The need for graduate nursing education and nursing research in The Netherlands: an exploratory study J. C. M. H. DIEPEVEEN-SPEEKENBRINK,

M. Phil.,

B.S.N.,

R.N.

Projecr Director for Nursing Science, University of Utrecht, The Netherlands

Abstract--In 1989 research was performed aimed at discovering the views of Dutch administrators of intramural health care institutions on the need for graduate nursing education and nursing research in The Netherlands. The study was completed in 1990. Because the research aim was to learn the informants’ point of view, a grounded theory method was applied. The sample size was 13. The subjects were selected by using two separate sampling procedures, so as to minimize bias. Data were collected by means of semi-structured interviews of I hour, which were tape recorded and transcribed verbatim. Analysis of the data was done by using the constant comparative method, involving concurrent collection, collation and analysis. The three major themes that finally emerged from the data analysis were named Change, Problems and Solutions. In order to keep as open a mind as possible the systematic review of the literature was done after the field work and analysis of the data. This article presents the findings and the implications of the study.

Introduction

Nursing

education

and levels of preparation

Nursing education has been a topic of discussion in many countries for numerous years. In nursing practice, care is provided by many different kinds of practitioners and educational preparation varies. Some countries have adopted clear positions on these matters, others are still debating them. The current deliberations in The Netherlands are probably as vivid as in the U.K. (Owen, 1988; Salvage, 1988). In the U.S.A. the American Nurses Association stated in 1965 that the minimum preparation for the professional nurse should be 393

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baccalaureate education (;McCloskey, 1981). Israel supports the same policy (Bergman, 1986b) and Canadian nursing has as a goal that by the year 2000 baccalaureate education will be the entry to professional practice (Bramadat and Chalmers, 1989). The relevant question here is what kind of nurse is needed today. According to Owen (1988) the professional nurse should be a mature, confident practitioner, vvho is capable of assuming responsibilities, and who can think analytically and flexibly; a nurse who recognizes the need for further preparation and is willing to accept self-development as a responsibility. Owen describes this nurse as a “doer-but a knouledgeabie doer”, who is capable of handling relevant information and who can assess, devise, plan, implement, monitor and evaluate care needs. Nursing education-must be at a level of producing this kind of a nurse. In other words, a practitioner capable of meeting today’s complex nursing care needs. Concurrent with the discussions about the desired preparation of the professional nurse, a second level of preparation has generally been accepted. The given name of the practitioner may differ from country to country. The Council of Europe (1982, 1983) published recommendations for a differentiation between the first and second level nurse in Europe as well as between the desirable preparation for each. In The Netherlands these differentiations have been generally accepted since the mid-1980s. The move into higher education Another significant evolution is that nursing is gradually being recognized as a developing academic discipline. This leads to the topic of higher education and immediately complicates matters. Educational systems differ and the concept of higher education may vary in different countries. The Anglo-Saxon system, for instance, distinguishes between undergraduate and graduate studies. Until only very recently the Dutch system did not recognize undergraduate higher education, as is explained in the following paragraphs. So when the move of nursing into higher education is addressed, it is not always clear what this actually means (Smith, 1988). The Netherlands The Netherlands is a relatively small and densely populated country. At the end of 1990 the population passed 15 million. According to the latest figures the working registered nurse population is 122,000. In addition there are approximately 34,000 student nurses. The total health care work force consists of 400,000 health care professionals (WVC, 1988). Dutch routes of higher education There are two main routes of higher education. One is offered by the country’s I3 universities and the other by approximately 85 schools for higher professional education. In addition there is a third possibility to obtain higher education at the Open University, where both university courses and courses in higher professional education are offered. This is in fact a distant learning system for students who are unable to attend regular onsite courses (Diepeveen-Speekenbrink, 1990). Up to 1986, the only degrees within the system were those equivalent to Master and Doctoral degrees, earned exclusively at universities. The system did not know nor recognize the baccalaureate degree. Today one can earn such a degree at the 85 schools for higher professional education. Master and Doctoral degrees can still be conferred only by the 13 universities.

