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CHAPTER IV
Education for Generalist
Positions in Nursing
The question of whether the aggregate supply of registered nurses
(RNs) will be sufficient in the future to meet the changing demands of
the nation's health care system was addressed in Chapter II. The
committee concluded that the nation's hospitals and other major
components of the health care system could expect an adequate supply
of RNs to be available through 1990 in the aggregate, but we also
noted aspects of nurse preparation about which failure to take
appropriate actions could unfavorably influence the size and
composition of the future supply. Chapter III dealt with one such
major set of factors--the cost and financing of basic nurse
education. In this chapter we turn to factors directly or indirectly
influenced by nurse educators.
Many forces in society that affect the quantity and quality of
candidates for nurse education are beyond the control of the educators.
However, educators can take advantage of new societal trends that can
increase the likelihood of beneficial forces prevailing over adverse
ones. This chapter discusses ways in which such a positive impact
could be made--by attracting new kinds of students to nursing, by
lowering current barriers to educational advancement, and by closer
collaboration between nursing education and nursing services.
Attracting New Kinds of Students
During the 1980s, in common with almost every other type of post-
secondary and vocational education, basic nurse education programs
must adapt to a new environment occasioned by a declining United
States birth rate that is shrinking the pool of high school
graduates. Further, because nursing predominantly is a woman's
occupation, education programs to prepare RNs must compete for gifted
young high school graduates who currently are attracted to increasing
opportunities for women in business, law, medicine, and engineering--
all occupations in which students' investments in the costs of
education yield a higher rate of return in salaries.
In these changed circumstances, the ability of nurse educators to
attract sufficient numbers of high-quality students in the future may
well depend on attracting greater numbers not only of new high school
116
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graduates to the established generic nurse education programs, but also
of people in older age groups looking for a career change, and other
nontraditional students for whom more flexible types of programs may
be needed. Whether nursing educators can attract the required future
supply depends in part on what hospitals and other major employers of
nurses are able to offer in salaries, conditions of work, and
opportunities for promotion, as is discussed in Chapter VII. However,
it also depends on the ability of nurse education programs to meet the
needs of new kinds of students and compete with the attractions of
other career possibilities.
There were 2.6 million high school graduates in 1971. By 1985
graduations will have dropped to 2.4 million, although a higher
proportion of the high school age group graduates than ever before.1
Between 1975 and 1981 the total annual applications for fall admissions
to the three basic nursing programs preparing for RN licensure declined
by 43,000.2 The number of fall admissions during this period,
however, increased by over 1,500.3 These phenomena translated to a
decline in the ratio of fall applications to fall admissions from 3.19
in 1975 to 2.61 in 19810 There were only minor differences in ratios
among the three types of programs preparing Ens in 1981, but
baccalaureate programs ranked slightly lower. The same trend of
declining ratios of applications to admissions is found in practical
nurse programs.4
These facts appear to suggest an overall decline in the quality of
students entering nursing programs, but appropriate data, such as the
high school grade point average of entering students, are not available
to test this hypothesis.
All education programs that prepare students for registered nurse
licensure and for practical nurse licensure have unrealized potential
for attracting nontraditional students. Although nurses' salaries are
low in comparison with many professions, there are offsetting
attractions. The practical nurse program or the associate degree (AD)
programs offer opportunities for people who can afford only a 1- or
2-year investment in education. Nursing has had historically high
employment rates--a particularly appealing attribute in the current
economic recession. Nursing also offers opportunities for geographic
mobility, part-time employment, and for people with family
responsibilities, a choice of days and shifts to work. Finally, for
those who enjoy working with and helping people, nursing offers
especially appealing challenges.
There are several different kinds of potential nontraditional
students to whom nurse educators can market their programs. One group
consists of people with college or graduate education who wish to
change careers. At a time when opportunities for teachers, social
workers, and other service professionals are declining, nursing has
attractions for such well educated and highly motivated people.
Because substantial investments have already been made in their
education, recruitment from this pool of potential candidates would
appear to offer a relatively quick and cost effective way to enlarge
the supply of KNs for generalist or subsequent advanced positions in
the profession.
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Women whose children reach school age and who wish to reenter the
labor force in a stimulating career may also see advantages in nursing.
Members of minority and immigrant groups, as in the past, may regard
nursing as an occupation that offers prospects for upward social and
educational advancement. Further, attracting more men to nursing could
help greatly to enlarge the future supply.
