STATEMENT
ON
Nursing Education: Status or Service
Oriented?*
490
STATEMENT
ON
Nursing Education: Status or Service
Oriented?*
BY
COMMITTEE
THE NEW YORK ACADEMYON MEDICAL EDUCATIONOF MEDICINE
ON MARCH 2, 1976 a bill proposing radical changes in the preparation
ofnurses for licensure in New York State was introduced into the
legislature. Briefly, Bills No. 10932 (Assembly) and No. 10146(Senate)
proposed that effectiveJanuary 1, 1984 the only access to a license as a
professionalnurse in New York State be through a baccalaureate degree.
The only other nursing license, accordingto this proposal, would be as a
practicalnurse through the associate degree programs of New York State.
Ineffect, this bill would close hospital diploma schools of nursing by
1980,or deny their graduates licenses as professional nurses.
The Committeeon Medical Education of the New York Academy of
Medicine appointed
this proposed legislation and
committee
Before the formation of this committee,
Lepore,an Ad Hoc Committee for Nursing Education to study.to submit proposals for action. This ad hocreports herewith.its chairman, Dr. Michael J.acting as an individual physician in New York City, prepared and
sent to
changesimportant legislators in Albany a memorandum decrying the proposedand warning that they would adversely affect both nursing
practice
sources,
end of theand the care of patients. Criticism of the bills came from manylegislators were deluged by adverse comments, and, toward thelegislative session of 1976, the bills were withdrawn. We are
advised that they probably
duringwill be presented again in some modified form1977.
The committeebegan its deliberations by reviewing the facts and some
ratherlengthy recent studies of the problems of nursing education, the
supplyof nurses, and the changing roles of nurses in our society. Discus-
*AdoptedMarch 10, 1977.
Bull.N.Y. Acad. Med.
NURSING491
sionswere held with well-informed individuals in these fields and relevant
literature wasreviewed.
The
eminent nursing educators andcommittee noted that, although studies have been published byadministrators, prestigious general educators,
medical administrators, deans, andsociologists, the grass roots of the
nursingprofession was seriously under-represented and the voice of an
experienced practicing physicianwas hardly ever heard. To paraphrase
Clemenceau, the committee believes thatnursing education and practice,
like war, arefar too important to leave to nurses, administrators, educators,
and sociologists alone.
Thecommittee identified what it takes to be a number of serious
problems, undesirable
and education
change.trends, and controversial areas in nursing practicein New York State to spur interest in and support for
Supply
The
Unitedof Nurses - Shortage or Surplus?first question is whether a surplus or deficit of nurses exists. In theStates in 1971, 700,000 professional nurses were in practice,
as
populationcompared with 50,000 in 1910-an increase from 55 nurses per 100,000to 341 per 100,000 over the past six decades. Despite this, the
rate
Theof hospital nursing vacancies now stands at somewhat less than 10%.U.S. Public Health Service has claimed that an additional 150,000
nurses-more than20% of the present supply-are needed to provide the
nation
Thesewith "safe, therapeutically effective, and efficient" nursing care.32estimates have little regard for changing patterns of nursing care,
increasing
each
evidence
talk
requirementsdemands for health care, and emerging new roles for nurses,of which tends to increase the need for nurses significantly. Availablesupports the belief that a shortage of nurses exists-there is noof an over-supply. The committee believes that any change in educationalor licensure which even threatens to reduce the number
ofcompetent nurses would be ill-advised and contrary to the public
interest.
Sourceof Nurses
Our
educational background?
THE
Traditionally, most nurses in America graduate from hospital schools ofnext question is where do our nurses come from and what is theirDIPLOMA SCHOOLS
Vol.53, No. 5, June 1977
NURSINGEDUCATION 491
COMMITTEEON MEDICAL EDUCATION
nursing, the
graduates by three years of intensive education in a hospital setting which
stresses bedside experience, direct care of patients, apprenticeship to roleso-called diploma schools. These prepare high school
models,
among the well who seek preventive care.and the nurse's work at the bedside, with the ambulatory sick, and
Inthe hospital setting students surrounded by the cries and the smells of
the sickget an educational experience for which there is no substitute; it is
afar cry from the detached, largely theoretical, impersonal atmosphere of
a
were
many hospital schools most ward nursing was performed by students and
only a few graduate nurses were employed. In the late 1920s it wascollege campus. The expenses of these diploma school programs at firstexchanged for the services rendered by the student nurses. Indeed, in
estimated
nurses.