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Dutch professional nurse preparation To date, nursing education in The Netherlands still takes place mainly in apprenticeship hospital schools, where students are simultaneously employees and trainees. In 1972 an important innovation was realized, when the first two undergraduate nursing education programs were started within institutions for higher education at Leusden and Nijmegen. Today there are 18 such programs and together they annually graduate 1200 nurses. Since 1986 the degree awarded upon completion of the studies is the baccalaureate degree in nursing. At present there are about 5500 graduates of this kind, where the total employed nurse population is estimated to be 120,000. The first important phase in the academization of nursing education is thus being realized (Diepeveen-Speekenbrink, 1987,1988). The above figures gain significance when compared with studies done by Van der Windt (1988) which show that in 1988 approximately 22 per cent of all newly registered nurses had completed baccalaureate nursing education, against only 10 per cent 5 years before. Nursing science in The Netherlands (a) The University of Limburg program. In September 1980 the University of Limburg established the School of Health Sciences with seven major programs. One of them is the country’s first Nursing Science program. Graduates are prepared to examine and develop the content of the nursing discipline. The primary purpose of the program is thus to prepare students for an academic and not for a professional degree. Many students are registered nurses, but the program is open to non-nurses as well. Some students, for instance those who choose clinical investigation as their field of interest, will desire or need formal preparation as a nurse. In order to acquire registration as a professional nurse these graduates of the Nursing Science program must complete an abridged nursing baccalaureate program. The Nursing Science program of the University of Limburg “focuses on the study of both professional and non-professional phenomena of nursing. It uses knowledge. insights and methods derived from humanistic, social and biomedical sciences as well as unique nursing theories and methodologies”.

The University of Limburg has adopted problem-oriented learning as its educational system. The guiding principles of this system are problem-based learning, self-directed learning, tutored small group sessions and continuous evaluation (University of Limburg, 1989). At this point more needs to be said about the Maastricht program. Hopman (1980) published an interesting study, in which he describes how nurses had, for quite some years already, expressed a clear desire for university education in nursing. They had also indicated a need for a scientific base for the practice of nursing. Since The Netherlands had no university programs in nursing prior to 1980 nurses went abroad for university education in their own discipline or chose other academic disciplines for further education. Hopman’s study (1980) indicates that in 1980 the plans of the University of Limburg did not correspond with the desires and needs expressed by the practicing nursing profession. He adds, however, how important it is that the program can start and that the future will tell what can be learned from the initial decisions. In a final chapter he indicates that, no matter what happens, the development of nursing towards an independent academic discipline will continue. Hopman’s publication is discussed more in depth under the heading “Literature Review”. (b) The joint Maastricht-Utrecht-Groningen program. In 1988 the universities of Limburg, Utrecht and Groningen joined efforts together with their regional schools for

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higher professional education. The aim was to establish a joint national part-time Master degree program in nursing and to unite efforts and expertise in nursing research. The first result was the start in September 1990 of a joint graduate program. The study Notwithstanding conclusions of earlier studies clearly supporting the need for nursing science it remained mandatory to address, again and again, the need for graduate education and nursing research. This article discusses a study whose aim was to ascertain the views of Dutch administrators of intramural health care institutions on the topic.

Research questions

What are the views of Dutch hospital administrators on the need for graduate nursing education and nursing research in The Netherlands? ?? (2) How do these administrators articulate their views? ?? (3) What major themes emerge from the data? ?? (4) What does the literature reveal on the research topic? ?? (1)

Methodology

Grounded theory research Because the main objective of the research was to discover the informants’ point of view, a grounded theory method was applied. Grounded theory research is qualitative research, based on the theory of Glaser and Strauss, as presented in 1967 in their well known book The Discovery of Grounded Theory. The term “grounded theory” refers to the data grounded in facts and to the theory that emerges from the data. The theory thus is grounded in the data. The grounded theorist looks for processes involved, rather than for static conditions (Stern, 1985). The most essential element of the methodology in grounded theory research is the joint collection, coding and analysis of the data. An important methodological technique in this process is constant comparative analysis. Every piece of data needs to be compared with every other piece (Glaser and Strauss, 1967; Burns and Grove, 1987). Data may be collected by means of interviews, observations, documents of a combination of these sources. The major mode however seems to be the interview, often combined with participant observation (Burns and Grove, 1987; Field and Morse, 1987; Stern, 1985). Stern (1985) makes the grounded research method quite understandable as she describes the entire process. According to Stern the method works well because it follows the same patterns people use to figure out what they do not understand. For instance, if one does not understand how something is done or what someone says, you ask: “How

do you do that?”

Or “What

do you mean? Could

you give me more information?“.

Every answer may shed new light on the subject. About the conduct of interviews she states that the interviewer soon realizes that “the interviewee is the teacher and you are the subject. ‘Teach me’ is asked of your subject, and if you attend well. the respondent will act like a professor” [Stern (1985). p. 1541.

the case of this study the researcher experienced Stern’s remarks to be quite appropriate. Stern (1985) also explains her views on the use of the tape recorder, while conducting an interview. She argues that it is better to write down key words and phrases while In