Present capabilities for providing nursing education to these
various kinds of nontraditional students are uneven. For example,
people with baccalaureate or master's degrees in fields other than
nursing encounter special hardships in attempts to switch careers into
nursing. Besides the nursing course work and clinical experience, they
sometimes must repeat non-nursing academic courses in order to obtain a
requisite baccalureate degree in nursing. Some nurse education
programs have been specially designed to meet the special educational
needs of such advanced students, as at the School of Nursing at Yale
University, Pace University, Case Western Reserve University, and the
Health Sciences Schools of the Massachusetts General Hospital.
Although AD programs, based in community colleges, have for some
years been attracting older students, diploma and baccalaureate
programs have not yet concentrated their efforts on recruiting this
group. In 1980 more than a third of newly licensed AD graduates were
30 years old or over, compared with hardly a tenth of either
baccalaureate or diploma graduates.5 Licensed practical nurse
programs also attract older women. In 1980 almost 40 percent of the
newly licensed practical nurses (LPNs) were 30 years old or older;
only about 6 percent were under 20 years of age. This suggests that
very few undertook their practical nursing education as part of or
immediately following their high school course of studies.6
Only about 6 percent of newly graduated nurses are men; they are
distributed fairly evenly among the three types of basic nurse
education.7 Specially designed efforts to attract them have been
few. Practical nurse programs graduate an even smaller proportion of
men.
In 1981, blacks made up 6 percent, Hispanics 2 percent, and
American Indians and Orientals combined less than 2 percent of newly
graduated nurses. A slightly higher proportion of blacks graduated
fray AD programs than from baccalaureate programs; diploma programs
had the lowest percent. Differences for other minority groups were
minimal.8 In recent years, practical nurse programs have graduated
a larger proportion of blacks, about 12 percent in 1981.9
The committee found many examples of attempts to attract new types
of students, but data on success or failure of any of these methods
are not yet being systematically collected, nor are many resources
available for those interested in investigating or implementing new
techniques to bring nontraditional students into the mainstream of
education.
Conclusion
Actions taken by nursing educators, professional associations, the
hospital industry, and other employers can affect both the number and
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the types of applicants to their programs. Because applications and
admissions to basic nurse education programs of recent high school
graduates have declined and are likely to continue downward,
administrators and faculty must attract recruits from other groups in
order to maintain their volume of enrollments and graduations. A
number of groups have been identified as being particularly likely to
respond to efforts made to facilitate their entry into nursing. They
include individuals making career changes, mature women first entering
the labor market, and minorities.
Attracting these people to nursing education programs and providing
support to retain them in programs, such as special counseling and
curriculum adjustments, entail certain costs. Nevertheless, many
educational institutions may find that their long-run economic
viability will depend on maintaining enrollments at a high enough
level to generate sufficient income. Those involved in planning for
individual educational institutions should carefully consider whether
their programs would benefit from this type of investment. Failure to
adapt to demographic realities and to take advantage of societal
changes will lead to higher unit costs of nursing education resulting
from unfilled places in education programs.
RECOMMENDATION 5
To assure a sufficient continuing supply of new applicants, nurse
educators and national nursing organizations should adopt
recruitment strategies that attract not only recent high school
graduates but also nontraditional prospective students, such as
those seeking late entry into a profession or seeking to change
careers, and minorities.
Opportunities for Educational Advancement
Many RNs and LENS seek further education to improve their knowledge
and skills and to enhance their chances of career promotion. Although
additional nursing education of such people does not augment the
overall numbers in the nursing supply, it alters the mix of the supply
toward Bachelor of Science in Nursing (BSN) degree, a goal that is
espoused by many leaders in the profession. If diploma and AD
graduates advance to the BSN degree level, they, together with
graduates from the generic 4-year BSN programs, enlarge the pool of
registered nurses (RNs) from which graduate nurse education programs
can subsequently draw.
By the time nurses become licensed, substantial investments in
their basic education have already been made. If appropriate academic
credits are transferred and clinical skills are recognized, the costs
to the student of obtaining a baccalaureate degree are minimized. To
the extent that hospitals and other employers contribute tuition for
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RN and LPN employees as fringe benefits, and to the extent that
students pay many other costs of their education, the burden on state
and local governments may be correspondingly reduced, leaving nursing
programs in public colleges and universities more resources to expand
their master's and doctoral programs and to support nursing research.
