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--> Professional Nursing Education—Today and Tomorrow Angela Barron McBride, Ph.D., R.N., F.A.A.N. So there is recognition of the fact that not one but several types of nurses are needed in the life of the country. … The gist of the matter is that (1) intelligent nurses are better than unintelligent; (2) physicians and hospitals demand much more of their nurses than formerly; (3) preparation for bedside nursing needs good basic teaching; preparation for public health nursing, which is largely instructing, needs further teaching; while those who are to teach other nurses, hold executive positions, and become leaders must not only be of a higher grade mentally but have had a more extended formal schooling (pp. 276–277). Minnie Goodnow, R.N. Outlines of Nursing History, fifth ed., 1937 Nurse Goodnow's words serve well as an introduction to a consideration of professional nursing education today and tomorrow, with their emphasis on the country's long-standing need for different kinds of nurses and on the importance to differentiated practice of different levels of formal education. This paper will summarize within a historical context how the existing programs of study, from associate degree through postdoctoral training, singly and collectively strive to meet the demand for professional nursing within the United States. Because nursing as a practice profession exists at the interface between the service sector Dr. McBride is distinguished professor and dean, Indiana University School of Nursing, Indianapolis.
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--> and academia, the current state of affairs will then be analyzed in terms of the forces shaping both health care delivery and higher education. Existing at the interface between these two major social institutions affords nursing both advantages and disadvantages, which will be articulated. The major challenges ahead for professional nursing education will then be summarized with an emphasis at the end on the importance of addressing fundamentals. Although the opinions expressed are those of the author, a number of nurses responded with helpful comments to a very detailed outline of the paper. They included the leadership of six major nursing organizations—the American Academy of Nursing, the American Association of Colleges of Nursing (AACN), the American Nurses Association, the American Organization of Nurse Executives (AONE), the National League for Nursing, and Sigma Theta Tau International (nursing's honor society). See the "Author's Note" section at the end for a full listing of respondents. A Brief History Of Nursing Education To understand the present, one must always have some sense of the past. The first "modern" school of nursing was founded in 1860 by Florence Nightingale at St. Thomas Hospital in London. A little more than a decade later, the first schools in the United States to build on her curriculum and philosophy (i.e., put patients in the best situation for nature to heal) came into existence; they were associated with Bellevue Hospital in New York City, New England Hospital for Women and Children (which became Massachusetts General), and New Haven Hospital in Connecticut. Hospital diploma schools were a boon to their institutions, since student nurses provided most of needed patient care as inexpensive apprentices. By 1900, an infrastructure for nursing education was taking shape; the American Society of Superintendents of Training Schools (which became the National League for Nursing), the Nurses Associated Alumnae of United States and Canada (which became the American Nurses Association), and the American Journal of Nursing had all been founded. The demanding working conditions soon contributed to a shortage of student applicants. In an attempt to de-emphasize apprenticeship training, nursing schools began to be affiliated with academic institutions. The earliest university-based nursing education took place at Howard University, Teachers College of Columbia University, Johns Hopkins University, what is now known as the University of Texas at Galveston, Rush Medical College in Chicago, and the University of Minnesota, which in 1909 became the first university to have an official school of nursing. By 1920, 180 nursing schools reported having college affiliations (Goodnow, 1937). In 1922, Sigma Theta Tau, nursing's honor society, was founded at Indiana University with the expectation that the baccalaureate degree was to be required for entry into professional practice; this has yet, however, to become the agreed-upon norm for the field. The 1920s saw the formation of two committees—the