butthat 73% of hospitals with nursing schools employed no graduateThis arrangement was economical and advantageous for the hospital,was attacked vigorously by some leaders in nursing education who
believed thatstudents were being victimized as cheap labor rather than
being trained. Diploma
training
leaders thought broad educationschools also were accused of merely giving vocationalto their students and neglecting broader education. Nursingwas essential to assure the nurse of her
properstation in society and to qualify the nurse for her expanded role in
healthcare. These pressures soon reduced the time student nurses were
assignedto hospital service. Additional general education courses were
addedto the program and the cost of administering diploma programs rose
dramatically.
CrossOne saving grace was the availability of funds from the Blueand government sources to support the hospital nursing schools.
Therewere advantages to having diploma schools. From the very first day
students
Uponwere immersed in the hospital, its clinics, and its outreach programs.graduation these students uniformly did well in their state
boardexaminations and immediately entered into work in the hospital. If
they
student
hospital, the indoctrinationchose to remain in their nursing school hospital, the transition fromto practicing nurse was simple. If they chose to go to anotherperiod was short and concerned chiefly with
localrules; it did not include the tight supervision of professional work
neededby baccalaureate graduates or graduates from associate degree
programs.Before 1960 diploma school graduates supplied most of the
nurses inthe United States.
In1960, 78% of nursing graduates across the nation came from hospital
diplomaprograms, 18% from baccalaureate programs, and only 4% from
Bull. N.Y. Acad. Med.
492
NURSINGEDUCATION
associate
new nurses,
graduatesdegree programs. By 1969 hospital graduates declined to 42% ofassociate degree graduates jumped to 34% and baccalaureateincreased to 24% of the total. The number of hospital schools
fellfrom 883 in 1962 to about 430 in October 1975; during this period
baccalaureate
programs rose
In
students,
programsprograms increased from 174 to 285 and associate degreedramatically from 69 to 491.New York State during 1975, 42 diploma programs enrolled 6,80638 associate degree programs enrolled 12,605 students, 26 baccalaureateenrolled 10,909 students, 39 practical nursing programs
enrolled 3,870 students,
nurses,and three baccalaureate programs, for registeredonly enrolled 818 students. Baccalaureate programs seem to
have levelled off,
hospital programs slowly diminish. A troublesome aspect of all of this isbut associate degree programs continue to proliferate as
thatmost new members of the nursing profession now come from the
two-year
of
extra expense upon hospitals forassociate degree programs which provide the worst nursing educationthe three avenues of training. Moreover, their graduates imposeremedial training programs before they
canbe considered minimally safe for bedside nursing.
CHURCH-RELATEDSCHOOLS
The church-relatednursing schools in New York State merit special
consideration.
schools with excellent reputations for teaching skilled and compassionateVirtually all such schools in New York State are diploma
patientcare, and are further characterized by the superior performance of
their
have been reluctant to undertake associate degree and baccalaureate programs
in nursing for many reasons, not the least of which is a well
differencegraduates in the state board examinations. Church-related institutionsfoundedof opinion as to how best to train a nurse. The major
church-related
best. The successhospitals believe that the hospital-based diploma program isof their programs is largely attributable to careful
selection of applicantsand daily emphasis on the care of patients, service
toothers, self-discipline, integrity, character, and good manners-all reinforced
by close exposure to idealistic, religious women who have dedicated
their lives to the welfare of others.
BACCALAUREATENURSES
Leadersin nursing education, dissatisfied with making compromises
withhospital schools, persisted in what they believed were efforts to
Vol. 53, No. 5, June1977
NURSING EDUCATION 493
COMMITTEEON MEDICAL EDUCATION
improve nursing education. Hostile toward the hospital as an educational
institution,they regarded a college or a university as by far the best place
for nursingeducation; but they underestimated the important advantages of
the
than its strengths and, in keeping with the times, moved toward the
panacea which they sought in academic institutions.