Thus, encouraging educational advancement allows licensed nurses to
capitalize on academic and clinical expertise already acquired and
appears to be a cost effective way of upgrading the skills and
knowledge of ~ portion of the existing supply of nurses. On the other
hand, the costs to programs of nurse education associated with
accepting transfer or advanced placement students may be somewhat
higher, not only because of increased administrative paperwork, but
also for the development of challenge examinations.*
Although there are clear advantages to facilitating the upward
movement through the profession for various levels of nursing
personnel, numerous barriers to such progress exist, and lowering
those barriers is not always easy. Educational advancement creates
problems for students, for nurse educators, and for accreditation
bodies.
Barriers to advancement often stem from the admission and transfer
policies of individual academic institutions. Candidates also can be
handicapped by lack of explicit goals of educational attainment in the
various required areas of nursing knowledge and by the lack of standard
performance to measure various types and levels of clinical and
judgmental skills acquired in practice (Chapter VIII). Perhaps as a
result, problems have been identified with accreditation criteria and
processes that can result in repetitious courses and clinical
instruction that many registered nurse students find wasteful of their
time and money. For highly experienced nurses, duplicative teaching
in the clinical area can be frustrating, especially if the faculty who
teach them have not kept abreast with changing practices. Because of
these barriers, some RNs elect to obtain higher degrees in another
field.
In 1981, referring to admission criteria for master's programs in
nursing, the executive director of the American Association of Colleges
of Nursing stated that it is logical to require that the applicant have
a bachelor's in nursing or an equivalent that has been validated. She
observed:
A major contrast between the early practice and recent
years is that the former's emphasis was how to assist able
applicants to get in, while currently the criterion seems
to be looked upon as a barrier to keep them out . ~ . if
we want to increase our numbers and not reject a
*Challenge examinations are designed to allow students who have taken
a given course at one institution without academic credit to obtain
credit for it at another, after demonstrating their mastery of the
subject matter. Candidates for such examinations are usually given
reading lists of the course to study before the examination.
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121
lot of worthy applicants, we should stop treating the
RN who has a bachelor's in another field like a leper.
No matter that the registered nurse applicant may have
graduated with honors in another major and had achieved
well on admission tests. Too often, the question; What
can I do to make it ups is answered by the suggestion
to enroll for at least the senior year in an accredited
generic nursing program. Very few adults can afford to
do that.l°
Nursing educators face problems in trying to develop workable
systems for accepting graduates of other basic nursing education
programs into their own programs, because although there are broad
guidelines, nurse education has few standard components of a kind that
can facilitate direct transfer of credits. Nor do accrediting agencies
have the benefit of systematic comparative analysis of the curricula
currently offered in the three basic RN programs. Nursing studies in
several states and testimony from nursing organizations say that the
lack of clearly differentiated and measurable knowledge and performance
expectations at the conclusion of diploma, associate degree, and
baccalaureate nurse education handicaps schools in designing programs
for professional advancement and creates confusion among their
students as they try to select programs appropriate to their career
goals.
The importance and complexity of addressing problems of educational
advancement of RNs from diploma and AD programs to baccalaureate
programs have been widely recognized by state education authorities
and by state and national nursing organizations. Both the American
Nurses' Association and the National League for Nursing have endorsed
the principle of educational advancement.11,12 Also, the American
Hospital Association (AMA) 1982 position statement on nursing education
states that "a baccalaureate degree should be an attainable goal for
each student practicing nurse in or from an associate or diploma
program, and provisions must be made for crediting their courses and
experience toward the baccalaureate degree."13 On a practical
level, a recent AHA survey reports that the majority of hospitals now
offer to contribute to their nurses' tuition as a fringe benefit.
State studies of nursing in almost half the states have recognized
the importance of designing nurse education programs to encourage the
progression of qualified students through the various levels of nurse
education in a manner that minimizes duplication of program and student
efforts and costs. To this end, some states have taken follow-up
actions to improve coordination among nursing education programs, as
will be discussed shortly.
Efforts by Individual Nurses
Notwithstanding barriers to educational advancement, it is clear
that nurses at many levels are making efforts to improve their
professional status, reflecting in part pressures from employers who
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122
today often demand higher academic qualifications, and possibly also a
more general desire for greater responsibility in the workplace.
Substantial numbers of nurses have pursued higher levels of
education and continue to do so. Among the total 364,000 RNs with
baccalaureate or higher degrees in 1980, 28 percent had initially
prepared for licensure in a diploma program and another 7 percent in
an AD program (Figure 12~. Analysis of the subset of RNs that had
Baccalau reate or H igher Degree
364,000 (total)
Diploma for Initial /
Preparation /
101,000(28%) /
~ D
Associate Degree for\ /
Initial Preparation
24,000 (7%)
\
B
/
Baccalaureate for I nitial
Preparation
239,000 (65%)
FIGURE 12- Contribution of educational mobility to the 1980 pool of
employed RNs with baccalaureate or higher degrees.
earned graduate degrees reveals that in 1980, of the 68,000 RNs with
master's or doctoral degrees, more than one-half had had their initial
nurse education in either a diploma or an AD program (Figure 13~.