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--> TABLE 1 Entry Into Practice: Nursing Programs, 1950–1990 1950 1961 1970 1973 1978 1990 Program Diploma 1129 875 636 494 367 152 ADN 3 84 437 574 656 829 BSN 61 176 267 305 349 489 SOURCE: DeBack (1994) and Murphy (1979). Committee on the Study of Nursing Education (1923) and the Committee on the Grading of Nursing Schools (1928)—that issued reports on themes that would concern nursing for the remainder of the twentieth century: the standardization of nursing education, restriction of the supply to ensure adequately paid work, and distribution and specialization of the aggregate work force. The 1930s were a period when hospitals expanded and private duty nursing declined, as the sick were unable to pay for home care because of the economic depression. Two reports in the 1940s were to sound once again the theme of the need for standardized nursing education. The Brown Report (1948), considered to be "the nursing equivalent of the 1910 Flexner Report in medicine" (Friss, 1994, p. 604), urged that only college graduates be regarded as truly professional. That same year, the Committee on the Function of Nursing (1948) recommended upgrading standards for both the licensed practical nurse (LPN) and the registered nurse (RN), the former with an associate degree and the latter with a bachelor's of science in nursing (BSN) degree. In 1951, Montag elaborated on the growing distinction between technical training, which was to be established under the ægis of the community college, and professional education, which belonged at the bachelor's level (Montag, 1951). The first associate degree in nursing (ADN) program was started in 1952 at Fairleigh Dickinson University. Programs offering ADNs have largely replaced diploma programs in the last four decades (see Table 1), but they became another means of acquiring the RN rather than the LPN (Deloughery, 1977; Murphy, 1979; Fondiller, 1983). Entry into professional nursing practice has been further complicated by the development of generic master's and doctoral programs on the grounds that undergraduate education is foundational to truly professional practice, just as it is for dentistry, law, and medicine (Dolan et al., 1983). For example, the first generic nursing doctorate (ND) was started at Case Western Reserve University in 1979, and there are now three such programs (Watson and Phillips, 1992). Graduate education for nurses, however, first took the form of additional preparation in the functional areas of education and administration as nurse leaders prepared for academic or supervisory roles. The first master's degree was awarded by Teachers College of Columbia University in the 1920s, and that
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--> institution also took the lead in doctoral education a decade later. The establishment of programs to develop advanced clinical skills occurred later. By 1949, Yale University Graduate School offered a master's of science in mental health (this program moved to the School of Nursing in 1958). In 1954, Hildegard Peplau founded at Rutgers one of the first master's programs to prepare clinical nurse specialists. The first nurse practitioner program was started a decade later by Loretta Ford at the University of Colorado. Three phases of doctoral education have been distinguished (Grace, 1978; Murphy, 1985; Hart, 1989). Before 1960, the emphasis was on functional role preparation, because nurses largely needed the EdD degree to develop the baccalaureate and higher education programs that began to be established during those years. In the 1960s, the importance of the PhD for research training gained favor as nurses sought degrees in other disciplines so as to apply that learning in developing the scientific base of their profession. Since the 1970s, the emphasis has largely been on research training within nursing. The clinical research orientation that began to take hold in the 1960s (Wald and Leonard, 1964) reached fruition in 1986 with the establishment of the National Center for Nursing Research, now the National Institute of Nursing Research (NINR), within the National Institutes of Health (McBride, 1987). That agency is organized to promote study of three general areas: (1) fostering health and preventing disease, (2) facilitating care of persons who are acutely or chronically ill, and (3) improving the delivery of nursing services (Merritt, 1986). Uncontrolled Diversity Versus Innovative Career Ladder Nursing in 1995 is a heterogeneous field; it covers the full spectrum of academic degrees from the associate degree through postdoctoral training. (See Table 2 for an overview of graduations from nursing programs in the last academic year for which full data exist, 1991–1992.) Seventy-one percent of the undergraduate degrees awarded that year were at the ADN level; if anything, "the proportion of new entrants into nursing that come from baccalaureate programs has declined" in recent years (Friss, 1994, p. 615). Of the 1,853,024 employed nurses in March 1992 (out of about 2.2 million altogether), 31 percent had baccalaureate degrees in nursing or a related field, 31 percent had associate degrees in nursing, and 30 percent were graduates of diploma programs; only 8 percent had graduate degrees in nursing or a related field (Moses, 1994). The traditional academic ladder for nurses begins with basic preparation at the undergraduate level—with a distinction between more technical preparation with the 2-year ADN and more professional preparation with the 4-year BSN—then presupposes advanced preparation in a specialty area at the master's level. At the doctoral level, the emphasis is on in-depth study of some specific problems within the specialty area for the purpose of expanding the field's knowledge base.