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interviewing, and type the interview and observations as soon as possible, rather than to use the tape recorder. This issue is controversial. Frequently the use of the tape recorder is recommended as a “must”. Field and Morse (1987), amongst others, clearly indicate that an interview must be transcribed word for word. Interviews can be structured, semi-structured or open-ended. The literature indicates a preference for the open-ended or semi-structured types. During and after the interview the researcher takes notes, which may also result in a large amount of hand-written data, that need to be sorted and analyzed. The techniques used during the process of data collection and analysis are described as concept formation, concept development, concept modification or integration (Burns and Grove, 1987; Stern, 1985). Lirerurwe

review

in grounded

research

Before describing the study itself the matter of the literature review needs to be addressed. In writings on the subject one encounters differences of opinion concerning the extent to which literature should be used as a guide in qualitative research. Field and Morse (1987) demonstrate three main viewpoints. The first is derived from Glaser and recommends not to consult the literature prior to the conduct of the research. The main argument for this position is that, by not consulting the literature prior to the conduct of research, the researcher does not become biased. The obvious disadvantage according to Field and morse is that, in following this procedure, the researcher risks wasting time in re-inventing the wheel. A second point of view is that all available information on the research topic should be located, read and utilized. The disadvantage here is the risk of invalidity. The third method is to critically examine previous research and to use it selectively. Field and Morse, who in fact recommend the latter, argue that in doing so the researcher is open and informed, but not restricted in his ability to analyze. Burns and Grove (1987) also recommend selective sampling of the literature. Stern (1985) in turn states that a pre-study of the literature is disadvantageous for three reasons: (a) the search could lead to pre-judgement and affect premature closure of ideas and research inquiry; (b) the direction could be wrong; and (c) the available data or materials could be inaccurate. In the case of this study the researcher was quite familiar with the most recent relevant literature concerning higher education in nursing and nursing research in The Netherlands. Selective sampling therefore could be considered as completed prior to the conduct of the research. In order to keep as open a mind as possible, the systematic review of the literature was performed after the field work and analysis of the data. The sample

(a) The sample population. The sample population consisted of administrators of intramural health care institutions, who all had the final responsibility for the nursing care within their institution. In addition all held a position of national importance. The Netherlands has 541 major intramural health care institutions (NVZD, 1989). Each is administered by a board of directors. The larger institutions have boards of two or more members, whereas the smaller ones frequently have only one director. ,1lany institutions no longer have a nurse as a member of their board of directors. The final responsibility for nursing care therefore will not necessarily be in the hands of nurse administrators. Frequently the physician member of the board will combine the responsibility for medical

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and nursing matters. Directors who have such a combined responsibility are often called patient care directors (directeuren patientenzorg). It should be acknowledged that in The Netherlands this situation is controversial. During the last decennium nurse directors are diminishing in number. Some regret this, others consider it to be appropriate. For this research project the issue is only relevant in demonstrating the situation of today. In identifying informants it was a matter that needed to be considered. It was therefore decided, if possible, to interview an equal number of nurse and non-nurse administrators responsible for the nursing care within the institution. (b) The size of the sample. The size of the sample was 13. Considering the fact that in each of the 541 institutions one member of the board holds the final responsibility for the nursing care, 13 is a little over two per cent of the patient care directors of intramural health care institutions. This figure actually has no more meaning than to give an indication of the total size of population from which the sample was drawn. In qualitative research the size of the sample is mainly determined by the factor “theoretical saturation” (Glaser and Strauss, 1967). It is not possible to predict the number of informants. In principle, data collection goes on until no new information is obtained, thus arriving at theoretical saturation. Hogstel and Sayner (1986) indicate that the researcher might want to limit the number to approximately 10. Since the purpose of qualitative research is to discover meaning, the number of informants is only relevant in relation to (increased) meaning. (c) Selection of the informants. The selection of informants was done by combining the convenience and network sampling methods. Convenience sampling means choosing subjects that are conveniently available (Burns and Grove, 1987; Hogstel and Sayner, 1986). Because of the risk of bias while using this method, only the first three interviewees were selected this way. The following informants were all identified by using the network, also called the snowball sampling system. This type of sampling takes advantage of existing social networks. The researcher asks his subject to provide names of possible new informants (Burns and Grove, 1987; Polit and Hungler, 1987). (d) Characterislics of the sample. The characteristics of the sample are summarized as follows: - all interviewees were administrators of intramural health care institutions; all had held their positions for more than 5 years (most for over 10 years); - all had the final responsibility for nursing care services as well as for related services, such as nursing educational programs (basic and continued); all informants were older than 45 years; - all held one or more positions at the national level, such as member of the board of the national organizations or member of national committees; and eight were nurses, five were physicians. (e) Advantages and disadvantages of the sampling methods used. The main advantage of these methods is the fact that informants are relatively easy to locate. In convenience sampling “subjects are included in the study because they happen to be in the right place at the right time” [Burns and Grove. (1987). p. 2161.