Enrollments of RN students in baccalaureate nursing programs
increased from less than 10,000 in 1972 to more than 33,000 in 1980.
The majority (58 percent) of such students were enrolled on a part-
time basis.14 All told in 1980 almost a third of the graduations
from BSN programs were of students who already were RNs.15
Practical nurses are also upwardly mobile. In 1978, about 7
percent of all graduates from basic RN programs, almost 5,000
individuals, had entered as LPNs. Associate degree programs had the
highest proportion of such students- galore than 12 percent.16
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Master's or Doctoral Degree
68,000 (total)
I n itial Master's i n
Nursing or Unknown
2,500 (4%)
Initial \\
Initial Diploma \ Baccalaureate
31,000 (45%) \ 30,000 (44%1
Initial Associate
Degree
4,500 (7%)
/
FIWRE 13 Contribution of educational mobility to the 1980 pool of
employed RNs with master' s and doc toral degrees .
Ef fort s by Nurse Educ at ors
Nursing education is making serious efforts to reduce barriers to
educational advancement. Many institutions have adjusted their
schedules and requirements to encourage ef f ic lent progression through
the various levels of nursing education. In 1981, 388 programs offered
the baccalaureate in nursing; 351 of those programs enrolled RNs who
had obtained their initial preparation in diploma and associate degree
programs.17 In addition, 12 3 other baccalaureate programs were
designed spec if ically for such RN students; 55 percent of the RN
enrollments were in NLN accredited programs.l8
Institutions that want to encourage educational advancement among
RNs should fac ilitate the transfer of academic credits, of fer challenge
exams to minimize duplicative course requirements, and give credit in
recognition of the students' clinical expertise. One example of a
program developed to fac i 1 it ate educ at iona 1 advanc ement i s in Orange
County, California. Here, vocational schools, community colleges, a
Endear college, and a university developed an articulated program
wherein successful students can progress from a certif fed nurse aide
program to a master's degree in a clinical specialty without loss of
academic credit and without repeating course work. The program has
operated successfully for more than 6 years.
Another particularly innovative program is the New York External
Degree program in Nursing, developed for use nationwide by the Univer-
sity of the State of New York under a series of W. K. Kellogg Founda-
tion grants . Registered nurses, pract ical nurses, and non-nurses meet
the program's formal requirements by building on their past academic
achievements and clinical experience. They can acquire any necessary
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additional academic credits and/or clinical instruction in academic
institutions and in-patient care settings of their choice, in their
own communities. When they have completed the requirements, students
take standardized external degree program examinations. These include
rigorous performance evaluation of their clinical skills in test site
hospitals located in New York and California. (Sites in other states
are planned.) Forty-five states accredit the program to allow its
graduates to take their state licensure examination. As of June 1982,
2,734 students were enrolled in the program leading to the BSN and
3,016 were enrolled in the program leading to an associate in science
or an associate in applied science. By June 1982, 352 graduates had
earned the BSN and 1,419 had earned the associate degree. The accep-
tance of the external degree by graduate schools has yet to be tested.
Efforts by States
Many states have educational advancement as a high priority,
viewing it as a relatively low-cost way of upgrading the nurse supply
that serves the needs of students, educators, and nurse employers. For
example, legislation in Arkansas mandates advanced placement options
for RNs and LPNs in state supported schools. The goal with respect to
LPN s is to produce more RNs within a shorter time period. By 1980-
1981, mechanisms had been developed for RNs, LPNs, and licensed
"psychiatric technician" nurses to take challenge examinations or
transfer credits toward a degree. In California, curriculum articula-
tion (systematic organization of courses among schools to facilitate
student transfers) has received considerable legislative attention:
(1) the RN Practice Act (since 1976) requires that an RN program must
be prepared to graduate a licensed vocational nurse (LVN) from its RN
program with no more than 30 additional credits; (2) California's
Business and Professions Code requires all LVN programs to grant
credit for prior knowledge; failure to do so may cause the Board of
Vocational Nurse Examiners to deny accreditation.
