addition, some methods which have evolved in nursing care will be discussed.
TRENDS IN NURSING EDUCATION Trends in nursing education cannot be separated from the concurrent social influences and cultural demands of the period in which they occur. The recent expansion of the concept of human rights to include the right to health care is of particular importance to this discussion. *Presented in a panel, Educating the Health Professions for High-Quality Care, as part of the 1975 Annual Health Conference of the New York Academy of Medicine, The Professional Responsibility for the Quality of Health Care, held April 24
and 25, 1975.
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This concept has brought into focus issues related to inequities and deprivations of identifiable societal groups. Demands for the expansion of health care to encompass a broad range of services-including prevention and promotion of health, rehabilitation, primary care, long-term care, and acute care-has required uis to reevaluate the health needs, in addition to the medical needs, of defined populations. These demands, in the light of our health-manpower deficits, have prompted a review of priorities in the organization of institutional resources; our goal is to educate health personnel to deliver humane, efficient, effective, and economical care. As providers of care, nurses have taken patients' rights seriously; they have guarded against violations of these rights by demonstrated accountability. Interestingly, today nurses, most of whom are women, also are demanding some rights of their own as professional persons. As nurses, women are taking their rightful places in society and in the health-care system. By enhancing the quality of life for every citizen, they increase the nation's capability to meet its commitment to democratic ideals. Today, many alterations in nursing education are accommodating these new social values. The major changes are in institutional control of nursing education, accreditation standards, recruitment of students, and innovations in curricula. These alterations have influenced significantly our course in developing high quality nursing care. CHANGES IN INSTITUTIONAL SUPPORT ANI) CONTROL In i955 hospital-based programs leading to diplomas enrolled 84% of the students who were preparing to be registered nurses.' By I974 this figure dropped to 260 .- This rapid decline in enrollments and the phenomenal growth of associate degree and baccalaureate programs places the locus of control of nursing programs in educational institutions. Many of these newer educational programs are supported primarily by public funds. In Johnson's words:-" The main stimulus for accelerating the trend toward decline of the diploma school has been the emergence of the two-year associate degree program in nursing that is anchored in the community college environment. . .. In i958, there were fewer than 1,ooo students admitted to 38 associate degree programs; only ten years later (i968), the number of admissions to 33o associate Bull. N. Y. Acad. Med.
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degree programs exceeded those to baccalaureate programs. In three more years (197I), admissions to associate degree programs finally surpasses admissions to diploma programs, a state of affairs that had never happened before in the history of nursing education. With 39% of nursing students now enrolled in baccalaureate schools and 35% in associate degree programs, 74% of all students who are preparing to be registered nurses are in institutions whose primary mission is education. For example, in New York State in I972 the distribution was as follows: diploma schools, 30.6%; associate degree, 39.9%; baccalaureate degree, 29.6%.4 Although this paper deals mainly with education for the registered nurse, it is noteworthy that the "admission of students to P.N. [practical nursing] schools had been marked by a steady and rather remarkable rate of growth that extends over a twenty year period, from the early 1950S to the early 1970s. An abrupt levelling-off process is now underway, being first noted in 1972."5 The impact of nurses educated in colleges who possess a wide range of health-care knowledge is now being felt beyond the walls of the hospital. These graduates have both academic and professional skills to assume positions in a variety of community settings: ambulatory care services, long-term care, and the traditional acute-care settings. Contrary to common belief, graduates of baccalaureate programs are prepared for and seek participatory clinical roles, not managerial roles, in the provision of care. The movement of nursing programs to colleges also resulted in the improved and expanded training of faculty. Federal legislation in I957 facilitated the development of graduate programs. It aided appreciably in the establishment of new programs through grants for special projects and gave direct financial assistance to students. According to Johnson," "Masters programs have doubled [in number], from 44 in 1958 to 89 in I974, whereas doctoral programs in nursing have risen from 2 in I958 to 8 in 1974." If we enumerate only the doctoral programs in related disciplines which enroll nurses (including the nursing doctorate), the total number rose from eight in i963 to 13 in 1974. In the same year (1974), more than i,ooo nurses held doctoral degrees and 28,ooo held master's degrees. Despite the growth of graduate programs (in I972, i6,ooo registered nurses were enrolled in 355 part-time or full-time Vol. 52, No. 1, January 1976
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education programs),7 the need remains for qualified teachers, expert clinicians, and knowledgeable researchers. However, these deficiencies have not hampered our efforts to elevate educational standards. QUALITY OF NURSING EDUCATION Now that nursing programs are being measured by academic standards, an increasing number have sought approval and public recognition through accreditation by state and national agencies. For instance, the National League for Nursing (NLN) newsletter reported: "This past academic year, the number of baccalaureate and master's degree programs accredited by the National League for Nursing wvas double the number accredited ten years ago, I964-1965." Of the I,373 schools of nursing which have programs culminating in associate degrees, diplomas, or baccalaureate degrees, 63.I% are accredited by the NLN, a voluntary national professional accrediting agency. At the professional level there are 240 accredited baccalaureate programs; at the master's level 65 are accredited.8 In the past IO years 34 programs, or i6.6% of the number requesting initial accreditation, were denied accreditation. Another 31 programs received deferrals, making a total of almost 32% which did not receive accreditation status. STUDENT RECRUIT]MENT The recent change in the composition of the student body of nursing schools also is interesting. While there has been a noticeable increase in the enrollment of all nursing students, there also has been an increase