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--> TABLE 2 Graduations from Nursing Programs, 1991–1992 Number of Programs Graduations Degree Associate 848 52,896 Baccalaureate 501 21,415 Master's 243 7,345 Doctorate 54 391 SOURCE: NLN (1994). The purpose of postdoctoral training is to enable new doctorally prepared nurses to set in motion a program of research. (See Figure 1 for an overview of nursing education pathways.) Existing programs have encouraged entry into the profession at various points, transitions from one academic level to the next, acceleration when career goals are clear, the acquisition of dual degrees as appropriate, and considerable experimentation. Professional nursing can be both criticized for its seemingly uncontrolled diversity and lauded for its innovative career ladder. Traditionally, such diversity has been regarded as antithetical to being a profession, since one of the characteristics of a profession was thought to be one entry point. There is a growing opinion, however, that such diversity can be an asset if the practice at each level is differentiated in terms of education, experience, and demonstrated competence (Pew Health Professions Commission, 1991; Conway-Welch, 1994). That is a very big IF. Historically, many employers have not encouraged differentiated practice according to type of education, ostensibly because both ADN and BSN graduates, as well as generic master's and doctoral students, sit for the same licensure exam to become an RN. What is more, ADN graduates tend to score somewhat higher on the examination largely for two reasons: basic knowledge is being tested, and that is the strength of the ADN program; and the BSN graduate, who has a longer program of study, is disadvantaged by taking the examination longer after having learned the material. The lack of differentiation in the examination has emboldened employers to compress salaries accordingly. Economic returns for BSN education "are modest at best, and well below the national averages for other professions" (Lowry, 1992, p. 52). Efforts are under way by the National Council of State Boards of Nursing to create a second level of licensure that would evaluate the complex decision making, community health, and management skills of BSN graduates, but widespread implementation has not yet occurred. Nurses themselves have contributed to the lack of differentiated practice. Faculty in the ADN and BSN programs do not always have different expectations
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--> Licensed practical nurse (LPN) to associate degree nurse (ADN) LPN to baccalaureate in nursing (BSN) LPN to master's of science in nursing (MSN) Diploma ADN Generic baccalaureate (BSN) Registered nurse (RN) to BSN Accelerated RN to BSN Accelerated BSN for nonnursing college graduates RN to BSN (external degree baccalaureate) MSN Accelerated BSN to MSN RN to MSN MSN for nonnursing college graduates Accelerated MSN for nonnursing college graduates MSN for nurses with nonnursing college degrees MSN/master's in business administration MSN/master's of public health MSN/master's of hospital administration MSN/master's of public administration Generic nursing doctorate (ND) Doctorate (DNS, DNSc, DSN/PhD) Postdoctorate FIGURE 1 Nursing education pathways. Program Definitions For Figure 1 Licensed practical nurse (LPN) to associate degree nurse (ADN); LPN to baccalaureate in nursing (BSN); LPN to master's of science in nursing (MSN)—Programs that admit licensed practical nurses and award an associate, baccalaureate, or master's degree in nursing. Generic baccalaureate (BSN)—A program of instruction that admits students with no previous nursing education and requires at least four but not more than five academic years of full-time-equivalent college academic work, the completion of which results in a bachelor of science in nursing. Registered nurse (RN) to BSN—A program that admits registered nurses with associate degrees or diplomas in nursing and awards a baccalaureate degree in nursing. "Accelerated" option or pathway—Programs that accomplish the programmatic objectives in a shorter time frame than the traditional program, usually through a combination of "bridge" or transition courses and core courses.