There are many other examples of state activity. Several state
boards of nurse licensure have appointed articulation subcommittees,
such as that appointed by the Kansas State Board of Nursing in 1977,
which recommended that "formal articulation" be established on a
statewide basis among all nursing education programs. In 1982, state
boards of nursing in 34 states had approved nurse education programs
in which LPNs can become eligible to take the standard examination for
RN 1icensure.
Analyses and recommendations in many state nursing studies focus
on educational advancement. For example, the Indiana Commission on
Higher Education's report in 1981 recommended that the General
Assembly provide support and incentives to facilitate movement from
LPN through MSN, using demonstration projects, nontraditional study
programs (such as the external degree), and tuition credit based on
years of work. Candidates can receive credit for courses offered
through a telecommunications network that reaches students at their
place of work in hospitals and other sites. The report's long-term
priorities included expanded baccalaureate completion programs for RNs
and mas t er's programs loc at ed throughout the state.
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1~5
Cone lus ion
Although pursuit of higher education by large numbers of nurses
already licensed will not necessarily augment the overall numbers in
practice, over time it can change the characteristics of the supply
and enhance individual opportunities for career advancement as well as
provide candidates for employment in categories that employers may
find in short supply. Substantial numbers of LPNs could advance to
become RNs. Advancing diploma and associate degree RNs to the
baccalaureate level not only produces a more educated group; it also
enlarges the pool from which graduate nursing education can draw.
Educational progression from less than a baccalaureate degree has been
characteristic of the careers of many nurses who now hold graduate
degrees.
In 1980, about 50,000 RNs were enrolled in some form of education
program intended to advance their academic credentials. Many more were
pursuing shorter-term training to obtain special skills leading to cez
tificates or to keep existing knowledge and skills current in continu-
ing education workshops and seminars. Although many educational pro-
grams have responded to the need of nurses for educational advancement
by facilitating credit transfers, many others do not yet actively
encourage this objective. Upward advancement for both LPNs and RNs
has been hindered by failure of some institutions to plan their pro-
grams on the premise that successive stages of nursing education should
be articulated so that the course credits students have already
obtained and the experience they have acquired can contribute maximally
toward admission and progression to the next stage.
Motivation is increasing for RNs and LPNs to pursue further educa-
tion. Pressures on the individual come, in part, from the growing
complexity and variety of nursing responsibilities, and in part from
anticipation that future promotional opportunities or career mobility
may rest on qualifications that differentiate nurses by academic
credentials. Attainment of future supply goals may depend in large
part on a continual upgrading of the quality of a pool of nurses that
is primarily nourished by streams of new entrants whose initial career
objective may be to ensure nursing employment at minimum personal cost.
Educational institutions inevitably will incur some added costs for
steps taken to ease students' transitions from one educational program
to another. They will have to implement systems for evaluating
students' credentials, design curricula sufficiently flexible to absorb
students from other schools and programs, and offer such students
special counseling--all of which create additional administrative
burdens. On the other hand, where experienced nurses successfully
challenge clinical requirements, educational institutions may benefit
from proportionately fewer enrollments in the more expensive clinical
components of their nurse educational programs
Employers of nurses make substantial contributions to education in
the form of tuition reimbursement as a fringe benefit. Because of this
financial investment, it is in the interest of hospitals to participate
actively in cooperative efforts with educational institutions to
facilitate educational mobility.
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RE COMMENDATION 6
Licensed nurses at all levels who wish to upgrade their education
so as to enhance career opportunities should not encounter
unwarranted barriers to admission. State education agencies,
nursing education programs, and employers of nurses should assume
a shared responsibility for developing policies and programs to
minimize loss of time and money by students moving from one
nursing education program level to another.
Collaboration Between Education and Service
Estimating the future need for RNs with various educational back-
grounds, as required by the congressional charge, is complicated by
differing perceptions of educators and employers about the appropriate
base of knowledge and skills new graduates need. These differences
began to be apparent when nursing education moved away from its histor-
ical base in hospitals in response to abuses and inadequacies that were
believed to characterize the apprentice type of training they provided.
They continue to plague the profession. Many nursing service adminis-
trators believe that academic nurse educators, removed from the reali-
ties of the employment setting, are preparing students to function in
ideal environments that rarely exist in the real and extremely diverse
worlds of work. In turn, many nurse educators believe that nursing
service administrators fail to provide work environments conducive to
the kinds of nursing practice their graduates--particularly baccalaur-
eate RNs--are equipped to conduct and that, furthermore, new graduates
of baccalaureate, AD, and diploma programs should be differentiated in
their functional work assignments. The report of a task force of the
American Association of Colleges of Nursing* observes that ". . .
conflicting philosophies, values, and priorities between nurse educa-
tors and nursing services administrators have generally served to deter
a mutual understanding and acceptance of responsibility for quality
patient care.''l9
Concerns about communication and collaboration between nursing
education and nursing service were brought to the committee's atten-
tion not only from the literature but also from state nursing studies,
from testimony, from reports of many individual nurse educators, nurse
administrators, and hospital administrators interviewed during the
course of site visits, and from personal communications.