Snowball sampling in turn, simply works because people know each other or, as said before, makes use of existing social networks. The most serious disadvantage of both sampling techniques is the risk for bias.

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Data collection Each informant was initially contacted by telephone. After a brief introduction to the research project, each was invited to participate. A brief explanation and sometimes a short dialogue usually followed. All administrators who were contacted immediately agreed to the interview. The next step was a letter in which the research project was again introduced and explained. The data were collected by means of semi-structured interviews. The researcher had prepared a small number of questions with which to start. The aim was to have the informants express their views as freely as possible. The only structure thus was created by the prepared questions and, because of the busy agenda’s of the participants, a time limit of 1 hour. (a) Advantages and disadvanfages of interviews. For the conduct of this type of research, effective communication skills are essential. If one achieves good rapport with the informants, the use of this research technique can lead to a wealth of information. Because of the face-to-face contact between researcher and informants, the researcher can take time to establish rapport and sense when it is appropriate to commence the actual interview. Furthermore, the researcher can clarify questions in order to obtain the most accurate data. As a part of this process the researcher should be alert to verbal as well as to non-verbal communication (Hogstel and Sayner, 1986). Burns and Grove (1987) point out that, because the interview technique is quite flexible, it enables the researcher to explore in greater depth. These authors also stress as an advantage the high response rate to interviews, which could lead to a more representative sample. In all literature the time consuming element of interview research techniques is considered as a major disadvantage. The immediate effect of this disadvantage is that the size of the sample usually needs to remain rather limited, which in turn endangers the representativity. Furthermore the risk of bias remains a threat to the validity of the findings. The issues of reliability and validity should therefore be attended to. (b) The actual interview. The actual interviews all started with the investigator’s invitation to the informant to briefly tell something about her or his background. This part would usually last a few minutes and suffice to gather some basic data, while establishing rapport. Then the first question was: “Will you share with me your views on the need for graduate nursing education in our country?” Usually this question sufficed to initiate the informant to start talking, even though the beginning was usually more or less hesitant. Sometimes the informant would address the subject of nursing research spontaneously. If not, the researcher brought up that topic later in the interview for instance by asking: “Would you now please give me your ideas on the needs for nursing research?” Or if appropriate: “You just mentioned research. Would you tell me something about your views on that topic?” Remarks and questions that turned out to be helpful were: “I do not quite understand. Would you go into that a little more?” “Would you explore that more in depth?” “Can you give me some examples?” One of the researcher’s experiences was that some informants tempted the investigator to enter into a dialogue. In such a case her own opinions could have influenced the data

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provided. The researcher therefore had to be very careful not to respond by actually going into a discussion. In some instances it was even necessary to explicitly explain this dilemma. All interviews lasted approximately I hour. In some instances this seemed (almost) too short, in others it was sufficient. Some notes were always made during the interviews. These consisted of key words to be remembered for later, or as items that had for some reason made a specific impression. The researcher systematically listened to all tapes as soon as possible so as to “recapture” or “relive” the interview. Sometimes this led to additional notes. It always led to reflection. The interviews were all transcribed verbatim. Upon completion of the transcript the researcher systematically read them while listening to the tape in order to make corrections. After this the data analysis commenced. Data analysis Burns and Grove (1987) articulate that qualitative analysis techniques employ words rather than numbers. The analysis process relies heavily upon intuitive processes and might appear easier than quantitative analysis. Qualitative research, however, requires essentially the same skills and analytic reasoning as those required for quantitative analysis. In a sense it is even more difficult, because much of the analytic process performed mathematically in quantitative data goes on in the head of the qualitative researcher: “The analytic reasoning process guides the organization, reduction and clustering of the findings and leads to the development of theoretical explanations” IBurns and Grove (1987). p. 5541.

Data analysis in qualitative research is an ongoing process. Miles and Huberman (1984) consider this process to encompass three concurrent flows of activity: data reduction, data display and conclusion drawing, frequently also referred to as coding, categorizing and theory development. (a) Coding (data reduction). All transcripts were read and reread and, when needed, for better grasp of the meaning, the researcher listened to parts of the tape again. Then coding started. This actually meant labeling the items, that were addressed by the informants, with index words. The average number of initial codes that emerged was approximately 80, and varied between 65 and 88 per informant. (b) Categorizing (dafa display). Then the process of categorizing started. Certain categories had already emerged during the process of coding. The attempts to organize the codes logically into categories first led to over 30 and subsequently to 13 themes. Further abstracting resulted in three main categories. Re-examining the initial codes and categories led to the conclusion that all major items, brought forward by the informants, fit logically into these three main categories. Summarizing this process makes it seem relatively simple. Reality was quite different! The informants had provided a wealth of information and it was quite a demanding task to select, simplify and abstract in order to arrive at an organized set of themes and subthemes. It is hardly possible to share the thinking through, constant reflection, constant comparison of the transcripts (meaning one informant’s information to the others). The intensity of the entire process was quite a challenge. Table 1 presents an overview of the process of data collection and analysis. Validity and reliability Qualitative research is a way of addressing the empirical world. The aim is to understand people from their own frame of reference (Taylor and Bogdan, 1984) or in other words to discover the informants’ reality. A serious concern in this type of research is the relative