in the number of men, minority students, and older students enrolled, primarily in associate-degree programs. A report to Congress') recently stated that "More than twice as many black students were graduated in I972, as compared with i963, and the number enrolled over this period of time increased five-fold. . . . [In I972 almost all students entering diploma and baccalaureate programs were wvomen under 20 years of age, single, and white." It is interesting to note that only a slight increase in the number of black students in baccalaureate programs was realized over the past decade. Expanded opportunities for career mobility have increased the number of nursing personnel who shift from vocational to technical levels and on to progressional programs. There are now more than 4,000 licensed practical/vocational nurses enrolled in proBull. N. Y. Acad. Med.
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grams which lead to registered nurse licensure. Increasingly, students who have earned high degrees in other disciplines and who seek fulfillment through a career in nursing are enrolling in baccalaureate nursing programs. Some of these changes have been attributed to the trends among young people to seek college careers and to enter service-oriented fields. Students also desire the assurance of employment following graduation, which the health field has traditionally offered. A longitudinal study of nursing career patterns reveals some interesting data on the academic mobility, social status, responsibilities, and age of students in different programs.'0 For instance, a trend which affects student recruitment is the retention of nurses in the work force. Since I966 there has been an increase in the number of nurses who remain actively engaged in nursing. This trend creates less turnover and a more stable work group. Predictably, the young have remained the most mobile in their search for a variety of work experiences.10 Today there are almost 245,000 students enrolled in programs preparing for registered nurse licensure: 39% in baccalaureate programs, 35%0 in associate-degree programs, and 26% in diploma schools. This phenomenal increase, especially at the lower level of educational preparation, will create hazardous ratios if adequate attention is not given to the preparation of clinical leaders, administrators, educators, and researchers for the field of nursing. Advanced preparation in all these areas greatly influences the development of basic curricula.
CURRICULA DEVELOPMENTS New philosophies and approaches to the education of professional nurses, specifically at the baccalaureate degree and higher levels, have appreciably influenced the graduates of these programs. The focus on the study of man in health and illness, emphasis on obtaining a general educational base preparatory to professional education, the identification of the nurse's accountability to client, patient or family, and society, and the development of a science of nursing all have influenced greatly the process, content, and outcome of nursing education. Innovations in curricula-including self-pacing, open curricula, independent study, and specialized elective study which includes sophisticated assessment skills-are all part of the new pedagogical trends. At the University of Nebraska, for instance, a conceptual frameVol. 52, No. 1, January 1976
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work has guided the inauguration of an articulated program, building from the associate degree to the baccalaureate and master's degrees. Crucial to this innovation in curriculum is the identification of varying clinical skills among the graduates. A number of schools are experimenting with modular curricula which provide students with progressive upward mobility and self-pacing. At Northeastern University a concept of credit allotments provides for upwardly mobile licensed practical nurses to take a battery of tests-including readmission, diagnostic, and, finally, qualifying tests-for which they may earn 29 quarter credit
hours.1' Further, the preparation of nurses for new roles at the continuing educational, baccalaureate, and graduate levels (such as the nurse practitioner, the clinical nursing specialists, and the nurse researcher) is effectively influencing patterns of practice and is changing our system of health-care delivery. A recent report to Congress declared:'!2 Expanded roles are being defined, developed and demonstrated through specialized nursing practitioner programs in various clinical areas, including pediatrics, geriatics, family health service, community or public health, nurse-midwifery, nursing care of medical patients, and care of patients in physicians' offices. In this area of expanded roles, the emphasis is on decisive, independent practitioner action and teaching of patients. Preparing nurses for expanded roles in child care as pediatric nurse practitioners originated at the University of Colorado as a postbaccalaureate demonstration project."3 It quickly caught the imagination of nurses and physicians in educational institutions and service agencies. Short-tenn programs proliferated with little or no certification standards. Today there is a trend not only to introduce into the baccalaureate and master's curricula the processes and content taken from nursingpractitioner programs, but also to certify programs and their graduates to insure the provision of quality care to society. Changes in curriculum at the graduate (master's degree) level and higher levels have occurred to prepare nurses to fill advanced clinical roles as both generalists and specialists in nursing. Most graduate programs prepare nurses to give expert nursing care; to teach patients, family, and staff members; to provide consultation; to investigate nursing problems scientifically; and to influence the nursing and health-care Bull. N. Y. Acad. Med.