One complaint frequently voiced by hospital nursing service admin-
istrators is that newly licensed nurses often lack basic clinical
skills. This requires extra expenses for orientation and staff devel
*The American Association of Colleges of Nursing is a membership
organization of 230 deans and directors of schools of nursing that
offer approved baccalaureate and graduate programs in nursing.
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127
opment that ultimately must be met through the patient care payment
systems. Further, some public hospitals report that newly graduated
nurses seek initial employment with them for a year's intensive
training but that after staff development programs and senior nurse
supervisor have turned these novices into fully functioning staff
nurses, they move on to better paying jobs in voluntary hospitals.20
This means that a large share of the scarce tax dollars these
institutions invest in the orientation process are lost to them.
Nurse educators note that the phenomenon is not unique to nursing.
All new professionals, including lawyers, engineers, physicians, and
architects, need extensive periods of orientation, regardless of the
length of their educational preparations. Employers routinely accept
that substantial investment in on-the-job training is part of the cost
of doing business.*
Nursing leaders on both sides of this issue have become sensitized
to these concerns and appear to be looking for positive ways to arrive
at mutually derived expectations of how best to relate nursing educa-
tion to nursing practice and to agree on cost effective education and
practice actions to realize such expectations. Many approaches are
being tried. These are reviewed in the background paper by Aydelotte,
"Approaches to Conjoining Nursing Education and Practice," prepared on
the basis of comments from the study's advisory committee on nursing
education and nursing practice and other nursing leaders.
Some examples of approaches designed to enhance collaboration
between nurse educators and nurses in practice settings are described
below. Goals include the provision of organizational structures that
foster common perspectives; engagement in additional clinical experi-
ences for nursing students; maintenance of the clinical skills of aca-
demic nursing faculty; and facilitation of a smooth transition from
student to practicing nurse.
Unification of Nursing Education and Nursing Service Schools of
nursing and service settings at a number of medical centers (including
the University of Florida, Rush-Presbyterian-St. Luke's Medical Center
in Chicago, the University of Rochester Medical Center in New York,
and the University Hospitals of Cleveland and Case Western Reserve
University in Ohio) have been pioneers in unifying nursing practice
and nursing education.21 Nursing education and service programs
that follow these leads use joint nurse faculty/nursing service
*
The contention of nurse educators that on-the-job experience, with
or without formal instruction, is needed by graduates of any type of
professional school is incontestable. However, nursing service
administrators point out that many professional schools plan and
provide such experience for their students. In medical schools, such
experience is incorporated into the formal education process through
clinical clerkships. Students of optometry and dentistry usually gain
clinical experience by working in school-operated clinics in community
settings. Law students are often encouraged to work in law firms
during their summer vacations. Many nursing students, too, work as
aides in hospitals during their vacations and during the school year.
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128
appointments and other mechanisms designed to provide teaching and
research environments where nursing theory and clinical practice can
enrich each other for the mutual benefit of students, faculty, and
patients. In such settings, the objective is to encourage common
professional interests and thereby promote close communication and
shared values. However, successful implementation of the unification
model may be difficult in some settings and unrealistic in others. A
major question is the prime loyalty of the nursing dean/nursing
services director: to whom is this person primarily accountable, and
for what? There also are questions of who decides tenure, promotion,
and salaries--and from whose budget they are paid. Staff may become
overstressed if loads and sequence of teaching and service activities
are not carefully planned and monitored.*
Joint Planning of Nurse Orientation Curricula Various demonstra
Lions sponsored by the Southern Regional Education Board's Nursing
Curriculum Project have brought nurse education and nursing service
principals together to improve the new nurses' orientation to practice.