GRADl:ATENURSING

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1. Telephone

contact with potential

RESEARCH

I. Data collection

offering

JO1

and analysis

of data collection

informants

IN THE,~ETHERLA.~DS

and analysis

initial information

and requesting

participation

2. Letters to participants explaining research topic and confirming appointment 3. Semi-structured interview 4. Listening to taped interviews in order to “recapture” or “relive” 5. Verbatim transcription in Dutch of taped interviews 6. Correction of transcripts by listening to tapes 7. Coding from Dutch transcripts directly into English 8. Initial categorizing in English 9. Higher order categorizing in English IO.Translation into English of excerpts of transcripts for write-up of findings II.Validity checks of translations and findings 12.Presentation of translated excerpts and findings to informants 13.Theory development Note: Coding started as soon as the first transcripts were ready. Interviewing was then still in process. Once coding was on its way. initial categories started to emerge and the constant comparison became part of the data analysis.

lack of strategies to determine validity and reliability. The key question underlying these concepts is: do the researcher’s data reflect the informants’ truth? Do the data truthfully reflect the informants’ perspectives? All interviews were tape-recorded. The tapes thus are verbatim recordings of the interviews and contain the information, relevant to the research topic, as provided by the informants. All interviews were transcribed verbatim by an assistant. To verify the accuracy, they were all read by the researcher, while listening to the tapes. This led to the discovery of a number of mistakes and omissions, which were corrected. As a next step all tapes and the translated excerpts of three interviews were given to an experienced Dutch academician, who himself is author of several scientific works in the English language. Upon request he listened to a number of interviews to assess them and he examined the presented excerpts. The conclusion was that the translations of the excerpts were, beyond doubt, valid. In addition he volunteered his opinion that the interviews had been conducted in a manner to ensure the least amount of bias. The interviewer’s questions were in no way suggestive and the informants were given ample opportunity to articulate freely their views. According to Stern, reliability is best established by asking the participants of the study to evaluate the findings. They serve as the most “reliable

judges of their reality”

[Stern (1985).

p. 1501.

Taylor and Bogdan (1984) also suggest presenting the findings to the informants in order to check validity and reliability. in the case of this study the three excerpts of the interviews, mentioned above, were sent to the informants concerned, together with an abridged writeup of the findings. The informants knew which of the excerpts pertained to their own interview. The names of the other two interviewees were not revealed. These informants were invited: first to read their own interview and establish whether the translated excerpt was reliable; then write down with a few key words the main themes, that had been addressed in the interview:

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next read the other two excerpts; and finally read the write-up of the findings. The principle questions were: “Does my translation reflect truthfully what you said in the interview?” “Do these findings reveal what you told me?” The informants’ responses were basically alike. All three confirmed the reliability of the translations, since they clearly reflect what had been said. The answers to the question about the key items differed somewhat. They did correspond though with the differences in emphasis the informants themselves had actually placed on different topics. All three indicated that they clearly recognized their views in the researcher’s findings. These indeed reveal what they had meant. “The purpose of research is not only to increase your own understanding that understanding with others” [Taylor and Bogdan (19SJ), p. 1491.

., but also to share

Doing this correctly was the next step. The difficulty to face was what the French call “l’embarras du choix”. There was so much information. How to organize this and how to select quotations, that would, in a balanced way, illustrate the thinking of the informants?

Findings

Verbalizing how the entire process of coding, categorizing, constant comparison and intense reflection finally led to the major headings was quite a challenge. The three major themes that finally emerged from the data analysis, were named: ?? Change ?? Problems 0 Solutions. The following tables present these major themes as well as the major sub-themes identified by the informants: Table

Main themes as they emerged Problems

Change ?? Advances

in science

?? Changing

systems

?? Changing

health

care needs

2. Conceptual

Nursing education Knowledge Skills Consensus Policies to solve problems Role models Doubts Social status

framework from the interviews Solutions ?? Restructure

and improve nursing education ?? Nursing research

Change

Health care in The Netherlands is at present in a state of change. Advances in science, changing systems and changing health care needs were identified by the informants as matters of importance for nursing. All informants mentioned them. Some did so at the onset of their interview, as if to outline a background. Others spoke about them later.