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delivery systems. Cooperation with other health workers often is cited as valuable; however, although some efforts have been made to function collaboratively-particularly with physicians-there are serious problems with these efforts. The diverse curriculum models, educational backgrounds, and maturational stages of students, plus the fact that few nursing and medical school faculties themselves function cooperativelyall are deterrants to cooperative explorations for interdisciplinary collaboration. At the upper end of the educational continuum the number of doctoral programs in nursing also is increasing; these programs can be expected to develop leaders with statesman-like potential. New programs which focus on the theory and science of nursing are expected to affect competencies in clinical research. Postdoctoral education in nursing has yet to be developed. However, continuing education is advancing and valued; professional nurses themselves are demanding continuing educational opportunities to increase their abilities and to meet society's demands for evidence of professional skill. Within the profession, repeated calls for individuals to demonstrate the ability to maintain their licenses to practice also are fueling these demands. Patterns of practice in nursing have been affected by the educational system.'4 Nursing is moving away from the inpatient setting and into the community with emphasis on primary care. Nurses are placing increasing emphasis on early detection of disease, and on efforts to predict and help control conditions that increase susceptability to disease. They are moving to expand their responsibility for counseling people in sound health practices and prevention of illness and fostering follow-up and administration to the health needs of the family and community as well as the individual.... It is predicted that "Nurses will have a markedly different philosophy regarding their roles in the health care system; that is, caring not only for the sick but for the well. They will be a vital part of the interdisciplinary health team, assessing the needs of patients, administering to some of these needs, and referring patients to other health professionals for other needs." IMPACT
CHANGES OF PRACTICE AND EDUCATION Changes are also occurring, albeit slowly, in the role of nursing Vol. 52, No. 1, January 1976
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faculty members. Separations between nursing practice and nursing education are under scrutiny. In some institutions changes are occurring through new organizational patterns. At the University of Rochester School of Nursing a unification model of service, education, and research is being developed. Interdisciplinary cooperation between the schools of nursing and medicine on the university's medical center campus and in the surrounding community and region is fostering the growth of all professional groups at Rochester. Special projects in primary care, sponsored by the Robert Wood Johnson Foundation and a grant from the Divisions of Nursing of the U.S. Department of Health, Education, and Welfare which provides for the retraining of nursing faculty members, will help these leaders to assume clinical roles and to become models in the provision of quality care for students and staff. These projects also will encourage research to improve clinical nursing practice. At the University of Rochester's School of Nursing, careeroriented students, both undergraduate and graduate, are learning how to improve nursing care through the study of patient-care problems. This approach precludes any preconceived method of dealing with patient-care problems since each situation is viewed as unique, wherein the needs of the patients dictate the specifics of care. This type of educational program breaks with the past technique of teaching nursing by formula. The dynamism and excitement of the patient-centered approach to nursing creates a learning climate in which human values and compassion have priority. It therefore attracts a special kind of person who is committed to these values. Advocacy of the rights of patients to know, to choose, and to become equal and respected partners in the process of health care are encouraging signs of professional growth in nursing. As the number of nurses who are educated in these professional roles increases, so does the prospect that they will have satisfying and intellectually challenging careers which do not hinder the development of other societal roles. Further, an involvement with society in general enables the professional nurse to share in an influential power base. Through the judicious use of this power, health-care delivery systems can be changed, thereby giving nurses control over their growth, development, and destiny. Standards for practice, education, certification of practitioners, and accreditation of programs through nursing organizations such as the American Nurses Association and the National League Bull. N. Y. Acad. Med.