Although the first collegiate school of nursing was founded in 1909, not
until 1933 were major steps taken in this direction. At first universities
were reluctant to undertake vocational training and resisted changes dehospital as the arena for educating the nurse, saw its weaknesses rathermanded
by nursing educators. Gradually some progress was made and a
four-year baccalaureateprogram evolved which stressed general education
and supplantedthe apprenticeship learning of diploma schools. Initially,
graduates ofcollege programs formed an elite group of registered nurses in
administrativeor public health positions. This changed as baccalaureate
programsproliferated and by 1970 the production of baccalaureate nurses
had
This was not entirely a blessing. Critics pointed out thatreached substantial proportions.baccalaureate
degree programs were longer than thoseof diploma schools, cost much
more,
stressrelied heavily on didactic instruction and general education, did notthe care of patients, had a higher attrition or drop-out rate, and that
fewer such graduates worked
and 44 years.as nurses, especially between the ages of 25Hospitals complained that it took three to six months to train
baccalaureate graduatesto perform duties that diploma graduates had
mastered before
baccalaureate degreegraduation. Other critics complained of shortcomings ofprograms in the practical skills needed to care for sick
people. Theybelieved that general education for a nurse is fine, but, if it
displacespractical bedside training, it fails to serve the public. The baccalaureate
nurseseldom was satisified with providing direct nursing care
andsoon coveted duties involving only administration and supervision.
People asked:What good is a supervisor who cannot perform the work
supervised?How many administrators and supervisors do we need? Who
really
nurses?cares for patients? Is service to patients subordinated to status forIs actual bedside nursing steadily passing by default to marginally
trainedaides and orderlies?
ASSOCIATE DEGREE NURSES
Disaster
degree collegiatestruck nursing education in 1952 when two-year associateprograms were introduced. These arrived to
Bull. N.Y. Acad.Med.
494
495
...prepare a
quality nursing care to patients. This
through the
It is
the associate degree program, will be capable
some
professional nurse.22
These programs soon werepractitioner who, in the beginning, is ready to renderpractitioner is not preparededucational program to assume administrative responsibilities.intended that this practitioner, upon completion ofof functioning withdegree of independence under the supervision of an experiencedswamped by applicants and helped to fill the
myriad communityand junior colleges, which were mushrooming at the
time. Theseinstitutions had little experience in nursing education and their
generalstandards often left much to be desired. The course lasted two
years,
becausenot because this was best for the education of this sort of nurse butlegal restrictions barred junior colleges from programs lasting
morethan two years. The professed objective of training competent bedside
nurseswas compromised by a lack of practical instruction, inadequate
hospital experience, and the introductionof courses which were not essential
fornursing but were for the nurse's general education. These programs
acquiredthe aura of a college degree in a society in which a college degree
wasconsidered a civil right. Being almost entirely tax-supported, the pupil
incurred no expense-indeed,in New York City if the student's family
wasreceiving welfare payments, the student would be paid to attend.
Complicatingthis was the open enrollment policy of the City University
of New York, which made
aptitudeno attempt to screen applicants or to test theirfor nursing. Small wonder that applicants swamped the colleges.
From
board examinations.
and
in the Daily News under the headline "City U Fails Its Nurse50% to 80% of the graduates of several schools failed their stateThis scandal became the target of a special inquiryon November 9, 1976 the following report by Michael Oreske appeared
Courses":
Halfof the students who completed nursing programs at eight
City Universitycommunity colleges were unable to pass state
licensingexams or get jobs after they graduated, a searing confidential
report hasconcluded.
The report by a City University task force recommends that four
of the
and that enrollment at theprograms be abolished because of their "poor performance"other four be drastically reduced.
Criticismof the $20 million-a-year nursing programs is the
highlightof a report that recommends a wide-ranging reduction of
Vol. 53, No.5, June 1977
NURSING EDUCATION 495
COMMITTEE ON MEDICAL EDUCATION
City University
The 16-member task force found that health-care programs had
been
"aprograms in health care and medical technology.allowed to grow "in an uncoordinated fashion," resulting incomplex array of programs, many of which are unnecessarily
duplicative,costly, poorly articulated and out of phase with regional
labor market needs and with professional trends."