One example is at St. Petersburg, Florida. There, faculty from the
Clearwater campus of the St. Petersburg Junior College Nursing Program
and representatives from eight community health careagencies (hospitals
and others) worked jointly to develop elements of an orientation plan
for newly graduated nurses. The plan has a core component that this
group deemed necessary for all employers. To this, each individual in-
stitution can add its module--setting forth its own institution's poli-
cies and detailed procedures. Participants in the development process
appear to have gained important new insights into each others' goals
and missions.22
Clinical Experience for Nursing Practice Even where communication
.
between nursing services and nursing education is not formalized in an
organizational structure, hospitals and nurse education programs alike
appear to recognize the necessity for well-planned clinical experience,
nurse externships and internships, and other means of smoothing the
transition of new kNs from education to practice.
Nursing service administrators believe that new graduates adjust to
professional responsibilities more easily if as students they have
acquired experience with groups of patients, rather than only with
individuals. They also hold that student experience on night and
evening shifts and on weekends is an important part of preparation for
the realities of nursing practice. Some nursing service administrators
report that nursing students who finance their education in part by
working as aides in patient care settings often make the most success-
ful transition to nursing after they graduate. However, in individual
situations, there often is no clear agreement between nurse educators
and service administrators on the division of responsibility for the
*For detailed discussion, see M. Aydelotte. Approaches to conjoining
nursing education and practice. Background paper of the Institute of
Medicine Study of Nursing and Nursing Education. Available from
Publication-on-Demand Program, National Academy Press, Washington,
DeC. ~ 1983.
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129
student's clinical supervision and guidance, or for the synchronizing
of clinical experience with instruction in nursing theory and science.
Although nurse educators and nurse employers appear increasingly
to agree that graduates should be able to function effectively in
today's clinical settings and should be employed in ways that make
effective use of their abilities, attempts to achieve this goal meet a
number of difficulties. For example, academic nurse education programs
often find it difficult to provide students with a proper balance of
classroom and clinical instructional experiences.
Wilson observes that nurse educators in academic programs often
face difficulties gaining access to appropriate facilities for their
clinical teaching. Because their programs are not formally a part of
an agency providing patient care, these educators must develop affilia-
tions and obtain agreements with hospitals, visiting nurse services,
and other provider organizations to allow arrangements to be made for
their students to receive clinical experience with patients. Such
hospitals and other health care agencies often have affiliations with
several different nursing education programs, most of which want to
schedule their students' clinical experience on weekdays, between 7:00
a.m. and 3:30 p.m. Thus, students may receive extremely light patient
assignments--a situation they will not experience once they graduate.
Further, on the day of scheduled clinical experience, the clinical
setting may be unable to provide the specific types of patients that
meet the needs of the students' educational program.23
Wilson makes several other observations. Nursing homes are not
routinely used as teaching sites because educators believe that the
quality of nursing care provided there does not usually meet the kinds
of nursing standards to which their students should be exposed, or that
the experience they receive in such homes is not sufficient to meet
course goals. Also, because academic institutions usually reward their
faculty for scholarship (published research) more than for their clini-
cal skills in nursing practice, which are difficult to measure, there
are few incentives for nurse faculty to maintain active clinical prac-
tice. However, some hospitals are now beginning to impose conditions
in their affiliation contracts to include demonstration of the clinical
competencies of the faculty who will be supervising students. This
may encourage faculty members to keep their practice skills up to date.
For their part, employers observe that all newly graduated RNs re-
quire the same initial orientation regardless of the type of basic edu-
cation programs they attended and must be able to demonstrate a common
level of basic skills before assuming full responsibilities for patient
care. Therefore, it is argued, there is no basis for differentiating
their initial staff assignments. Although nursing service administra-
tors may take the type of initial educational preparation into account
in recommending subsequent promotions, they report that criteria of
individual demonstrated performance weigh more heavily.24 These
situations illustrate some of the differences in priorities between
educators and nurse employers.
Conclusion
Inadequate collaboration between nurse educators and employers has
resulted in dissatisfaction among both groups. Employers feel that
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many newly licensed nurses are unprepared to assume the responsibili-
ties of clinical nursing, and some nurse educators believe that employ-
ers are unprepared to make optimum use of the knowledge and skills that
their graduates--especially those with baccalaureate preparation--bring
to the job. However, there is increasing concern in nursing to
identify ways of reducing this discord. Collaborative arrangements of
various kinds have successfully brought together educators and employ-
ers of nurses for their mutual benefit and for improved patient care.
The development of practical arrangements for improving communica-
tion and collaboration between nursing educators and nursing service
administrators requires the solution of a great many logistical, organ-
izational, and financial problems among a large variety of institutions
that do not today have close affiliations. These tasks are sufficient-
ly difficult and time consuming as to require special funding and staff
to provide an incentive to test untried relationships and to develop
new patterns of accountability. Further experimentation and demonstra-
tion are needed to guide institutions of all types in moving toward
mutually designed goals.