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for Nursing all attest to this emerging professionalization of nurses. Another factor which has an impact on changes in education is the type of financial support for nursing education required to maintain the number and kinds of nurses necessary to serve the burgeoning health needs of the nation. Insurance companies, concerned about the cost of care, are questioning the expense incurred by health agencies for educational programs. This raises the issue of adequate societal support: it simply must be forthcoming! Indeed, appropriate utilization, distribution, and reimbursement for services rendered by nurses are related to cost factors. Disuse, misuse, and abuse of nursing talent has wasted the potential of nurses to deliver high-quality health care. Often nurses are underutilized. Rather than examining the health-care needs of people, we have concentrated on the roles that professionals will play. Geographical and specialty distribution, too, have been problems. Today, although there is no demonstrable market overflow, we have evidence of a pending oversupply of nursing personnel at the lower level; yet the need for those with advanced preparation remains overwhelming. The issue of reimbursement for nursing services must also be addressed if comprehensive, quality health care is to be delivered to 2 12 million people within the next decade. At present, prospects for federal support for nursing education is uncertain. It is to be hoped that the Congress will address health needs rather than medical needs alone; these include preparing nurses for teaching, clinical specialization, and research. Regardless of the problems surrounding issues of financial support and their tenuous solutions, however, nursing's concerns, interest, and efforts will remain focused on searching for new methods of delivering quality care and on evolving new ways to evaluate the results of that care. Three tools to measure the quality of nursing care have been described by Maria C. Phaneuf in an excellent overview of recent developments in the field;15 In nursing, concern for measurement of quality of care provided to patients is not new, but acknowledgment that quantitative measurement of quality is possible is relatively recent. Three examples of instruments for appraising the quality of care are the Slater Nursing Competency Grading Scale, which measures the competencies displayed by a nurse under observation Vol. 52, No. 1, January 1976
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in nurse-patient interaction; the Quality Patient Care Scale, for measuring the quality of nursing care being received by the patient while care is ongoing; and the Nursing Audit, for measuring the quality of nursing care received by a patient. All three methods and others that are now evolving use a conceptual framework of evaluation which generally reflects the nursing process, focuses on the functional potential of the patient, and may account for one or all of the major aspects of quality assurance: structure, process, and outcome. Probably the most commonly used method to assure quality is the nursing audit. This audit is a retrospective, systematic, recorded appraisal of the completed process of nursing care which is made on discharge of the patient from a nursing service. "The process of nursing," says Phaneuf,16 "encompasses all major steps taken in the care of the patient with attention to the nature and purpose of the steps, their sequence, and the degree to which they help the patient reach specific and attainable therapeutic goals. Tasks and activities are considered in the context of practice." Concurrent with the development of these methods, there is a movement in nursing to identify the patient's responses to the processes of health and illness, and to define and classify these in a universal manner. Efforts to develop a classification system for nursing diagnosis-to identify systems, signs, and the effectiveness of nursing-are underway at St. Louis University School of Nursing and Allied Health Professionals. The stated mission of this investigation is a monumental task: to describe "the entire domain of nursing."117 As Kristine Gebbie and Mary Ann Lavin interpret it,"8 This does not mean the identification of all of the tasks performed by nurses or of all the things that nurses have ever done in any situation or under any circumstances. It is the identification of those patient problems or concerns most frequently identified by nurses, problems which are usually identified by nurses before they are recognized by other health care workers, and problems which are amenable to some intervention which is available in the present or potential scope of nursing practice. These diagnoses focus mainly on the broad health needs of people. The interpretation and identification of these needs can only be addressed by nurses. Some nurses, organized in a national conference format, have begun to gather data and classify them for nursing diagnoses.19 Bull. N. Y. Acad. Med.
