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Nursing Staff in Hospitals and Nursing Homes: Is It Adequate? (1996)

Chapter: Professional Nursing Education - Today and Tomorrow

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Suggested Citation:"Professional Nursing Education - Today and Tomorrow." Institute of Medicine. 1996. Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?. Washington, DC: The National Academies Press. doi: 10.17226/5151.
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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.

Suggested Citation:"Professional Nursing Education - Today and Tomorrow." Institute of Medicine. 1996. Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?. Washington, DC: The National Academies Press. doi: 10.17226/5151.
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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

Suggested Citation:"Professional Nursing Education - Today and Tomorrow." Institute of Medicine. 1996. Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?. Washington, DC: The National Academies Press. doi: 10.17226/5151.
×

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

Suggested Citation:"Professional Nursing Education - Today and Tomorrow." Institute of Medicine. 1996. Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?. Washington, DC: The National Academies Press. doi: 10.17226/5151.
×

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.

Suggested Citation:"Professional Nursing Education - Today and Tomorrow." Institute of Medicine. 1996. Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?. Washington, DC: The National Academies Press. doi: 10.17226/5151.
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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

Suggested Citation:"Professional Nursing Education - Today and Tomorrow." Institute of Medicine. 1996. Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?. Washington, DC: The National Academies Press. doi: 10.17226/5151.
×

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.

Suggested Citation:"Professional Nursing Education - Today and Tomorrow." Institute of Medicine. 1996. Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?. Washington, DC: The National Academies Press. doi: 10.17226/5151.
×

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.

Suggested Citation:"Professional Nursing Education - Today and Tomorrow." Institute of Medicine. 1996. Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?. Washington, DC: The National Academies Press. doi: 10.17226/5151.
×

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

Suggested Citation:"Professional Nursing Education - Today and Tomorrow." Institute of Medicine. 1996. Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?. Washington, DC: The National Academies Press. doi: 10.17226/5151.
×

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

Suggested Citation:"Professional Nursing Education - Today and Tomorrow." Institute of Medicine. 1996. Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?. Washington, DC: The National Academies Press. doi: 10.17226/5151.
×

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

Suggested Citation:"Professional Nursing Education - Today and Tomorrow." Institute of Medicine. 1996. Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?. Washington, DC: The National Academies Press. doi: 10.17226/5151.
×

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

Suggested Citation:"Professional Nursing Education - Today and Tomorrow." Institute of Medicine. 1996. Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?. Washington, DC: The National Academies Press. doi: 10.17226/5151.
×

TABLE 4 Some of the Paradigm Shifts that Professional Nurses Are Experiencing

Traditional

Expanded

Nursing at bedside (hospital)

Nursing at patient's side (spanning boundaries)

Disease management

Disease prevention and health promotion

Limit mortality

Limit mortality, compress morbidity, and facilitate quality of life

Organized by illness episodes

Organized to provide continuity of care

Shaped by the military metaphor

Shaped by the ecologic metaphor

Unbounded expectations for meeting a patient's needs

Expectations bound by resources, hierarchy of needs

Nursing seen as providing care

Nursing seen as providing care, directing care provided by others, developing population-based programs, and managing systems

All-RN staff models of care

Partner models of care with RN mix

Process oriented

Outcomes oriented

Oblivious to costs

Mindful of costs

Nurses support the primary care provider (dependent)

Nurses provide primary care (independent/interdependent)

Nurses have responsibility

Nurses have responsibility and corresponding authority

Discipline-specific education and practice

Interdisciplinary education and practice

Diversity seen as antithetical to being professional

Differentiated practice emphasized

Job security

Career development

notion that needs should be triaged in terms of available resources, and that there should be fewer nursing imperatives—e.g., everyone should be bathed every day. Nursing has been equated with providing care, but care as a one-to-one relationship will not be as large a component of professional nursing in the future because the RN is increasingly expected to direct the care provided by others (Hines et al., 1994), develop programs for vulnerable populations, and manage complicated, boundary-spanning systems. These changes are prompted, in part, because all-RN staff models of care are giving way to so-called partner models of care, with the RN skill mix dropping from 76 to 100 percent to 52 to 79 percent in some settings (Smeltzer et al., 1993). The in-process component of nursing will be less emphasized than what is actually achieved by way of outcomes, particularly cost-effective outcomes. Where the nurse has traditionally supported the physician as the primary care provider, there will be increasing emphasis on the nurse, particularly the APN, as a primary care provider, which means that responsibility must be balanced with corresponding authority (e.g., prescriptive authority).

Up until now, the emphasis has been on discipline-specific education and practice, but this is shifting to become more interdisciplinary as cost-effective

Suggested Citation:"Professional Nursing Education - Today and Tomorrow." Institute of Medicine. 1996. Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?. Washington, DC: The National Academies Press. doi: 10.17226/5151.
×

care requires all health care providers to avoid duplication of efforts and make full use of the best, least expensive care giver according to need. Such differentiated practice will replace the notion that the physician is the health care provider of choice for all situations. Collectively, these shifts make it impossible to promise job security to any nurse, because of the extent to which institutions and systems are being reconfigured. In place of job security, nurses need to take comfort from the career opportunities that will continue to hold for individuals who are skilled, as they are, in health promotion, boundary spanning, and clinical decision making.