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--> BSN for nonnursing college graduates—A program that admits students with baccalaureate degrees and with no previous nursing education and, at completion, awards a baccalaureate degree in nursing. RN to BSN (external degree baccalaureate)—A degree awarded by transcript evaluation, academically acceptable cognitive and performance examinations, or both, without residency and classroom attendance requirements. Master of Science in Nursing (MSN)—A program of instruction that admits students with baccalaureate degrees in nursing and, at completion, awards a master of science in nursing. RN to MSN—A program that admits registered nurses without a baccalaureate degree in nursing and awards a master's degree in nursing. MSN for nonnursing college graduates—A program that admits students with baccalaureate degrees and with no previous nursing education and, at completion, awards a master's degree in nursing. MSN for nurses with nonnursing college degrees—A program that admits registered nurses with nonnursing baccalaureate degrees and, at completion, awards a master's degree in nursing. MSN/master's in business administration; MSN/master's of public health; MSN/master's of hospital administration; MSN/master's of public administration— Dual degree programs that admit registered nurses with a baccalaureate degree in nursing and award a master's degree in nursing in combination with a master's degree in business administration, public health, hospital administration, or public administration. Generic Nursing Doctorate (ND)—A generic doctoral program with a clinical focus primarily designed for baccalaureate-prepared college graduates with no nursing experience. Doctorate—A program of instruction requiring at least three academic years of full-time-equivalent academic work beyond the baccalaureate in nursing, the completion of which results in a doctoral degree that is either a doctorate of nursing science (DNS, DNSc, or DSN) or the doctor of philosophy degree (PhD). Postdoctorate—A program environment for multidisciplinary research training involving more than one unit of a university and a recruitment plan that will attract the most highly qualified candidates (individuals must have received a doctoral degree) from throughout the nation. In such a program environment the nursing unit has the ability to demonstrate that graduates of the program remain active in research. NOTE: These program definitions are based on the typology used by the American Association of Colleges of Nursing in their annual institutional data survey.
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--> regarding the competencies to be developed (Conway, 1983). Graduates of ADN programs, who are on average more mature and experienced at graduation (the mean age was 35.7 years in 1992), have resisted the notion that they were less professional than their younger BSN colleagues (29.2 years old on average). This tension between undergraduate programs is further exacerbated by all of the tensions between community colleges and universities. To the extent that different kinds of RNs are educated in different educational systems, there is little opportunity for learning how to work together. Matters have been further complicated by the fact that ADN graduates are regarded by the public at large, and especially by many a state legislature, as the success story of community colleges because of their speedy access to a relatively well-paid field. Graduates of BSN programs, in contrast, are regarded as requiring an expensive undergraduate education by universities, which tend to equate professional education with graduate education. Legislators would resist efforts to limit the production of ADN graduates, while some universities may countenance the elimination of BSN programs (as has happened, for example, in the University of California system). The more that RN production is relegated to ADN programs, the more nursing is seen solely in vocational terms by the public, including career counselors, rather than as a career choice for the best and brightest. Nursing is so equated in the public mind with doing procedures and giving medications that nurses who manage complex systems and conduct research are viewed by many as not being ''real" nurses. What has frequently been confused in ADN versus BSN discussions is the question of whether one is working at the bottom or the top of one's scope of practice. While the ADN and the BSN recipient may look relatively comparable technically and interpersonally at graduation, their progress from novice to competent practitioner, and on to expert, will not be comparable (Conway, 1983). The liberal education that is considered foundational to the development of critical thinking, decision making, and independent judgment in the BSN graduate is likely to facilitate the acquisition of the imaginal and systems skills required of advanced practice (Koerner, 1993). Considerable efforts are under way to articulate a model for differentiated nursing practice; Table 3 provides a schematic synthesis of current thinking based on the recent AACN-AONE Task Force on Differentiated Nursing Practice (1995) and the work of Davis and Burnard (1992) as well as that of Koerner (1992). It should be noted that a characteristic of recent consensus development in this area has been giving up the technical versus professional distinctions of previous ADN-BSN debates, because of the pejorative implications in characterizing ADN graduates as not professional, in favor of distinguishing between practice in structured and unstructured environments. Celebrating 40 years of ADN education, Simmons (1993) noted that that degree is no longer considered to be "terminal" in nature, but a pathway for career and educational mobility. Nursing education must move to an interconnected system of distinct educational levels with differentiated outcomes (Fagin