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Table 4. Problems Basic Lack Lack -

nursing education of/need for knowledge Individual Body of knowledge of/need for skills Hands on patient care Management (organizational - Communication - Technical - Financial (budgeting) - Leadership - Abstract thinking - Strategic thinking - Problem solving - Research skills Lack of consensus - Basic education - Further educational needs Lack of policies to solve problems Lack of role models - Nurses with higher degrees - Nurse researchers Doubts Social status of nursing

4‘

In our hospital education.” .

we have apprenticeship

education

development)

. . Please let us continue

our present

forms

of basic

The present needs for knowledge as well as for a variety of skills emerged as matters of vital importance: a‘. . . There is an urgent need for knowledge . . There is a dramatic lack of knowledge . We need a knowledge base for practice . . .“. L1. . In particular I have in mind management and policy making skills academic education to handle the complex problems we must face . knowledge.”

. . . We need people with There

is great

need for

Finally, serious concern was expressed about the lack of consensus concerning the potential solutions for existing problems. As will be recalled the research topic was to clarify the need for graduate nursing education and nursing research as viewed by administrators of Dutch intramural health care organizations. In some instances the informants were quite clear in acknowledging such a need. In others the ambivalence was almost tangible. By and large the informants were unfamiliar with nurses with graduate education in nursing (lack of role models) as well as with nursing research. Often an uneasiness was expressed and some informants articulated that a lack of role models made it difficult for them to envision nurses with higher degrees in nursing and nurse researchers, working in their organizations: 6‘ . . . Our organizations are not ready for nurses with graduate education . . . A few yes, that we could “I do 6. . .. . . . would

manage. Our health care is not really ready for graduates who want to get ahead.” not really know about nursing research.” I can hardly imagine functions in which nurses work academically.” We need nurses with university education . We do not need too many though . . . What . . . But not too many.” I do with them? . . Yes, we really need nurse researchers

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3. Change

?? Advances in science Medical Related disciplines Technology ?? Changing systems National J Health care 31 Education 3 Nursing Institutional ? Management 0 Levels of nursing ,J Education ?? Changing

-

The

following

illustrations

health care needs

Demography/aging Illnesses and handicaps New, intensive, treatments/care Home care

from different interviews demonstrate

this:

‘6. . , When I look

at all that is developing in health care today I identify great changes in the needs _At present there are serious thoughts about setting for care . . . Patients’ hospitalization is short up projects, in which the family doctor, the medical specialist, hospital and home nursing care will all work together . . I fear, that if nurses do not quickly start preparing themselves for this new situation, they will not be able to cope with it, while I think, that well educated nurses could contribute tremendously to these new developments”. I‘. . I think that we are indeed in a changing situation and that means a different role for nursing . . . There is a tendency to create much larger patient care units. For those we will also need much better educated nurses . Management would be in the hands of a physician, a nurse and a financial specialist . . . Within these teams the nurse must be able to function on an equal level. I think that it would be quite desirable to have university educated nurses in these positions . . . Let us also remember, that within these larger units the nursemanager should be able to create the desired climate for nurses, who are performing the actual hands on patient care. She can also stimulate research projects . . . Within these new organizational models we will definitely

need nurses with higher education”.

“ Look at the changing health care . . You need to look beyond hospitals and nursing homes . . . And the needs for care will needs . . . The aging of the population . . . Changing care needs increase . . I really think we need leading nurses with university education to cope with all the processes involved.” ‘L . . Somuch is changing today. For instance in the organization of nursing services we are faced . They cannot cope with the increased with having to give head nurses more responsibilities demands for skills . ..‘ I

Problems

Most informants very soon focused on problems and a major problem appeared to be basic nursing education. Most informants, and of those all nurse administrators, expressed concern, often even very serious concern, with the present professional preparation of nurses. Many informants criticized apprenticeship education, although others still clearly supported this concept: 44. . . Apprenticeship education should be abolished. We should have independent schools only . . . Look ‘1

at the present apprenticeship

system. It is a real catastrophy.”

. . . In my view we should have independent the first as well as at the second level.”

schools only. We need that kind of education

at

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At times it was almost as if the nurse with a Master’s degree was considered as a being from another world, instead of as a mature confident practitioner, able to meet today’s professional demands. A nurse who is able to accept a leading position within the profession, who is willing and capable of accepting today’s professional responsibility and who is able to think analytically, creatively and flexibly. In summary, a nurse, who can meet today’s challenge of leadership in professional nursing. In addition to the above, some informants identified the social status of nursing as a problem. Solutions Table

5. Solutions

??

Restructure and improve nursingeducation - Basic education i? Abandon apprenticeship o Improve apprenticeship 2 More independent schools (first and second level) Increase higher education (undergraduate and graduate) Structure and improve post basic education

??