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At the first conference in St. Louis nurses provided a tentative list of nursing diagnoses, including estimations of alterations and relations in self-concept and faith, anxiety, levels of comfort, impairment of digestion, family adjustment, level of consciousness, malnutrition, impaired mobility, pain, sensory disturbances, ineffective sleep and rest patterns, and impairment of verbal communication. These diagnoses are early labels which require explication through stated characteristics (signs and symptoms). The subsequent effective nursing interactions should be followed by evaluation of outcomes which will result in greater usefulness and predictability. After the first conference a task force on miodus operandi was established and charged with responsibility for identifying and executing "any activities which could further the goals of the conferences, namely, the identification of those health states diagnosed primarily by nurses, the development of a nomenclature of the labelling problem." Data on 25 patients were requested from 33 institutions during a 3o-day collection period. Analyses of the data are planned during the interim period between conferences; this process will be facilitated by transferring the diagnostic labels, vital statistics, and patients' symptoms to separate cards from which groupings can be made by a panel of nurse experts. If it receives funding, this pilot project will be expanded to a five-year cooperative study and then to a national plan to make explicit nursing diagnoses. The assurance of quality in nursing also has been advanced by the standard of nursing practice published by the Congress on Nursing Practice of the American Nurses Association. These standards, now in their implemental stages, were developed as20 "descriptive statements which reflect the dynamic nature of nursing practice and reflect the best current knowledge available." The individual practitioner of nursing will be assisted by programs of continuing education, peer review, and certification. Nursing education has evolved from a beginning outside of academic control, namely, diploma schools, to become part of institutions of higher education. Through this evolution major progress has been made in the preparation of faculty, the development of curriculum, and the identification of the unique mission of nursing in health care. Throughout these processes there has been a concurrent effort to scrutinize not only the educational process, but also the manner in which care is given and the outcomes which are elicited. The methods deVol. 52, No. 1, January 1976
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scribed in this paper are still in the early stages, but in a very short time they have had a tremendous impact. This impact would not have been possible without nurses wvho were alert in recognizing patients' rights and who responded with a high degree of accountability and unfaltering determination to provide good care. REFERENCES York, January 1975. 1. Scott, M. and Levine, E.: Nursing 9. Report to Conigres .... p- l;. manpo wer analysis: Its past, present, and future. Coiif. onl Currentt liforma- 10. Knopf, L.: From Student to R.N.: A tion oni Heallth Manpower, April 17-18, R~eport of the Nurse's Career Pattern. 1975, T-arrytown, N.Y. Washington, D.C., Govt. Print. Off., 197o. 2. Personal conmaunication with the National League for Nursing. April 1975. 11. Na'ationial Leaigue for Nursing: NLN Vews2..:7, 1974. 3. Joohnson, WN. L.: Trends in nursing education and projectionls of the supply 12. Ibid., 1). 4. of nurses. Cmof. on Currendt Informa- 1:3. Ford, L. C. ;¢and Silver, H. K.: Ihe tionI on Health 31Mnpower, April 17-18, exp)ande(l role of the nurse in ehild (are. Nu.)r.'inq Outlook 1.5-:43-45, 1967. 1975, 'Larrytown, N.Y., 1). 8. 14. 11)1i(., p. :3. 4. Educatiownl Prep(aration for Practical anid Professional Nursing in the State 15. h'lianeuif, M. C.: Quality Assurance: A Nursing View. In: Quality Assurof New York, 1972. University of the aone of Medwicat (aore. Regional MediState of New York, the State Depart(cail Progranis Service. Dept. of eIacilth, ment, Office of Professional Educration, Education, aned \Welfare mionograpihl. Nursing Education, Albany, N.Y., Washington, L).C., Govt. Print. Off., 1973. 1973, 1). :351. 5. Johnson, W. L., op. cit., p. 10. 16. Ihid., 1). :3.52. 6. Ibid. 7. Dept. Public Health Service, Health Re- 17. (Gebbie, K. and 1Lavin, M. A.: Classifving- nursing diagnoses. Amer. J. sources Administration, Division of Nursin( 'i'7;:250, 1974. Nursing, Dept. of Healtlh, Education, and Welfare: Report to the Conrgress- 18. Ibidl., p. 252t. Nurse Training, 1974. DHEW Publica- 19. Gehbie, K. M. (1and Lavin, M. AX., editors: C(la.silicatiOi of Aurshin Diagtion No. (HRA) 7.5-41. Bethesda, Md., nioses. St. Louis, Mosby 1975. p. 10. 8. Memo to Members, Council of Ba(fcca- 20. Activities of the Congress on NYursiig Practice. Kansais City, Mo., Aimer. laureate and Higher Degree Programs. Nurses Assoc., 1975. National League for Nursing, New
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