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--> TABLE 3 Toward Differentiated Practice Associate Degree Bachelor's Degree Master's Degree Doctoral Degree Characteristic(s) of knowledge Broad Broad and deep, with integration across subjects Specific and deep Very specific; expected to extend or generate new knowledge Relationship between teacher and student Contact high; courses structured Contact high; courses structured with opportunities for independent study Partnership, but within relatively structured curriculum Emphasis on expert guided study Practice Provides care in structured settings where policies and procedures are established Provides and coordinates care, health promotion, and illness prevention in structured and unstructured environments Applies specialized knowledge and skills within a broad range of practice settings; develops policies and procedures for routine care; solves complex care problems Extends the knowledge base for policy-making and resolving care problems
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--> and Lynaugh, 1992; Hanner et al., 1993), but do so with pride in the articulations across pathways that are already in place and that build on experience and demonstrated competence (Shalala, 1992). The need to address these issues is crucial, because too many ADN graduates and too few BSN and higher degree nurses are being produced relative to future needs (Aiken and Salmon, 1994). As health care delivery systems become increasingly primary care oriented and boundary spanning, the roles in which nurses will be needed will require more professional judgment and clinical autonomy (Clifford, 1990). Expectations regarding educational level and competencies for advanced practice nursing roles are also in need of some clarification. The American Association of Colleges of Nursing (1994) has taken the position that all advanced practice nurses (APN) should hold a graduate degree in nursing and be certified, and that the American Board of Nursing Specialties should serve as the umbrella board to assist member-certifying bodies adopt professional and educational standards for the evaluation and certification of APNs. The effectiveness of this level of nurse has been documented (Office of Technology Assessment, 1986; Safriet, 1992); APNs provide needed services with consumer satisfaction, demonstrable effectiveness, and significant cost savings (Brooten et al., 1986; Pew Health Professions Commission, 1994a,b). The term APN is used, however, to refer to a number of roles—clinical nurse specialists, nurse practitioners, certified nurse midwives, and nurse anesthetists. Nurse practitioners have a history of providing primary health care services, while clinical nurse specialists have traditionally worked with less educated nurses to solve complex care problems, although psychiatric clinical nurse specialists and those majoring in community health or gerontology have also provided considerable first contact care. There is substantial debate as to whether the clinical nurse specialist role, with its systems orientation, should merge with the nurse practitioner role, with its emphasis on delivering primary care, so that the public will be less confused by different titles (Fenton and Brykczynski, 1993; Page and Arena, 1994). At the doctoral level, the debate centers on whether the research focus of PhD programs should supplant the clinical focus of professional-degree programs (e.g., a doctorate of nursing science (DNS) program) (Flaherty, 1989; Martin, 1989). Most of the original DNS programs were as research minded as any PhD program; the decision to establish a DNS program rather than a PhD program was often a political decision rather than an academic decision (Downs, 1989). Professional-degree programs were more numerous when graduate schools were not very welcoming and took the attitude that a doctorally prepared nurse was an oxymoron. As the quality of nursing research became established, so, too, did PhD programs in nursing. There is, however, some renewed interest in professional-degree programs as a means of preparing clinical leaders capable of the evaluation research that is needed for a quickly changing health care delivery system (Starck et al., 1993). All of the emphasis within nursing education on the spectrum of academic