Nursing research Research areas (see Table Create support systems Create climate

6)

All who are familiar with the Dutch situation will not be surprised that the suggested solutions concerning basic education contradict each other. Most informants strongly believe that apprenticeship education should be abandoned, while some still support it. Concerning higher education the articulated views also differed. Some support undergraduate higher education as the most desirable professional preparation. Others seem quite ambivalent about it. The same trend was identified concerning graduate nursing education and nursing research. Some informants clearly indicated that facilities for graduate nursing education should be increased, while here again, others were hesitant. Those who supported the concept of graduate education in nursing and nursing research also identified spontaneously a number of research priorities (see Table 6). Examples of specific topics needing research are: care of oncology patients, AIDS patients, transplantation patients, diabetes patients, stoma patients, psychogeriatric patients (reality orientation problems of the aged, mobility problems of the aged); consequences of technology for nursing care and relationships between nursing and other disciplines.

Literature

review

In order to keep as open a mind as possible during data collection, an extensive systematic review of the literature was done after the field-work and analysis of the data. In no way was it surprising though, to establish a distinct resemblance between the findings of the study and the deliberations in the Dutch literature. The same agreements, diverging views and inconsistencies, in particular about basic nursing education, emerged, with apprenticeship education versus independent school education as a central theme (Dassen,

406

J. C. ,Cf. H. DIEPE VEEN-SPEEKENBRI,vK

Table

6. Research areas Research areas

Patient care ?? Neonatal nursing ?? Medical nursing 0 Surgical nursing ?? Acute intensive care nursing 0 Geriatric nursing ?? Psychiatric nursing ?? Home nursing care 0 Pain management ?? Psychological aspects of care ?? Multidisciplinary research Administration ?? Management and decision making 0 Organizational concepts ?? Manpower problems ?? Relationship between responsibilities, knowledge and skills Education ?? Relationship between education and job satisfaction ?? Relationship between education and practice

1986a-c; Horenberg, 1986; Bakker, 1987, 1988; Dorama-Fokkens, 1988; Erwich, 1988; Heitink, 1988; Treek den, 1988; AkonC, 1989; Janssen, 1989; Van der Windt, 1989). Similar discussions are encountered in the English literature (Melia, 1987; Owen, 1988; Salvage, 1988; Bircumshaw, 1989; Bramadat and Chalmers, 1989). Many countries seem to struggle with the “uneasy

compromise

between education

and service”

[Melia

(IY87).

p. 161).

In this article discussion of the literature must be limited. The first topic to be addressed of a selected few is Hopman’s study (1980), which presents an interesting review of the history of health care and nursing education in The Netherlands. Hopman analyzes the past systems and problems as well as those of the day. He devotes a chapter to practice and science, discusses in depth university education in nursing and criticizes the Limburg program. He adds, however, that notwithstanding the differences in opinion and the problems to be overcome, it is of immense importance that the program should start. The future will show what should be learned from both right and wrong initial decisions. He finally presents 10 theses. In summary they strongly support academic education, since modern nursing should be science based. Other disciplines should not be permitted too strong a voice in further developments. The nursing profession itself should take its own matters in hand. If need be, nursing experts from abroad can be invited to assist as consultants in the creation of academic programs and to assume key positions temporarily. Eventually, students with high intellectual qualities will emerge to become teachers. Hopman finally suggests that the development of the science of nursing will progress. Maybe the process of maturation will be slow, but nursing will certainly become a full value academic discipline amongst other academic disciplines (Hopman, 1980). Another topic of specific interest is Israel’s masterplan towards a fundamental change from diploma school basic education to baccalaureate education. Bergman’s writings (1986a, b) portray the “academization of nursing education” in Israel as a move, that started to take form in the late 1960s and resulted in a 25 year enterprise, comprising fundamental

GRADL.‘A T& ,VUR.SI.VG EDUCATlO,V

A.VD RESEARCH

IM THE ,VETHERLA.VDS

407

restructuring of nursing education. As part of the plan it was foreseen that all existing apprenticeship schools of nursing were either to be absorbed in the existing universities, or to become schools for practical nurses. At present this move of nursing education into higher education is nearing completion. A group of nurse leaders apparently convinced decision makers at all levels, including the government, that to meet today’s health care needs, higher education for professional nurses is a must. Bergman reports that “The need for academization has been re-examined several times over the years and will continue to be scrutinized

in the future”

[Bergman

(1986a).

p. 228j.

She describes the route each new program must go to obtain approval from committees within the universities as well as from external committees and finally from the Council of Higher Education. National committees regularly report to the government on the progress of the “academization process”. Apparently all reports thus far have been quite positive and reveal “raised standards in education and services, the quality of care in the work

force”

[Bergman

(1986a).

and high retention of graduates

p. 2281.

