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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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117 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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118 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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119 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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120 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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123 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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124 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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126 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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130 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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131 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 .