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--> degrees has had the unintended consequence that continuing education (CE) has received comparatively short shrift. Many states do not have mandatory CE requirements for maintaining RN licensure. This state of affairs is particularly problematic because of the knowledge explosion and the many forces dramatically reshaping health care delivery. As with other professions, learning in nursing must be a lifelong enterprise that cannot stop with the awarding of a degree (IOM, 1995). Forces Shaping Health Care Delivery Health care delivery is changing dramatically, with the drive toward cost effectiveness leading to: shorter hospital stays; the downsizing of acute care hospitals and corresponding increase in acuity levels within those institutions; more judicious use of high-priced technology; the advance of capitated payment and growth of health maintenance organizations (HMO); expansion of home health care and corresponding increase in acuity levels within the community; encouragement of health promotion and informed consumers; downward substitution of personnel (from LPN to aide, from RN to LPN, from physician to APN); and less emphasis on specialization but more on primary care delivery and cross training. These trends and their work force implications have been chronicled in a number of publications and reports (Pew Health Professions Commission, 1991, 1993; de Tornyay, 1992; Bureau of Health Professions, 1993; AAMC, 1994; Fineberg et al., 1994; Iliffe and Zwi, 1994; IOM, 1994; Larson et al., 1994). Professional nursing is, therefore, experiencing paradigm shifts. (See Table 4 for an overview of some major changes as care moves away from traditional conceptualizations to expanded ones.) Most nurses are still hospital based, but a shift is taking place away from nursing at the bedside to nursing at the patient's side wherever (s)he may be. In the future, nurses must be able to span boundaries in providing continuity of care, particularly as case managers. Heretofore nursing, like medicine, has been organized to manage diseases and illness episodes, but henceforth emphasis will be placed on disease prevention and health promotion as cost containment measures. This means a renewed interest in compressing morbidity and facilitating quality of life, as opposed to focusing largely on limiting mortality. Instead of the military metaphor of health, with its view of the patient's body as a battlefield and the physician as captain of the ship, the ecologic metaphor offers the promise of "halfway technology," more concern about wastefulness, and a community orientation (Annas, 1995). It should be noted, however, that the market metaphor with its language of "covered lives," market share, vertical integration, and customer satisfaction may be an intermediary step in reframing the debate. Traditionally, nurses have been expected to meet as many of a patient's needs as possible. Those unbounded expectations are being superseded by the
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--> practice between the RN and the LPN or unlicensed aide; the American Association of Critical Care Nurses (1990) has recommended five criteria to facilitate these distinctions. Levels of nursing must be particularly differentiated with regard to the needs of an aging society because society still has the mistaken notion that the least well prepared are best suited to provide gerontological care when the converse is true (Aiken, 1990; McBride and Burgener, 1994). State strategies for health care work force reform must be encouraged (Pew Health Professions Commission, 1994c), particularly the establishment of a methodology for modeling work force needs by competency sets across the educational continuum. Creating a More Educated RN Work Force The aggregate supply of nurses is impressive, but there are too many ADN graduates and too few baccalaureate and higher degree nurses (Moccia, 1990; Aiken and Salmon, 1994). The Pew Health Professions Commission (1994a) has estimated, for example, that the number of graduates from nurse practitioner programs needs to double by the year 2000. Something must be done to provide incentives to community colleges to limit their number of graduates. Depictions of nursing must portray the career opportunities that are only available to baccalaureate and higher degree nurses, so the public is less likely to think that ''a nurse is a nurse is a nurse." Recruitment efforts must communicate in a visionary way the extent to which the professional nurse of the future is not like the traditional nurse of the past, so applicants can make informed career choices. New kinds of articulation agreements (e.g., RN-BSN, RN-MSN) between community colleges and universities must be forged to facilitate mobility across programs and educational systems. This is of pressing concern because articulation strategies exist (Mathews and Travis, 1994), but the percentage of RN-BSN graduates has remained flat over the last decade (about 10 percent) despite the large number of ADN graduates and the many mobility programs (Salmon, 1995). Federal policies that deliberately encourage diploma nursing and ADN education are outmoded and must be reformulated to encourage baccalaureate and higher degree nurses who are in limited supply. For example, Medicare currently supports diploma nursing education, which is hospital owned; the Department of Education supports only ADN programs through the Perkins Act; and graduate education in nursing has none of the supports that are available to medicine through graduate medical education (GME) funds. Reconfiguring RN Work Force Demographics The nursing work force is aging more rapidly than the overall population. More traditional college-aged students must be recruited to the field since the proportion of RNs under age 30 declined from 25 to 11 percent between 1980 and