At present 50 per cent of the Israeli nursing manpower consists of registered nurses, of whom growing numbers have completed undergraduate university education. The other 50 per cent include practical nurses and midwives. Also inspiring serious reflection, Melia (1987) sheds a somewhat different light on the above matters pertaining to nursing education. She addresses the diverse views on education and service needs by asking whether there is one entity, called “nursing”. Nursing is generally referred to as an organized group of persons, who are all engaged in providing nursing care. This group comprises a wide range of personnel. Levels of education, types of work and responsibilities held vary, often even quite significantly. This results in diverse, at times even competing and conflicting views. There certainly seems to exist a conflict of interests between the apprenticeship system, nursing service and the educational needs of students, who are part of the hospital’s work force. Melia argues that, given the present situation, nursing will have to accept the wide range of interests, skills and levels of education, existing within its ranks. Bergman (1976a, b, 1987) demonstrates how Israeli nursing has achieved as a national, government supported policy, that entry into the professional practice of nursing requires baccalaureate education. Melia (1987) strongly emphasizes the present state of change of nursing in the U.K. and argues that the British “Project 2000 Report” calls for serious reconsideration of the present relationship between service and education. She recommends a new and fresh approach to nursing education and the organization of nursing services. Both authors stress the need for unity within nursing, in order to achieve the fact that nurses themselves and not others will determine their future. Pertaining to this point Chapman’s view (1983) is also relevant: “Nurses form a large group within society and as such can exert considerable . of their patients and for the general health and welfare of the population p. 247;.

power for the good (1983),

.” IChapman

J. C. ,\I. H. DIEPEVEEN-SPEEKE.VBRI,vK

408

Conclusions

and implications

of the study

Conclusions The data, obtained from the interviews, suggest the following conclusions: 0 The informants generally agree that the many and diverse changes in today’s health care have weighty effects on nursing care. Advances in science, changing systems and changing health care needs are topics of siggficance. ?? Most informants demonstrate discontent with the present preparation of nurses for nursing practice. This pertains to basic, as well as to post-basic education programs. ??

Most informants seriously criticize apprenticeship education, while only few support it.

?? Most informants demonstrate serious concerns about the perceived lack of knowledge and skills of nurses. Often nurses are described as not being sufficiently equipped to meet today’s health care needs. ?? Pertaining to the above, the majority of the informants clearly indicate a need for graduate nursing education and nursing research. Others express ambivalence. Notwithstanding their pronounced concerns, these interviewees demonstrate doubts about the need for graduate nursing education and nursing research. ?? Some informants express concern&about the lack of consensus concerning potential solutions for existing problems. This4ack of consensus has a negative effect on policy making, resulting in a lack of adequate national policy decisions. ?? Most informants suggest fundamental restructuring of nursing education, including basic and post-basic programs, and plead for an increase in higher education. ?? A significant number of informants indicate the need for developing a body of scientific nursing knowledge and plead for nursing research. Pertaining to this point, some informants emphasize that nursing research should be done by nurses, rather than by investigators of other disciplines. Some also stress the value of multi-disciplinary research.

Because of the small sample size these conclusions do not permit generalization. Therefore, one of a series of recommendations for further research was to perform similar studies using the same or different methodologies and including larger and more varied samples. Implications of the study “Nursing ~111 have to consider its own internal reorganization carefully if it is not to find that. once again, its future has been determined from outside” (Melia (1987). p. 1861.

The findings of this study, including the data from the interviews and literature, are a challenge for Dutch nurse leaders and other leaders in the fields of health and education. The wide-spread discontent with the present preparation of nurses, linked with today’s pressures on nursing, which require knowledge and skills not previously expected, demand fundamental re-appraisal of current Dutch systems. Studies, performed in Israel and in the U.K. (Bergman et al., 1982; Bergman, 1990; Bircumshaw and Chapman, 1988), reveal

GR.4DCi.A TE NURSING

EDUCATION

A.VD

RESE-IRCH

IN

THE

NETHERLA‘VDS

WJ

a clear correlation between higher education in nursing, work retention and satisfaction. They also suggest that manpower problems cannot be solved by lowering standards of education, nor by maintaining programs with extremely high attrition rates. In conclusion decision makers together have the responsibility of establishing and implementing solid long-term programs for nursing education, nursing research and the organization of nursing care services. These must meet today’s and tomorrow’s nursing education and health care needs, which implies in-depth studies of existing systems and most likely readiness for fundamental change.

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Rijswijk.

(Received 27 May

I99

I ; accepted for publication 3 February

1992)