The Nurse Training Act Special Project Grants--authorized at the
$15 million level between 1977 and 1980-formerly included among its
many purposes the funding of cooperative arrangements among hospitals
and academic institutions. This authority was repealed in the Budget
Reconciliation Act of 1981. Financial assistance should be offered to
demonstrate innovative ways of implementing collaborative arrangements,
including those that emphasize faculty clinical and research appoint-
ments. Although the financial burden of developing new collaborative
arrangements should fall primarily on those to whom benefits will
accrue, the availability of small federal grants to support additional
administrative personnel to devote their efforts to developing and
implementing necessary new program linkages would hasten the advent of
effective collaboration. Reinstituting even a small amount of federal
support would help draw attention to the magnitude of the problem and
provide impetus for wider experimentation. It is crucial to demon-
strate under widely varying conditions how reconciliation of differ-
ences between the goals and expectations of leaders in nursing practice
and in education can improve both the education of students and the
care of patients.
RECOMMENDATION 7
Closer collaboration between nurse educators and nurses who provide
patient services is essential to give students an appropriate
balance of academic and clinical practice perspectives and skills
during their educational preparation. The federal government
should offer grants to nursing education programs that, in
association with the nursing services of hospitals and other
health care providers, undertake to develop and implement
collaborative educational, clinical, and/or research programs.
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REFERENCES AND NOTES
1. Western Interstate Commission for Higher Education. High school
graduates: Pro Sections for the fifty states. Boulder, Colo.:
Western Interstate Commission f or Higher Educat ion, 19 79.
2. National League for Nursing. NLN nursing data book 1982. In
press, 1982, Table 32.
3. Ibid.
4. Ibid., Table 159.
-
5. National League for Nursing. NLN nursing data book 1981.
(Publication No. 19-1882~. Net York: National League for
Nursing, 1982, Table 130, p. 132.
6. Ibid., Table 186, p. 187.
7. National League for Nursing. NLN nursing data book 1982, Op.
cit., Tables 48, 49, 50, and 51.
8. Ibid., Tables 48, 49, 50, and 51.
9. Ibid., Table 149.
10. Murphy, M. I. Master' s programs in nursing in the eighties:
Trends and issues--Relationship to professional accreditation
~ Publication No . 81-2) . Washington, D.C.: American Association
of Colleges of Nursing, 1981.
American Nurses' Association. Statement on flexible patterns of
nursing education (Publication No. NEMO. Kansas City, Mo.:
American Nurses ' Assoc fat ion, 19 78.
12. National League for Nursing. Position statement on educational
mobility (Publication No. 11-1892~. New York: National League
for Nursing, 1982.
Assembly of Hospital Schools of Nursing of the American Hospital
Association. Hospital Schools of Nursing (newsletter),
September-October 1982, 15~5), 7.
14. National League for Nursing. NLN nursing data book 1981, Op.
cit., Table 68, p. 73.
15. Ibid., p. 57.
16. American Nurses' Association. Facts about nursing 80-81. New
18.
19.
York: American Journal of Nursing Company, 1981 , Table 2A-20 , p.
145.
17. National League for Nursing. NLN nursing data book 1982, Op.
c i t ., Tab le s 1 2 and 67 .
Ib id .
Task Force on the Responsibilities of Nursing Education for the
Quality of Patient Care in Clinical Settings. Responsibilities
of nursing education for the quality of nursing care in clinical
settings: Position statement (Publication No. 81-3).
Washington, D.C.: American Association of Colleges of Nursing,
1981, p. 1.
20. Institute of Medicine. Site visit to the Health and Hospital
Corporation, New York, by staff for the Study of Nursing and
Nursing Education, National Academy of Sciences, Ilay 1981.
21. Ford, L. C. Creating a center of excellence in nursing. In L.H.
Aiken (Ed.), Health policy and nursing practice. New York:
McGraw-Hill, Inc., 1981.
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132
Southern Regional Education Board. Acclimating the novice
nurse: Whose responsibility? (No . 4 in series of f inal reports
on the nursing curriculum pro Sect) . Atlanta, Gal: Southern
Reg tonal Educat ion Board, 1982.
Wilson, R. There will always be enough. Paper presented at The
Deans Seminar, Smuggler's Notch, Vt., July 1981.
24. American Hospital Association. Preliminary data from nursing
personnel survey, 1980, Unpublished .
Representative terms from entire chapter:
nurse education