Nurses will continue to be in demand with the graying of America and the move toward community-centered practice, with its emphasis on a broad range of practice sites—schools, day care and senior centers, outpatient clinics, shelters, workplaces, homes, shopping malls, and church basements. Computer literacy will become more important as technologies are developed to connect care givers in remote sites to information and assessment systems. The outcomes orientation of health care will also increase the demand for competencies like those of nurses who collect and analyze data to evaluate their own effectiveness and that of their institutions (Oermann, 1994b). A return to community-centered care also requires that health care professionals "look like" the communities served; this means taking steps to recruit minority faculty and students in numbers proportionate to their representation in the area (Morris and Wykle, 1994), and to expand the number of men in the profession.

A Time Of Redirection On Campus

Higher education is changing almost as fundamentally as health care delivery systems and in the same general direction toward greater accountability at a time of restricted taxpayer support. In the name of cost effectiveness, there have been a number of changes: the adoption of responsibility-centered budgeting; increased emphasis on teaching and credit hour production; increased use of part-time faculty with corresponding decreases in full-time and tenure track faculty; examination of faculty entitlements and productivity; increases in class size and setting minimum expectations for class size; some experimentation with capitated payment; examination of administrative bloat; and stemming the proliferation of programs through greater clarity about mission. These shifts have been chronicled in a number of publications (Lynton and Elman, 1987; Shulman, 1987; Rice, 1991; El-Khawas, 1994; Brand, 1995; Magrath, 1995).

The traditional university activities of teaching, research, and service are being rethought. (See Table 5 for an overview of some major changes as these activities are reconceptualized.) The emphasis has shifted away from teaching to learning, with a concomitant new regard for the teacher as "guide by side" rather than "sage on stage." Instead of stressing the accumulation of facts, the thrust is on the application of knowledge to real problems, many of which may demand an

Suggested Citation:"Professional Nursing Education - Today and Tomorrow." Institute of Medicine. 1996. Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?. Washington, DC: The National Academies Press. doi: 10.17226/5151.
×

TABLE 5 Some of the Paradigm Shifts That Academia Is Experiencing

 

Traditional

Expanded

Teaching

• Emphasis on teaching;
• "Sage on stage";
• Obtain and retain facts;
• Obtain degree;
• Process oriented;
• Discipline based;
• Place bound

• Emphasis on learning;
• "Guide by side";
• Apply knowledge to real problems;
• Develop portfolio of competencies;
• Outcomes oriented;
• Interdisciplinary;
• "Virtual university"

Research

• Scholarship narrowly defined; &
bull; Congruent with personal interests;
• Emphasis on refereed publications;
• Supported largely by federal government

• Scholarship broadly defined;
• Congruent with institutional mission;
• Emphasis on dissemination to professionals and public alike;
• Supported increasingly by private sector

Service

• Undervalued and discouraged;
• Confused with volunteer community activities;
• Seen as quasi-charity;
• Emphasis on university and disciplinary service

• Valued and encouraged;
• Based on professional expertise;
• Seen as a profit center for university;
• Emphasis on public service

interdisciplinary perspective. This moves the educational goal away from degree acquisition toward the development of a portfolio of competencies that can be described to prospective employers. Outcomes have replaced the curriculum as the preoccupation of pedagogical attention. Furthermore, all of these activities are less and less place bound as the advent of new technologies and distance learning techniques make the "virtual university" possible.

Thanks to Boyer's landmark work (1990), scholarship is no longer narrowly defined to include only the scholarship of discovery (i.e., traditional basic research), but also includes the scholarship of integration, utilization, and teaching or pedagogy. Where once the emphasis was solely on the investigator's interests, the expectation increasingly is that faculty research should be congruent with the campus mission. The product of that research should not only be scholarly publications but also contributions to the public good, which means that the private sector may be more interested in supporting some efforts with entrepreneurial possibilities.

Where service was once undervalued and discouraged, the opposite is increasingly the case. Indeed, there has been renewed interest in the concept of service learning. When the emphasis is on applying professional expertise for the public's well-being, these activities can even be conceptualized as a possible profit center for the university. Most professional schools are beginning to ex-

Suggested Citation:"Professional Nursing Education - Today and Tomorrow." Institute of Medicine. 1996. Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?. Washington, DC: The National Academies Press. doi: 10.17226/5151.
×

plore practice plans, contracts with local agencies, and continuing education for professionals and the public alike as possible new revenue streams.

Like the health care delivery system, higher education is increasingly sensitive to community need, focused on performance-based outcome measures, and concerned about differentiated faculty roles with a concomitant reliance on some mix in expertise. Data management systems assume a new importance in an environment concerned about policy-making to achieve efficiency and effectiveness. New initiatives are increasingly being funded by redirecting existing resources rather than acquiring new ones from traditional public sources. The lifting of mandatory retirement requirements has created an additional concern about whether the faculty in place have the skills and knowledge base needed for the future.