The task force found that some employers refused to hire
graduates of the City University programs, particularly the community
college nursing programs, "because of the perceived low
quality of skills" achieved by students.
Only half of
nursing programs were able to pass the registered nurse licensing
examthe graduates of the eight community collegeadministered by the State Education Department, the task
force reported.Nursing programs at the senior colleges were found
to
The
Boroughbe acceptable, however.task force recommended the abolition of programs atof Manhattan Community College, Hostos Community,
Kingsborough, and
but offersat Medgar Evers, which is a four-year schoola two-year nursing program.
Officials
nursingat Hostos have already decided to phase out theirprogram, according to university sources.
Nursingprograms at Bronx Community College, New York
City Community College,Queensborough Community and Staten
IslandCommunity would be curtailed if the task force recommendations
are
Board of Higher Education.
University officials stressed that
would beapproved by Chancellor Robert Kibbee and thestudents currently in the programsallowed to finish. But they predicted that most of
the task force recommendationswould probably be adopted.
Within 24 hours
associate degreeof the Daily News story Gerald Griffin, director of theprogram for the National League of Nursing, responded.
"I
inthink it would be tragic if they closed all four of these schools," he saida Daily News story of November 10, 1976. He expressed no concern
overthe number of graduates who failed to pass licensing examinations or
aboutspending millions of dollars of public funds to no purpose. He
intimatedonly that the four colleges served large numbers of black and
Hispanicstudents. It would have been more constructive to investigate
Bull.N.Y. Acad. Med.
496
NURSING EDUCATION497~~~~-
why these colleges failedso miserably with their students. Was it failure of
theinstitution, its teachers, or the students? Were leaders in nursing
education
waste two years studying nursing only to
The committee
have goodnot concerned that hundreds of individuals were encouraged toend as failures?does not condemn all associate degree programs. Somerecords, when judged by performance on the state board examinations,
but, on the whole, two-year
proved inferior
graduatesassociate degree programs haveto the three-year hospital course, and many two-year(especially of the City University of New York) can barely
function
PRACTICAL NURSES
Aas practical nurses.scarcity of professional nurses and pressure by nursing educators to
relieve professionalnurses of bedside nursing led, some years ago, to
programs to
National Association for Practical Nurse Education andtrain practical nurses. By 1941, with the organization of theService, these
programs began togain numbers. Today there are approximately 1,300
practical nursingprograms in the United States; 39 of them in New York
Statewith an enrollment of 3,870 students. The practical nurse usually is a
high school graduate who hascompleted a one-year course in a public
vocational education
college, and is eligible
practicalsystem, community agency, or junior or senioron graduation to take examinations for licensednurse or licensed vocational nurse. The course includes elementary
biological and social sciencesand practice in rudimentary nursing
care.Licensed practical nurses may give direct patient care in hospitals
under the
in various
the doctor'ssupervision of a professional nurse or physician. They may worklocations, such as hospitals, clinics, community agencies, or inoffice, but they increasingly replace registered nurses in
bedsideand personal patient care.
Performanceon New York State Board Examination for R.N.