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--> 1992; "by 2000, two thirds of all RNs are expected to be over age 40" (Aiken et al., 1995, p. 4). If the average ADN graduate is over 35 and the overwhelming majority of new RNs are ADN graduates, then the aging of the RN work force is easy to understand. The BSN is the most cost-effective route for the individual to the RN (Lowry, 1992), and the one with the highest percentage of minority graduates (Aiken and Salmon, 1994). It is also the program most likely to supply applicants to APN and doctoral programs. Expectations must change to encourage RNs to obtain graduate education and research training at an earlier age, so that the expertise obtained can be utilized over a longer period of time. This approach is not intended to deny opportunities because of age, but to limit practices that discourage and disadvantage younger students. It is also vitally important that recruitment and retention policies encourage underrepresented populations to enter the profession. About 23 percent of the U.S. population consists of racial and ethnic minorities, but only 9 percent of nurses are from these groups. What is more, these groups are further underrepresented in APN, doctoral and postdoctoral programs, and in management roles. The accelerated growth of specific populations, for example Hispanics, has consequences for the language skills to be expected of nurses. The diversification of the citizenry in general also requires all health care professionals to be able to deliver culturally competent care (Andrews, 1992). Only 4 percent of all nurses are male, although they are better educated than their female counterparts and more prominent among nurse managers (Salmon, 1995). Supporting Creative Pedagogy and Community-Centered Care Nursing education must test the validity of its most cherished practices, such as reliance on person-to-person transmission of information or the practice of keeping education separate from the "business" side of health care (Hegyvary, 1991, 1992). Creative pedagogy must become the order of the day, particularly with respect to clinical teaching in community settings (Aiken, 1990; Alexander, 1991; Barger and Kline, 1993; Benner, 1993; Baird et al., 1994; de Tornyay, 1994; Knuteson and Wielichowski, 1994). The majority of existing faculty are not prepared to advance models that collapse boundaries between education and practice (Andreoli and Musser, 1986; Chickadonz, 1987). Developmental supports must be provided for faculty renewal and experimentation in light of the needs created by quickly changing practice conditions, including the need for nurses to be preventionists and not just interventionists; the need to bridge experiences to help new graduates handle the escalating acuity level of hospitals; and the use of nurses as house staff (Mallison, 1993); the reorganization of master's education programs to emphasize core competencies across specialty areas; the role of nursing in health maintenance organizations and reconfigured academic health centers (Moore et al., 1994; Valberg et al., 1994); and the development of
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--> greater competencies in community assessment and in teaching clinical skills to family members. Encouraging Interdisciplinary Collaboration With the blurring of disciplinary lines, the education and practice of health care professionals must become more interdisciplinary. This will necessitate the development of new models of collaboration that are not rigidly hierarchical, but that provide for differentiated practice by education, experience, and demonstrated competence (Fagin, 1992; Pike et al., 1993). Studies of such collaboration have demonstrated improvements in care (Knaus et al., 1986; Garcia et al., 1993). Perhaps no phrase is more bandied about, despite any agreement about its meaning, than "interdisciplinary collaboration." Indeed, some physicians think it refers to cooperation across medical specialties (e.g., pediatricians and psychiatrists working respectfully together) rather than to practice involving different kinds of providers working collegially together (e.g., a mental health strategy involving psychiatrists, psychologists, psychiatric nurses, and psychiatric social workers). Supporting Informatics and Health Systems Delivery Research Computers and telecommunications are likely to become more important in the education and practice of RNs as nurses organize patients into electronic self-help groups and customize health promotion (Rheingold, 1993). Technology will be increasingly regarded as an aid to clinical decision making, particularly in ensuring that guidelines and standards are implemented appropriately (Donaldson and Sox, 1992). Electronic links offer the promise of consultation across vast distances, easy access to the latest information, and the possibility of lifelong learning opportunities across state lines. For this promise to be realized, informatics must be mainstreamed into the curriculum. Nurses must become adept at evaluation research and develop the corresponding technologic and data management skills to achieve that objective (Fagin and Jacobsen, 1985). The large data bases that will be developed to monitor quality and cost effectiveness must include variables of concern to nursing, and nurses must be prepared to make use of these data sets in shaping their practice and policies (NLN, 1993). There is no obvious home for such research, however, since the Agency for Health Care Policy Research is biased toward medical outcomes and work force issues and NINR is geared toward clinical interventions and biomedical research rather than health systems delivery research. Efficacy (what works under relatively ideal conditions) and effectiveness (what works under ordinary conditions) must be monitored not only in terms of patient outcomes, but in terms of what happens to vulnerable populations as a group. There is an important role for the nurse researcher to play in clinical and community