Health Care And Academia: Nursing's Advantages And Disadvantages

With the two social institutions of health care delivery and higher education undergoing such fundamental change, nursing will have distinct advantages and disadvantages. In the reconfigured health care delivery system, nursing has much to offer: a comfortableness about operating within systems; conceptual models capable of analyzing the person-environment fit; a family-centered care focus; a history of interdisciplinary collaboration; community assessment skills; experience with health promotion and consumer education; the ability to span boundaries; a nonreductionist philosophy of care; relationship-centered care (Tresolini and the Pew-Fetzer Task Force, 1994); established links with community agencies and long-term care facilities; long-standing encouragement of functional ability and quality of life; expertise in behavioral outcomes research; and several hundred community-based nursing centers attached to schools of nursing. In a reconfigured health care delivery system, a major advantage is that the cost of educating an APN may be as little as one-third of the cost of physician training, and that nurse practitioner can provide about 80 percent of primary care services at an equivalent level of positive outcomes and patient satisfaction (Pew Health Professions Commission, 1994a,b).

Nursing also is disadvantaged in the reconfigured health care delivery system. The downsizing of hospitals is displacing RNs more than any other worker, and those in place may be more prone to burnout because of increased workload (McClure, 1991; Gordon, 1995). Many of the changes that are taking place are not based on tried-and-true principles, but on a frustration with current realities. The downsizing of nursing within hospitals is also taking place at the same time that nurses are being expected to supervise the work of more unlicensed assistive personnel, which is itself a time-consuming task (ANA, 1992). Joel (1994) has noted that coordination of care is further complicated when these assistive per-

Suggested Citation:"Professional Nursing Education - Today and Tomorrow." Institute of Medicine. 1996. Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?. Washington, DC: The National Academies Press. doi: 10.17226/5151.
×

sonnel are assigned directly to patients as if they operated on their own authority, rather than being assigned to nurses for delegation purposes.

High-level strategic planning for fundamental institutional change frequently does not include RNs, yet they are regularly expected to work out the operational details of restructuring, mergers, and consolidations. There is a move in many hospitals to incorporate nursing with other patient care services under a single vice president for patient care services. This has diminished the importance of the nursing director in the senior hierarchy, who was previously comparable to the medical director. Although nurses are best suited to take these new positions, the emphasis has shifted in many institutions away from the patient-care focus of nursing to "patient-focused care" which is sometimes used as a rallying cry for providing services at the lowest cost. These trends are disturbing because lower mortality has been associated with a higher ratio of RNs to patients (Hartz et al., 1989; Prescott, 1993) and with nurses having control over their practice (Aiken et al., 1994).

Advanced practice nurses are typically hired by physicians or administrators to staff a particular service and have no formal ties to nursing service delivery in other parts of the institution, so their connection to their profession can easily weaken over time, particularly if they are utilized only as physician substitutes rather than for their nursing expertise. The danger is that the growing use of APNs may replicate what happened to psychiatric clinical nurse specialists in the 1960s with the development of community mental health centers, when they were used as interchangeable members of the mental health team and consequently forsook nursing's traditional focus on maximizing functional ability in favor of "doing therapy" in 50-minute hours. As managed care systems grow in size across state boundaries, they have begun to push for institutional licensure to promote uniform practice, but such a move could further remove individuals from control over their profession's practice. Considerable legal and institutional barriers do exist to prevent reimbursement for nurse-provided primary care, for example, Medicare policies (Inglis and Kjervik, 1993).

Nursing may be in a more advantageous position in the universities of tomorrow for a number of reasons. The emphasis on service learning has made the activities of nursing students and faculty much more valued, particularly in those instances in which course requirements or contracted faculty time have benefited participating clinical or community agencies. The areas of scholarship that are being regarded with renewed appreciation—the scholarship of integration, utilization, and teaching—have been areas where nursing faculty have traditionally excelled. Nursing's accrediting body, the National League for Nursing, shifted to an outcomes orientation well ahead of other professional associations.

Nursing has a long history of being interdisciplinary; for example, the doctoral preparation of nurses has actively made use of the models of various disciplines such as ethics, education, anthropology, psychology, sociology, public health, and physiology. Nursing has never emphasized just regurgitating facts,

Suggested Citation:"Professional Nursing Education - Today and Tomorrow." Institute of Medicine. 1996. Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?. Washington, DC: The National Academies Press. doi: 10.17226/5151.
×

but weaving those facts into clinical decision making (Tanner, 1987, 1993). Nontraditional educational methods are not new to nursing (Lenburg, 1986). Distance learning has become a staple in many nursing schools with outreach commitments (Billings et al., 1994). The problem-solving orientation, consensus-building techniques, and interpersonal skills of nurses enable them to demonstrate competencies in great demand across settings.

On the other hand, nursing is likely to be disadvantaged in the universities of tomorrow. Because it is a field that has come later to research (i.e., the scholarship of discovery), an infrastructure to support that mission within schools of nursing is not fully in place. The current devaluation of research in support of teaching is likely to have more negative consequences for a field that has long valued teaching but only recently made research a priority, for it will be more difficult to get the resources for research in a climate less supportive of that activity.

Clinical teaching is labor intensive, particularly when students are spread throughout the community rather than concentrated in a single hospital (Rothert et al., 1994), so universities will be increasingly critical of such costs, particularly in the face of dropping enrollments occasioned by a tight job market. This problem is also likely to be an issue in the merger or consolidation of university hospitals with other kinds of hospitals that are less inclined to believe they should subsidize clinical teaching even indirectly. The demand for master's and doctorally prepared faculty is outstripping supply (Mullinix, 1990; Rosenfeld, 1992); indeed, today's "nursing shortage" is at those levels of preparation. What is more, the nature of practice is changing faster than the curriculum of most schools of nursing and the knowledge base of existing nursing faculty (VanOrt et al., 1989; Oermann, 1994a).

Major Challenges Ahead

The major challenges ahead for professional nursing education reflect the key themes of this paper.

Differentiating Practice

Both nurse educators and employers must be encouraged to differentiate nursing practice by education, experience, and demonstrated competence. This movement can be facilitated by deliberately encouraging different levels of nurses to work together as part of their educational preparation, standardizing the second level of licensure for BSN graduates, and requiring advanced practice nurses to have a graduate degree and certification from a professional association approved by the American Board of Nursing Specialties. It should be recognized that one of the difficulties that is likely to complicate differentiated practice between ADN and BSN nurses is the extent to which there also needs to be differentiated

Suggested Citation:"Professional Nursing Education - Today and Tomorrow." Institute of Medicine. 1996. Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?. Washington, DC: The National Academies Press. doi: 10.17226/5151.
×

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

Suggested Citation:"Professional Nursing Education - Today and Tomorrow." Institute of Medicine. 1996. Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?. Washington, DC: The National Academies Press. doi: 10.17226/5151.
×

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

Suggested Citation:"Professional Nursing Education - Today and Tomorrow." Institute of Medicine. 1996. Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?. Washington, DC: The National Academies Press. doi: 10.17226/5151.
×

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

Suggested Citation:"Professional Nursing Education - Today and Tomorrow." Institute of Medicine. 1996. Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?. Washington, DC: The National Academies Press. doi: 10.17226/5151.
×

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

Suggested Citation:"Professional Nursing Education - Today and Tomorrow." Institute of Medicine. 1996. Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?. Washington, DC: The National Academies Press. doi: 10.17226/5151.
×

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

Suggested Citation:"Professional Nursing Education - Today and Tomorrow." Institute of Medicine. 1996. Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?. Washington, DC: The National Academies Press. doi: 10.17226/5151.
×

Bill Holzemer

Jane Norbeck

Gail Ingersoll

Nancy Opie

Norma Lang

Marla Salmon

Carol Lindeman

Catherine Scott

Brenda Lyon

Mary Lou de Leon Siantz

Barbara Manz

Phyllis Stern

Geraldine Marillo

Diana Weaver

Patricia Moccia

Judy Williams

Sue Morrissey

May Wykle

References

AACN (American Association of Colleges of Nursing). Certification and Regulation of Advanced Practice Nurses. Washington, D.C.: AACN, 1994.

AACN-AONE (American Association of Colleges of Nursing and American Organization of Nurse Executives) Task Force on Differentiated Nursing Practice. A Model for Differentiated Nursing Practice. Washington, D.C.: AACN, 1995.

AAMC (Association of American Medical Colleges). Academic Medicine and Health Care Reform. Roles for Medical Education in Health Care Reform. Washington, D.C.: AAMC, 1994.

Aiken, L.H. Educational Innovations in Gerontology: Teaching Nursing Homes and Gerontological Nurse Practitioners. Washington, D.C.: Association for Gerontology in Higher Education, 1990.

Aiken, L.H., and Salmon, M.E. Health Care Workforce Priorities: What Nursing Should Do Now. Inquiry 31:318–329, 1994.

Aiken, L.H., Smith, H.L., and Lake, E.T. Lower Medicare Mortality Among a Set of Hospitals Known for Good Nursing Care. Medical Care 32:771–787, 1994.

Aiken, L.H., Gwyther, M.E., and Friese, C.R. The Registered Nurse Workforce: Infrastructure for Health Care Reform. Statistical Bulletin 76(1):2–9, 1995.

Alexander, B.W. Team Learning. Geriatric Nursing 12:248, 1991.

American Association of Critical Care Nurses. Delegation of Nursing and NonNursing Activities in Critical Care: A Framework for Decision Making. Newport Beach, Calif.: The Association, 1990.

ANA (American Nurses Association). Progress Report on Unlicensed Assistive Personnel: Informational Report. Report no. CNP-CNE-B. Washington, D.C.: ANA, 1992.

Andreoli, K.G., and Musser, L.A. Faculty Productivity. Pp. 177–193 in: H.H. Werley, J.J. Fitzpatrick, and R.L. Taunton, eds. Annual Review of Nursing Research (vol. 4). New York: Springer, 1986.

Andrews, M.M. Cultural Perspectives on Nursing in the 21st Century. Journal of Professional Nursing 8:7–15, 1992.

Annas, G.J. Reframing the Debate on Health Care Reform by Replacing Our Metaphors. New England Journal of Medicine 332:744–747, 1995.


Baird, S.C., Bopp, A., Schofer, K.K.K. et al. An Innovative Model for Clinical Teaching. Nurse Educator 19(3):23–25, 1994.

Barger, S.E., and Kline, P.M. Community Health Service Programs in Academe. Nurse Educator 18(6):22–26, 1993.

Benner, P. Transforming RN Education: Clinical Learning and Clinical Knowledge Development. Pp. 3–14 in: N.L. Diekelmann and M.L. Rather, eds. Transforming RN Education: Dialogue and Debate. New York: National League for Nursing Press, 1993.

Suggested Citation:"Professional Nursing Education - Today and Tomorrow." Institute of Medicine. 1996. Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?. Washington, DC: The National Academies Press. doi: 10.17226/5151.
×

Billings, D., Durham, J., Finke, L., et al. Faculty Perceptions of Teaching on Television: One School's Experience. Journal of Professional Nursing 10:307–312, 1994.

Boyer, E.L. Scholarship Reconsidered: Priorities of the Professoriate. Princeton, N.J.: Carnegie Foundation, 1990.

Brand, M. Higher Education and Obligations to the Future. The IU Newspaper 19(2):9–12, January 1995.

Brooten, D., Jumar, S., Brown, L., et al. A Randomized Clinical Treatment of Early Hospital Discharge and Home Followup of Very Low BirthWeight Infants. New England Journal of Medicine 315:934–939, 1986.

Brown, E.L. Nursing for the Future: A Report Prepared for the National Nursing Council. New York: Russell Sage Foundation, 1948.

Bureau of Health Professions. An Agenda for Health Professions Reform. Washington, D.C.: U.S. Government Printing Office, 1994.

Chaska, N.L. The Staff Nurse Role. Pp. 185–203 in: J.J. Fitzpatrick, R.L. Taunton, and A.K. Jacox, eds. Annual Review of Nursing Research (vol. 10). New York: Springer, 1992.

Chickadonz, G.H. Faculty Practice. Pp. 137–151 in: J.J. Fitzpatrick and R.L. Taunton, eds. Annual Review of Nursing Research (vol. 5). New York: Springer, 1987.

Clifford, J.C. The Future of Nursing Practice. Pp. 617–623 in: N. Chaska , ed. The Nursing Profession—Turning Points. St. Louis, Mo.: Mosby, 1990.

Committee on the Function of Nursing. A Program for the Nursing Profession. New York: Macmillan, 1948.

Committee on the Grading of Nursing Schools. Nurses, Patients, and Pocketbooks. New York: The Committee, 1928.

Committee on the Study of Nursing Education. Nursing and Nursing Education in the United States. New York: MacMillan, 1923.

Conway, M. E. Socialization and Roles in Nursing. Pp. 183–208 in: H.H. Werley and J.J. Fitzpatrick, eds. Annual Review of Nursing Research (vol. 1). New York: Springer, 1983.

Conway-Welch, C. National Initiatives for Change. Pp. 196–201 in: J.C. McClosky and H.K. Grace, eds. Current Issues in Nursing (4th ed.). St. Louis, Mo.: Mosby Year Book, 1994.


Davis, B.D., and Burnard, P. Academic Levels in Nursing. Journal of Advanced Nursing 17:1395–1400, 1992.

DeBack, V. Debate: Diversity in Nursing Education. Does it Help or Hinder the Profession? Pp. 153–157 in: J.C. McCloskey and H.K. Grace, eds. Current Issues in Nursing (4th ed.). St. Louis, Mo.: Mosby Year Book, 1994.

Deloughery, G.L. History and Trends of Professional Nursing. St. Louis, Mo.: C.V. Mosby, 1977.

de Tornyay, R. Reconsidering Nursing Education: The Report of the Pew Health Professions Commission. Journal of Nursing Education 31:296–301, 1992.

de Tornyay, R. Creating the Teachers of Tomorrow's Professionals. Inquiry 31:283–288, 1994.

Dolan, J.A., Fitzpatrick, M.L., and Herrmann, E.K. Nursing in Society. A Historical Perspective (15th ed.). Philadelphia: W. B. Saunders, 1983.

Donaldson, M.O., and Sox, H.C., eds. Setting Priorities for Health Technology Assessment. Washington, D.C.: National Academy Press, 1992.

Downs, F.S. Differences between the Professional Doctorate and The Academic/Research Doctorate. Journal of Professional Nursing 5:261–265, 1989.

Drucker, P.F. Knowledge Work and Knowledge Society. The Social Transformations of This Century. Cambridge, Mass.: John F. Kennedy School of Government, Harvard University, 1994.


El-Khawas, E. Campus Trends 1994. A Time of Redirection. Washington, D.C.: American Council on Education, 1994.


Fagin, C.M. Collaboration between Nurses and Physicians. No Longer A Choice. Nursing and Health Care 13:354–363, 1992.

Fagin, C.M., and Jacobsen, B.S. Cost-Effectiveness Analysis in Nursing Research. Pp. 215–238 in:

Suggested Citation:"Professional Nursing Education - Today and Tomorrow." Institute of Medicine. 1996. Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?. Washington, DC: The National Academies Press. doi: 10.17226/5151.
×

H.H. Werley and J.J. Fitzpatrick, eds. Annual Review of Nursing Research (vol. 3). New York: Springer, 1985.

Fagin, C.M., and Lynaugh, J.E. Reaping the Rewards of Radical Change: A New Agenda for Nursing Education. Nursing Outlook 40:213–220, 1992.

Feldman, H.R. Preparing the Nurse Executive of the Future. Nursing Leadership Forum 1:18–22, 1995.

Fenton, M.V., and Brykczynski, K.A. Qualitative Distinctions and Similarities in the Practice of Clinical Nurse Specialists and Nurse Practitioners. Journal of Professional Nursing 9:313–326, 1993.

Fineberg, H.V., Green, G.M., Ware, J.H., and Anderson, B.L. Changing Public Health Training Needs: Professional Education and the Paradigm of Public Health. Annual Review of Public Health 15:237–257, 1994.

Flaherty, M.J. The Doctor of Nursing Science Degree: Evolutionary and Societal Perspectives. Pp. 17–31 in: S.E. Hart, ed. Doctoral Education in Nursing: History, Process and Outcomes. New York: National League for Nursing, 1989.

Fondiller, S.H. The Entry Dilemma. New York: National League for Nursing, 1983.

Friss, L. Nursing Studies Laid End to End Form a Circle. Journal of Health Politics, Policy and Law 19:597–631, 1994.

Garcia, M.A., Niemeyer, D.B.J., and Robbins, J. Collaborative Practice: A Shared Success. Nursing Management 24(5):72–78, 1993.

Goodnow, M. Outlines of Nursing History (5th ed.). Philadelphia: W.B. Saunders, 1937.

Gordon, S. Cutbacks on Caregivers. Is There a Nurse in the House? The Nation 260(6):199–202, February 13, 1995.

Grace, H. The Development of Doctoral Education in Nursing: An Historical Perspective. Journal of Nursing Education 17(4):17–27, 1978.


Hanner, M.B., Heywood, E.J., and Kaye, M.J. The Curriculum Revolution: Implications for Associate Degree Nursing Education. Pp. 61–68 in: J. Simmons, ed. Prospectives. Celebrating 40 Years of Associate Degree Nursing Education. New York: National League for Nursing Press, 1993.

Hart, S.E., ed. Doctoral Education in Nursing: History, Process and Outcome. New York: National League for Nursing, 1989.

Hartz, A., Krakauer, H., Kuhn, E., et al. Hospital Characteristics and Mortality Rates. New England Journal of Medicine 321:1720–1725, 1989.

Hegyvary, S.T. Education. Calculating the Stakes. Journal of Professional Nursing 7:325, 1991.

Hegyvary, S.T. Education. Nursing Education for Health Care Reform. Journal of Professional Nursing 8:3, 1992.

Hines, P.A.P., Smeltzer, C.H., and Galletti, M. Work Restructuring: The Process of Redefining Roles of Patient Caregivers. Nursing Economics 12:346–350, 1994.


Iliffe, S., and Zwi, A. Beyond 'Clinical'?: Four-Dimensional Medical Education. Journal of the Royal Society of Medicine 87:531–535, 1994.

Inglis, A.D., and Kjervik, D.K. Empowerment of Advanced Practice Nurses: Regulation Reform Needed to Increase Access to Care. The Journal of Law, Medicine and Ethics 21:193–205, 1993.

IOM (Institute of Medicine). America's Health in Transition. Protecting and Improving Quality. Washington, D.C.: National Academy Press, 1994.

IOM. Dental Education at the Crossroads: Challenges and Change. M.J. Field, ed. Washington, D.C.: National Academy Press, 1995.


Joel, L.A. Viewpoints: Changes in the Hospital as a Place of Practice. Pp. 220–225 in: J.C. McCloskey and H.K. Grace, eds. Current Issues in Nursing (4th ed.). St. Louis, Mo.: Mosby Year Book, 1994.


Kirchhoff, K.T. The Role of Nurse Researchers Employed in Clinical Settings. Pp. 169–181 in: J.J.

Suggested Citation:"Professional Nursing Education - Today and Tomorrow." Institute of Medicine. 1996. Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?. Washington, DC: The National Academies Press. doi: 10.17226/5151.
×

Fitzpatrick and J.S. Stevenson, eds. Annual Review of Nursing Research (vol. 11). New York: Springer, 1993.

Knaus, W.A., Draper, E.A., Wagner, D.P., and Zimmerman, J.E. An Evaluation of Outcome from Intensive Care in Major Medical Centers. Annals of Internal Medicine 104:410–418, 1986.

Knuteson, C.J., and Wielichowski, L.M. A Unique Approach to Designing Specialty Clinical Rotations. Journal of Nursing Education 33:167–168, 1994.

Koerner, J. Differentiated Practice: The Evolution of Professional Nursing. Journal of Professional Nursing 8:335–341, 1992.

Koerner, J. Values: A Foundational Factor in Role Selection, Corporate and Curriculum Design for Professional Nurses. Santa Barbara, Calif.: The Fielding Institute, 1993.

Larson, P.F., Osterweis, M., and Rubin, E.R., eds. Health Workforce Issues for the 21st Century. Washington, D.C.: Association of Academic Health Centers, 1994.

Lenburg, C.B. Nontraditional Nursing Education. Pp. 195–215 in: H.H. Werley, J.J. Fitzpatrick, and R.L. Taunton, eds. Annual Review of Nursing Research (vol. 4). New York: Springer, 1986.

Lowry, L.W. Is a Baccalaureate in Nursing Worth It? Nursing Economics 10(1):46–52, 1992.

Lynton, E.A., and Elman, S.E. New Priorities for the University. San Francisco: Jossey-Bass, 1987.


Magrath, C.P. The Future of Public Universities in the 21st Century. Bloomington, Ind.: Indiana University, 1995.

Mallison, M. Nurses as House Staff. American Journal of Nursing 93:7, 1993.

Martin, E.J. The Doctor of Philosophy Degree: Evolutionary and Societal Perspectives. Pp. 1–16 in: S.E. Hart, ed. Doctoral Education in Nursing: History, Process and Outcome. New York: National League for Nursing, 1989.

Mathews, M.B., and Travis, L.L. Research on the Baccalaureate Completion Process for RNs. Pp. 149–171 in: J.J. Fitzpatrick and J.S. Stevenson, eds. Annual Review of Nursing Research (vol. 12). New York: Springer, 1994.

McBride, A.B. The National Center for Nursing Research. Social Policy Report (a publication of the Society for Research in Child Development) 2(2):1–11, 1987.

McBride, A.B., and Burgener, S. Strategies to Implement Geropsychiatric Nursing Curricula Content. Journal of Psychosocial Nursing 32(4):13–18, 1994.

McClure, M.L. The Nurse Executive. Nursing and Hospital Cost Containment. Journal of Professional Nursing 7:4, 1991.

Merritt, D.H. The National Center for Nursing Research. Image: Journal of Nursing Scholarship 18:84–85, 1986.

Moccia, P. Toward the Future: How Could 2 Million Registered Nurses Not Be Enough? Nursing Clinics of North America 25:605–612, 1990.

Montag, M. The Education of Nursing Technicians. New York: G.P. Putnam's Sons, 1951.

Morris, D.L., and Wykle, M.L. Minorities in Nursing. Pp. 175–189 in: J.J. Fitzpatrick and J.S. Stevenson, eds. Annual Review of Nursing Research (vol. 12). New York: Springer, 1994.

Moore, G.T., Inui, T.S., Ludden, J.M., and Schoenbaum, S.C. The "Teaching-HMO": A New Academic Partner. Academic Medicine 69:595–600, 1994.

Moses, E.B. The Registered Nurse Population. Findings from the National Sample Survey of Registered Nurses, March 1992. Washington, D.C.: Division of Nursing, Bureau of Health Professions, Health Resources and Services Administration, U.S. Department of Health and Human Services, 1994.

Mullinix, C.F. The Next Shortage: The Nurse Educator. Journal of Professional Nursing 6:133, 1990.

Murphy, J.F. Doctoral Education of Nurses: Historical Development, Programs and Graduates. Pp. 171–189 in: H.H. Werley and J.J. Fitzpatrick, eds. Annual Review of Nursing Research (vol. 3). New York: Springer Publishing, 1985.

Murphy, M.I. The Evolution of Professional Degrees and Roles in Nursing. Pp. 1–12 in: Changes

Suggested Citation:"Professional Nursing Education - Today and Tomorrow." Institute of Medicine. 1996. Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?. Washington, DC: The National Academies Press. doi: 10.17226/5151.
×

in Nursing Education. Implications for Practice. Washington, D.C.: American Association of Colleges of Nursing, 1979.

NLN (National League for Nursing). A Vision for Nursing Education. New York: NLN, 1993.

NLN. Nursing Data Review. New York: NLN, 1994.

Noer, D.M. Healing the Wounds. Overcoming the Trauma of Layoffs and Revitalizing Downsized Organizations. San Francisco: Jossey-Bass, 1993.


Oermann, M. Professional Nursing Education in the Future: Changes and Challenges. JOGNN (Journal of Obstetric, Gynecologic and Neonatal Nursing) 23:153–159, 1994a.

Oermann, M. Reforming Nursing Education for Future Practice. Journal of Nursing Education 33:215–219, 1994b.

Office of Technology Assessment, U.S. Congress. Health Technology Case Study 37: Nurse Practitioners, Physician Assistants and Certified Nurse Midwives: A Policy Analysis (Pub. no. 224-8996). Washington, D.C.: Office of Technology Assessment, 1986.


Page, N.E., and Arena, D.M. Rethinking the Merger of the Clinical Nurse Specialist and the Nurse Practitioner Roles. Image: Journal of Nursing Scholarship 26:315–318, 1994.

Pew Health Professions Commission. Healthy America: Practitioners for 2005. Durham, N.C.: The Commission, 1991.

Pew Health Professions Commission. Health Professions Education for the Future: Schools in Service to the Nation. San Francisco: University of California Center for the Health Professions , 1993.

Pew Health Professions Commission. Nurse Practitioners—Doubling the Graduates by the Year 2000. San Francisco: University of California Center for the Health Professions, 1994a.

Pew Health Professions Commission. Primary Care Workforce 2000—Federal Policy Paper. San Francisco: University of California Center for the Health Professions, 1994b.

Pew Health Professions Commission. State Strategies for Health Care Workforce Reform. San Francisco: University of California Center for the Health Professions, 1994c.

Pike, A.W., McHugh, M., Canney, K.C., et al. A New Architecture for Quality Assurance: Nurse-physician Collaboration. Journal of Nursing Care Quality 7(3):1–8, 1993.

Prescott, P. Nursing: An Important Component of Hospital Survival under a Reformed Health Care System. Nursing Economics 11:192–199, 1993.


Rheingold, H. The Virtual Community: Homesteading on the Electronic Frontier. Reading, Mass.: Addison-Wesley, 1993.

Rice, R.E. The New American Scholar. Metropolitan Universities 1(4):7–18, 1991.

Rosenfeld, P. Recent Trends in Nursing Education. Pp. 11–19 in: A. Graubard , ed. Perspectives in Nursing 1991–1993. New York: National League for Nursing Press, 1992.

Rothert, M.L., Talarczyk, G.J., and Awbrey, S.M. Partnerships in Nursing Education. Expanding the Boundaries. Pp. 170–176 in: J.C. McCloskey and H.K. Grace, eds. Current Issues in Nursing (4th ed.). St. Louis, Mo.: Mosby Year Book, 1994.


Safriet, B. Health Care Dollars and Regulatory Sense: The Role of Advanced Practice Nursing. Yale Journal on Regulation 9:417–497, 1992.

Salmon, M.E. Report to the American Association of Colleges of Nursing. Washington, D.C.: Bureau of Health Professions, Health Resources and Services Administration, March 21, 1995.

Shalala, D.E. Nursing and Society—The Unfinished Agenda for the 21st Century. Pp. 3–8 in: A. Graubard, ed. Perspectives in Nursing 1991–1993. New York: National League for Nursing Press, 1992.

Shulman, L. Knowledge and Teaching: Foundation of the New Reform. Harvard Educational Review 57(1):1–22, 1987.

Simmons, J., ed. Prospectives. Celebrating 40 Years of Associate Degree Nursing Education. New York: National League for Nursing Press, 1993.

Smeltzer, C.H., Formella, N.M., and Beebe, H. Work Restructuring: The Process of Decision Making. Nursing Economics 11:215–222, 1993.

Suggested Citation:"Professional Nursing Education - Today and Tomorrow." Institute of Medicine. 1996. Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?. Washington, DC: The National Academies Press. doi: 10.17226/5151.
×

Starck, P.L., Duffy, M.E., and Vogler, R. Developing a Nursing Doctorate for the 21st Century. Journal of Professional Nursing 9:212–219, 1993.

Tanner, C.A. Teaching Clinical Judgment. Pp. 153–123 in: J.J. Fitzpatrick and R.L. Taunton, eds. Annual Review of Nursing Research (vol. 5). New York: Springer, 1987.

Tanner, C.A. Rethinking Clinical Judgment. Pp. 153–123 in: N.L. Dickelmann and M.L. Rather, eds. Transforming RN Education: Dialogue and Debate. New York: National League for Nursing Press, 1993.

Tresolini, C.P., and the Pew-Fetzer Task Force. Health Professions Education and Relationship-centered Care. San Francisco: Pew Health Professions Commission, 1994.


Valberg, L.S., Gonyea, M.A., Sinclair, D.G., and Wade, J. Planning the Future Academic Medical Center . London, Ont.: Canadian Medical Association, 1994.

VanOrt, S., Woodtili, A., and Williams, M. Prospective Payment and Baccalaureate Nursing Education: Projections for the Future. Journal of Professional Nursing 5:25–30, 1989.


Wald, F.S., and Leonard, R.C. Towards Development of Nursing Practice Theory. Nursing Research 13:309–313, 1964.

Watson, J., and Phillips, S. A Call for Educational Reform: Colorado Nursing Doctorate Model as Exemplar. Nursing Outlook 40(1):20–26, 1992.

Wolf, G.A., Boland, S., and Aukerman, M.A. A Transformational Model for the Practice of Professional Nursing. Part 1, The Model. JONA (Journal of Nursing Administration) 24(4):51–57, 1994a.

Wolf, G.A., Boland, S., and Aukerman, M. A Transformational Model for the Practice of Professional Nursing. Part 2, Implementation of the Model. JONA (Journal of Nursing Administration) 24(5):38–46, 1994b.

Suggested Citation:"Professional Nursing Education - Today and Tomorrow." Institute of Medicine. 1996. Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?. Washington, DC: The National Academies Press. doi: 10.17226/5151.
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Hospitals and nursing homes are responding to changes in the health care system by modifying staffing levels and the mix of nursing personnel. But do these changes endanger the quality of patient care? Do nursing staff suffer increased rates of injury, illness, or stress because of changing workplace demands? These questions are addressed in Nursing Staff in Hospitals and Nursing Homes, a thorough and authoritative look at today's health care system that also takes a long-term view of staffing needs for nursing as the nation moves into the next century. The committee draws fundamental conclusions about the evolving role of nurses in hospitals and nursing homes and presents recommendations about staffing decisions, nursing training, measurement of quality, reimbursement, and other areas. The volume also discusses work-related injuries, violence toward and abuse of nursing staffs, and stress among nursing personnel--and examines whether these problems are related to staffing levels. Included is a readable overview of the underlying trends in health care that have given rise to urgent questions about nurse staffing: population changes, budget pressures, and the introduction of new technologies. Nursing Staff in Hospitals and Nursing Homes provides a straightforward examination of complex and sensitive issues surround the role and value of nursing on our health care system.

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