Licensure
Theaccompanying table shows that in 1976 a total of 6,908 candidates
passed the
oflicensing examination for Registered Nurse (R.N.), an increase3,034 since 1970-1971. Since 2,011 diploma-school graduates passed in
1976-virtually
total number ofidentical with figures for 1970-1971, the increase in thesuccessful candidates was mainly due to an influx of
associate-degree candidates-3,141compared to 1,101 in 1970-1971-
Vol. 53,No. 5, June 1977
NURSING EDUCATION 497
COMMITTEEON MEDICAL EDUCATION
FIRST-TIME CANDIDATES FROM NEW YORK STATE PROGRAMS
WHO PASSED R.N. LICENSING
BY TYPE OF PROGRAM, JUNE 1970-JULY 1976EXAMINATION IN THE STATE(ABRIDGED)*
All New
candi- Diploma Associatecandidates by type ofprogramdegree Baccalaureate degree
Testing
periodsdates Passed Passed Passed PassedNo. % Total No. % Total No. % Total No. %
June
May 1971
June 1971- 5,554 76.2 2,263 1,948 86.0 2,330 1,411 60.5 961 877 91.2
May 1972
June 1972- 6,681t 74.6 2,415 2,048 84.9 3,277 2,031 62.0 967 878 90.8
May 1973
June 1973- 7,361 76.3 2,494 2,176 87.3 3,664 2,410 65.8 1,203 1,031 85.7
May 1974
June 1974- 7,862t 75.1 2,363 1,996 84.5 3,908
May 1975
July 1976 8,680 79.0 2,335 2,011 86.01970- 5,019 77.2 2,340 1,981 84.6 1,817 1,101 60.5 862 792 91.82,579 66.0 1,558 1,331 85.44,175 3,141 75.0 2,170 1,756 80.0
*The data for years ending 1971-1975were obtained from Table 10 of Educational Preparation for
Practical and Professional
New
Figures forNursing in the State ofNew York, 1974, issued by the University of the State ofYork, The State Educational Department, Office of Professional Education, Nursing Education.1976 were obtained from the same agency in a report entitled: Number and Percent of
First- TimeCandidatesfrom New York Schools of Nursing Passing State Board Test Pool Examinations.
tAsshown in original source.
and, for baccalaureatenurses- 1,756 compared to 792 in 1970-1971. The
major
programs, thenincrease in the number of new nurses came first from associatedegreefrom baccalaureate programs, with the number of
diploma-school
The lowestgraduates holding steady since 1970-1971.percentage of graduates passing the state boards was in the
associate-degreeprogram, 75%, an improvement over the 60.5% who
passedin 1970-1971. The percentage of passing diploma graduates held
steady
programsat 86%, a very consistent performance over the years. Baccalaureatehave not done so well; a pass rate in 1970-1971 of 91.8%
dropped graduallyto the 1976 level of 80%.
Based solelyupon their performance on the New York State Board
Examination forRegistered Nurses, the diploma schools clearly hold the
best record,with the baccalaureate schools lagging substantially behind,
and associate-degreeprograms in the lowest position. We regard this as
compellingevidence for keeping diploma schools open and strengthening
ratherthan closing them.
We have discussed fourtypes of programs in nursing education.
Clearly,with few exceptions, nursing education is moving away from the
Bull.N.Y. Acad. Med.
498
NURSING~ EDCTO
hospital towardthe college campus. In 1972 S. H. Altman predicted several
other national trends:32
1) New admissionsto nursing training programs will grow from 69,000
in 1969 to between
2) Diploma85,000 and 92,000 in 1980.programs either will become extinct by the mid-i1970s or
will account for about 1.0% of newadmissions by 1980.
3)
associate-degreeThe usual training for professional nurses ultimately will be inprograms, and by 1980 between 62% and 66% of new
admissions will bein such programs.
4) High attrition rates in baccalaureate and
will reduce the average
1969
5)associate-degree programscompletion rate in nursing training from 62% into 56% in 1980.In the future a greater proportion of nurses will come from foreign
countries.
United States averagedThe number of foreign-trained nurses who were licensed in the1.7% of the output of United States schools in
1950, 6.1% in
The
rejects1960, 10.0% in 1967, and will grow to 16.4% in 1980.committee disagrees with some of these projections and especiallythe belief that diploma programs are doomed to extinction.
Altman's prediction of
beentheir near-demise by the mid- 1970s already hasdisproved. Serious weaknesses in associate-degree and baccalaureate
programs are becoming too evident to overlook with time and critical
review,and the need for hospital-based diploma schools is reasserting
itself.
Conclusions
1) Noobjective evidence suggests that a four or five-year education
program innursing leading to a baccalaureate collegiate degree produces a
better
of evidence and opinion exists thatnurse than the three-year hospital or diploma program; a strong bodyit does not.
2)
the nurse's
education: directTransferring nursing education from the hospital to the campus aidsgeneral education, but dilutes the most essential part of herand intimate contact with patients. This trend has already
gone
3) Existing associate-degree
preparation,too far and must be corrected.programs for nursing typically offer inadequaterank considerably below the performance of the
diploma
4) New York City, to paraphrase Abraham Flexner, may be the plague
spotschools, and, in their present form, cannot replace them.of associate-degree nursing schools in the United States. Four schools
Vol. 53, No. 5, June 1977
NURSING EDUCATION 499
COMMITTEEON MEDICAL EDUCATION
had failure rates averaging
and should50% or more on the state board examinationbe closed forthwith.
5)A proper balance must be struck in nursing education between the
patient'sneeds and the nurse's aspirations. If nursing education is too
expensive andtoo long, many highly motivated people will be unable to
participate,particularly those from working-class homes who are not paid
toattend by welfare departments. Years ago Dr. Charles Mayo expressed
the fearthat the nurse might end up being "undertrained for a doctor and
overtrainedfor the duties of a nurse."10 Many share his viewpoint today.
6)Nursing is well along a road previously traveled by medicine in the
United
theStates, and is heading for the same mistakes. Briefly, in turning touniversity to cure the ills of medical education, scientific progress was
made,but the price included scarcity of physicians, oversupply of scientists
and administrators,excessive specialization, neglect of the bedside
careof patients, and, most importantly, culpable neglect of primary care.
Medicinenow is painfully reorienting its teaching and training programs to
re-emphasizepatient care and primary care against the passive resistance of
atenured faculty. To put it bluntly, medical education forgot about sick
people and clearly has been given the
shaped
American
in orderchoice between shaping up and beingup.*medicine also has robbed developing countries of their physiciansto obtain cheap hospital labor. Legislation to correct this evil
already istoo late and in any event is being fought hard by a bizarre
coalition of institutionsand individuals. Altman detects a similar phenomenon
innursing. Our unrealistic plans and restraints result in a domestic
scarcity, and we loot foreigncountries to supply our patients' needs and
demands.A bedside nurse or primary-care physician must share American
culturefully to understand our patients. We should not rely on foreign
countriesfor our nursing needs; doing so has proved wholly undesirable in
medicine. Nursingmay yet avoid the same errors.
Discussion
A
nurses has beenmajor result of emphasis on baccalaureate and higher degrees forthe transfer of bedside nursing to doubtfully trained aides
and
seldom
culture becomes eitherorderlies who need close and time-consuming supervision which isgiven. The collection of a clean mid-stream urine specimen fora major research project or a small disaster. Vital
*Four members ofthe committee dissented from this paragraph.
Bull.N.Y. Acad. Med.
500
501
signs
nurse is occupiedare often monitored by the lowest person on the totem pole, while theby attractive graphic charts of data accumulated by
nonprofessional personnel,with little thought given to possible errors and
inaccuracies. Physicians
importanthave learned to check these findings before makingclinical decisions. An accurate record of something as
simple
inas fluid intake and output or body weight is now too much to expecta hospital charging $200 a day for a bed. This is what happens when
nursing
andstrays from the bedside and relegates its duties to poorly qualifiedinadequately supervised personnel. The least adequately trained members
of the hospitalstaff have frequent and often intimate personal contact
with patients while nursesare occupied with their paperwork and charting.
Amodem redefinition of a nurse and what should be expected of her by
thesociety which she is committed to serve clearly is needed. Such a
definition
have lost touch withshould not be prepared only by nursing educators who usuallypatients. The voices of knowledgeable practicing
physicians, nurses who actually take care
and patients should be heard.*
The committee warns that, asof the sick, hospital administrators,nursing retreats from the primary care of
patientsand delegates its traditional activities to nonprofessional personnel,
it may
imaginationdestroy its most important function in our society. It takes littleto envision a hospital where a very small number of professional
nurses
uponsupervise semiskilled nonprofessionals. The impact of thisnursing and on the care of patients would be catastrophic.
The hostilityof nurse-educators toward the hospital as a teaching institution
mustbe reduced. A modern hospital provides community-based
facilities,patients, and faculty for education in both nursing and medicine.
Improvement in this environment during the past two decades has been
substantial. The
havecommittee flatly refutes the idea that the hospital shouldonly a minor role in the training of nurses, and believes that the
hospital's
There is a strong movement among nursing leaders to establish nursingrole is primary in training both physicians and nurses.
as a
physician. Indeed, bills have been proposed to give nurses legal authoritycompletely autonomous profession without accountability to the
to
supports the Pennsylvania Medical Society's official position (adoptedpractice on their own, to diagnose, and to prescribe. The committee
October 20,
1) The delivery of optimum health care should be a cooperative effort1973) that:
*Four members of the committee dissented from this paragraph.
Vol. 53, No.5, June 1977
NURSING EDUCATION501
COMMITTEEON MEDICAL EDUCATION
underthe physician's leadership, wherein nurses and other health-care
personnel workunder his supervision. An independent, autonomous nurse
practitioneris inconsistent with this position and must lead to second-class
medicalcare.
2) The
primary nursing care of the patient in the environment most conducive tobasic core of undergraduate nursing education at all levels is
effective
fundamental to nursing education, whether practical, associate degree,and practical instruction, the bedside of the sick. This basis is
diploma,
serve as the common denominator for progress up the career ladder. Theor baccalaureate. It must permit upward career movement and
emphasis
lecture, or conference.
3) Nursing in the future will be an increasingly important and demand
professionon the care of the patient must never be abandoned to the book,ingwith room for people with a wide variety of talents, skills,
aspirations,
growth, development,
must makeand capabilities. Nursing education must provide for theand fulfillment of those who enter its portals. Itits educational programs so sound at every level of entry that
mobility will
and encouraged.
Nursingbe assured and a high quality of performance will be rewardededucators must not be permitted to forget that young people
becomenurses to serve others. This is and always has been the objective
ofalmost all who become nurses. This idealistic attitude is fundamental to
all healthcare. To lose or displace it would ill serve both profession and
public.Most nurses are needed to take care of human beings, sick or well.
A
research, and
Advancementminority, albeit an important one, is needed for administration, teaching,paper work.up the career ladder must be available to all nurses.
Rewards and recognition shouldnot be based solely on extra credentials
anddegrees, but also must be given to those who excel in the care of
patients. Mobilityof the individual nurse from one level of achievement to
another shouldbe encouraged and facilitated, not hampered by extraneous
paper
Mobilitycredentials.of Nurses
The committeehas received complaints from registered nurses that
acquisitionof a baccalaureate degree has been extremely difficult for those
who
made regarding the number of
Bull.work as nurses. Arbitrary and perhaps capricious decisions have beencredits awarded for diploma-school courses.N.Y. Acad. Med.
502
NURSINGEDUCATION 503
Degree-granting institutionshave insisted on repetition of some courses
already
expense. To add
in nursingtaken by the nurse, a wasteful duplication of effort, time, andto the confusion, colleges offering a baccalaureate degreeperiodically change their policies: first giving registered nurse
applicants blanket credit, thenno credit, and finally credit by examination
only. Theseserious complaints indicate that upward mobility of nonbaccalaureate
nursesleaves much to be desired. The committee suggests that a
body be establishedto review such complaints and perhaps to assist
diploma-school graduates whoare being treated unfairly.
A recentdevelopment designed to facilitate career mobility for nurses is
theNew York Regents External Degree Program in Nursing of the
Universityof the State of New York. Essentially a university without
walls,a rigid time frame, or residency requirements, it assesses knowledge
andexperience without a responsibility to teach the student or to prescribe
special methods of learning. Flexibility andadaptability to individual
requirements has made
thethis program attractive to many nurses. Initially,emphasis was on associate degree programs, but since April 1976 a
Regents External Bachelor of Science
approved(Nursing) Degree program has beenand is accepting enrollments.
Recommendations
The
1)committee recommends:Existing well-qualified and successful diploma schools of nursing
should be urged to apply to the New York
degree-grantingState Board of Regents forpower. Consideration should be given to granting the
degree
2) Hospitalto their past graduates.schools of nursing should be strengthened and encouraged,
notclosed. They have made major contributions to the care of the sick and
havea strong tradition of education and training of nurses. They are a
nationalresource of enormous and long-proved value. If half of the energy
devotedto closing diploma schools had been directed to improving or
closingthe poorer associate-degree schools, nursing would not be in the
predicamentit is in today.
3)Graduation from an approved diploma school should carry 90 credits
(approximately30 per year) toward a baccalaureate degree, such credit
being retroactivefor past graduates of such programs.
4) Thetrend to the so-called open curriculum in post-graduate nursing
educationthrough the External Degree Program of New York State de-
Vol. 53, No. 5, June 1977
NURSING EDUCATION 503
COMMITTEEON MEDICAL EDUCATION
serves support and implementation to encourage the upward movement of
those with an R.N. degree. It is a positive forward step in fostering career
mobility.The committee recommends that those in charge emphasize
professionalnursing performance rather than general education. The nation
already isamply supplied with people with baccalaureate degrees-many
of whom
not.cannot find jobs. Nurses are in scarce supply, baccalaureates are
5)Steps should be taken to bring the campus and hospital into a more
appropriate relation.Nursing education is too far from the hospital. Teaching
nursing
hospital over a college campus for this education far outweigh any possiblein a hospital remains sound today. The advantages of the
disadvantages.
6)
be metThe demand for a broader education of the professional nurse shouldby strengthening diploma-school programs and by establishing
affiliations
another unspecialized baccalaureate dilettante.
7) Thorough investigation of existingwith colleges which would train a competent nurse, not simplytwo-year associate degree programs
shouldbe implemented, with special reference to the selection of
students,curriculum, and record on licensing examinations. This should be
done witha view to closing the poor schools. The committee has grave
reservationsconcerning the two-year associate-degree nursing curricula
and
herring.suspects that they may produce neither "fish, nor flesh, nor good red"
8) The
performance of
thatcommittee has substantial reservations about the curriculum andsome of the baccalaureate programs in nursing, and recommendsthese be studied with particular reference to the validity of
their hospital affiliations,the quality and extent of the students' exposure
to
science of nursing.patients, and emphasis on general education at the expense of the art and
Comment
The committee's study of nursing
majoreducation and practice has uncoveredareas of conflict and controversy. The most important seems to be
the shift of nursing
which
with patients. The nurse's "handsaway from the patient and the hospital environmenttraditionally have brought to nurses personal fulfillment and empathyon" work is clearly visible to
patients, theirphysicians, and hospital administrators. Neglect of direct
careof patients in favor of emphasis on academic education has weakened
Bull.N.Y. Acad. Med.
504
505
and may destroy hard-earned gains by generations of dedicated, idealistic
people who became nurses primarily to serve, not to gain status.
Nursing is drifting dangerously away from its traditional warm and
extremely
committee recall those days when the head nurse made rounds with house
and attending physicians and played a visible and important role on theproductive relation with practicing physicians. Members of this
team
hospital nursing scene some years ago as follows:
Nor is time 'wasted'
doctors around the wards has long since lapsed. Indeeddelivering health care. A British visitor commented on the Americanon the doctors. The convention of escortingI was
there a
to each other. A large notice reminded alllong time before I ever saw a doctor and a nurse speakingcomers that verbal
orderswere on no account to be accepted. The doctors wrote
orders for the nurses, who in
and each stood around
word
could rummageturn wrote reports for the doctors,reading each other's writing with never aexchanged. Professors got as short shrift as anyone else, andaround in the nursing station looking for notes of
their
routinepatients without disturbing for a moment the unhurriedof the nurses.5
To
preserved andwish for a return to the past is not nostalgic; its good features must bestrengthened. Both sides must heal the wounds of discord
andreturn to a mutually respected, supportive, and collaborative team
working
The
study isfor the common good of patients.committee believes that these problems are so serious that furtherindicated, despite a plethora of published studies of nursing
educationwhich seldom have been read and almost never have led to
positive action.
Proposal
The committee proposes an independentfoundation-supported study of
nursing educationin New York State. This study should stress on-site
inspectionand evaluation of all existing New York nursing schools,
whether baccalaureate, associate-degree, diploma or practical. The cooperation,
but
and of government agencies should be sought. The voice of nursing's
proletariat as well as its elite, must be heard and, above all, practicing
physicians and patients must be strongly represented in the deliberations.
Suchdecidedly not the domination of existing nursing organizationsa commission could do much to improve nursing practice and educa-
Vol. 53,No. 5, June 1977
NURSING EDUCATION505
506 COMMITTEE ON MEDICAL EDUCATION
tion in New York State and the nation withsubstantial benefits to the care
of patients.
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