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--> settings (Chaska, 1992; Kirchhoff, 1993), and both doctoral and postdoctoral research training should develop those competencies. Removing Practice Barriers An extremely broad scope of practice is accorded physicians in some states, which makes it possible for the medical profession to occupy the entire health care field (Safriet, 1992). Barriers to practice (e.g., lack of prescriptive authority) and to reimbursement of APNs must be systematically removed. "In view of the serious access problems among poor and minority Medicare beneficiaries in urban areas, the continued systematic exclusion of nurse practitioners from Medicare is striking" (Aiken and Salmon, 1994, p. 323). Medicaid and Medicare laws should be revised to cover those services provided by APNs within their scope of practice. Renewing Displaced Nurses Programs must be provided to renew displaced nurses. Such programs will, for example, develop severance packages that support additional education, enable nurses who have previously been hospital-based to learn how to work effectively in community settings, and help MSN graduates who are not certified as nurse practitioners to move quickly in that direction. Mandatory CE should be required and supported in all states, given the knowledge explosion and the quickening pace of changes in practice. Related to this is the obligation of universities and professional associations to provide CE programs on career assessment and the transformational leadership skills necessary in times of rapid change (Wolf et al., 1994a,b; Feldman, 1995). Relationships between employee and employer are much more explicit with regard to task outcomes and development expectations than they once were (Noer, 1993), and it is incumbent on nursing education both to prepare a work force capable of revitalizing itself in a time of fundamental organizational change and to act accordingly as it, too, becomes reconfigured. Addressing Fundamentals In an article humorously entitled "Nursing Studies Laid End to End Form a Circle," Friss (1994) acknowledged that nurses have been one of the most studied groups in history, but that fundamental problems remain: no single route to entry into professional practice; lack of differentiated practice and corresponding salary compression; an impressive aggregate supply of nurses but the wrong educational mix; a scope of practice too often shaped by what others permit nurses to do rather than by what they can do; and periodic nurse shortages that lead to the attraction of casual workers rather than to a stable dedicated core. Her conclusion
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--> is that nursing alone cannot address these fundamental issues, but must press physicians and administrators to change those practices of theirs that promote inefficient and ineffective use of nurses. It should be noted that the time is ripe for such fundamental change because nursing's work force has itself undergone a major shift in the last quarter century—away from a situation in which the personal flexibility of nursing was valued as the overarching consideration, to one of being largely peopled by individuals with a full-time work commitment. Workers with a career orientation are more likely to be prepared to change the conditions of practice. Now that the health care delivery system is downsizing acute care hospitals in favor of community-centered care, the need for nursing in unstructured environments will become more visible and with it the need for a more educated nursing work force. (Recall Nurse Goodnow's words at the beginning of this paper that public health nursing requires more educated nurses.) Drucker (1994) identifies the fastest growing work force group as being knowledge workers who take responsibility for making themselves understood by people who do not have the desired knowledge base. That actually is a very accurate depiction of nursing—using knowledge to help people do for themselves what they would do unaided if they knew what to do. Alas, the popular conception of nursing still emphasizes carrying out discrete tasks more than the weaving together of various knowledge bases into a coherent plan of care. But such situation-specific integration of diverse knowledge from the behavioral and biological sciences is the promise of professional nursing in the twenty-first century. Author's Note The author wishes to acknowledge the many nurses who were asked to review an outline of this paper and who made very helpful suggestions: Dyanne Affonso Penny Cass Carole Anderson Bianca Chambers Margaret Applegate Luther Chrisman Joan Austin Dawn Daniels Geraldine "Polly" Bednash Donna Diers Ginna Betts Jerry Durham Marge Beyers Geraldene Felton Diane Billings Linda Finke Donna Boland Joyce Fitzpatrick Rachel Booth Juanita Fleming Faye Bower Janet Gerkensmeyer Judy Campbell Nancy Dickenson Hazard Sara Campbell Jan Heinrich Janie Canty Thomas Hicks
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Representative terms from entire chapter: