Nursing Education As It Affects Specialty Nursing Care

Volume 3, Number 1 , January/February 1974

JOGN Nursing Journal of The Nurses Association of The American College of 0bs tetr icians and Gynecologists

Nursing Education As It Affects Specialty Nursing Care JEROME P. LYSAUGHT, EdD

This article is adapted from a presentation by Dr. Lysaught at the 1973 Conference of NAACOG District Vl1 at New Orleans in October. I t akears by populh demand of numerous NAACOG Menibers who heard 07. Lysaught at the Conference. Although I took my AB and MA degrees in Political Science, I am currently directing a national study in nursing, The National Commission for the Study of Nursing and Nursing Education. At first thought this might seem to be a@uncomplementary set of circumstances; however, there is something about my former academic discipline that is particularly appropriate to the topic of nursing education. And I feel I can best illustrate this with an incident that occurred shortly before I left The University of Kansas to seek my fortune in the East. Kansas University is one of those state institutions which has generally prohibited the' use of alcoholic beverages on campus. As a result, faculty parties tend to be staid and parched affairs. People, for the most

part, arrive late and leave early, seldom with much trace of gaiety. On one particular evening, however, the faculty from the behavioral science departments came together for a party, and I am not certain whether someone spiked the punch or whether there was simply a general outpouring of old frustrations, but in any event, the party began to liven up perceptibly. Couples began to dance, laughter could be heard around the room, and the tempo of the party accelerated. At the height of the festivities, near midnight as I recall, the lights suddenly went out. When that occurred, an interesting set of behavior patterns emerged. The anthropologist-the philosopher of the behavioral scientists-immediately began to grumble because he

Dr. Lysaught, widely acclaimed for his work as Director of the National Commission for the Study of Nursing and Nursing Education, will deliver the keynote address at the FIRST NATIONAL MEETING OF THE NURSES ASSOCIATION OF THE AMERICAN COLLEGE OF OBSTETRICIANS, in May 1974, at Las Vegas, Nevada.

JanuaryFebruary 1974 JOGN .Nursing

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had never written that seminal article on why modern man should eat carotene so that he could see in the dark as his primitive ancestors had. The psychologist-the worrier of the behavioral scientists-attempted to predict how he would feel when the lights came on, and why. Then he began to worry about the prediction. The sociotogist-the craftsman among the disciplinesmade a seating diagram from memory, noting where people had been when the lights went out, for comparison when visibility returned. While all that highpowered thinking was going on, the political scientist got up and replahed thC fuse. Political scientists are generally regarded as the bumblebees, or the gadflies, of the behavioral disciplines because they are loathe to indulge in grand designs or high theory that is not related to the observable world in which they live and work. They are professional skeptics, and it i s this skeptical attitude and a desire to know what is truly going on that is most essential when reviewing nursing education. I must confess that, for the past six years, I have become more and more skeptical about some aspects of nursing education, particularly its relationship to the real world of practice and patient care. Concern for the Future - T w o short statements-both of which are drawn from the report of Former Secretary Richardson’s Committee to study the expanded role of the nurse, a committee chaired by Former Assistant Secretary Roger Egeberg-pinpoint these areas of skepticism and concern. T h e first is: W e believe that the future of nursing must encompass a substantially larger place within the community of the health professions. Moreover, we believe that extending the scope of nursing practice is essential if this Nation is to achieve the goal of equal access to health services for all its citizens.

I don’t know how anyone could state the issue more forcefully or bluntly than that. Certainly, the National Commission has worked in the same belief and toward the same end. If the practice role of the nurse clinician is to be expanded, however, our educational system and patterns must function in ways compatible with those same ends. The Committee had this to say about an expanded role for nurses: There is much concern about the implementa18

tion of expapded roles for the nurses: many nurses, graduates of hospital diploma schools, associate degree, or baccalaureate programs, are not now prepared to assume this expanded role and some are reluctant to accept it; many believe that present nursing school curricula do not prepare the nurse to function in an expanded role. . . , This, then, is the paradox we face. On the one hand, we say that to meet the health care needs of the nation we need more practitioners functioning in expanded nursing roles. On the other, we confess that our educational system is not producing these kinds of practitioners and is seemingly reluctant to change its ways in order to develop the nurses that we need now and most certainly will need in the months and years ahead. This is why the Commission for the Study of Nursing and Nursing Education, after three years of study and investigation, is now engaged in an additional threeyear effort to implement its recommendations, secure agreement on needed changes, and initiate new departures in nursing education that will facilitate role expansion and enlarge the career perspectives of the profession. I would like to suggest that most of the problems facing nursing education are well-known and welldocumented. The Goldmark Commission in 1923 catalogued and described a number of them. Oddly enough, 25 years later Esther Lucile Brown highlighted many of the same problems and recommended appropriate changes. It is not coincidental thad the National Commission, some 50 years later, is laboring to solve many of the same difficulties. One might infer from this that the establishment in nursing education isn’t exactly eager for change. However, one must also be aware t h t nursing no longer has a 50-year margin to mend its educational problems. With the national concern for health care dylivery, and with the acceptance by both medicine and the consumer of nursing’s key role, further failure of the profession to put its educational structure in tune with the times is likely to lead to a disillusionment so great that nursing’s very relevance will be in doubt; and while some nurses may still be in meetings with practitioners, I wonder how many will still carry the title of “nurse.”

Six Fundamental Problems I suggest that there are six fundamental problems in nursing education that have a particular impact on the practice of all nurses, particularly those who seek to expand and specialize their roles and functions. January/February. 1474JOGN Nursmg

Lack of Single System

The first of the six fundamental problems in nursing education is that it still has not developed a single rational system for preparatory education. Of all the professions, or near-professions, nursing alone enters the last quarter of the twentieth century with a bifurcated, belligerent system half located in the collegiate mainstream and half within the hospital schools of nursing. Year after year this patchwork quilt takes its toll of individual nurses caught between incompatible segments. Each graduate of a hospital school who wishes to continue up the educational ladder finds this, at best, a hazardous climb and, at worst, a damnable hoax. Perhaps as many as 80 percent of our current baccalaureate nurses received their RN certification from a hospital school. Each can testify to the frustrations and impediments they experienced-placement examinations, challenge tests for credit, course repetition and learning redundancy, extra costs, extra time, and constant pressure to prove one’s self again, and again, and again. Goldmark proposed a collegiate system of nursing education 50 years ago; Brown recommended a collegiate system of nursing education 2 5 years ago; the National Commission has worked to rationalize the system today and has had the satisfaction of seeing, for the first time ever, the majority of institutions and the majority of students under the collegiate roof. This is not to say that all hospital schools are “poor,” or that they have not made a contribution to nursing over the years. It is time, however, to establish a single, rational, compatible system for nursing education that will not frustrate career mobility for the nurse practitioner. For 50 years, the majority of-nurses have suffered needlessly because educational leaders maintained the status quo. It is time to end that-and to do it at once. Two-Year us Four-Year Programs

The second problem in nursing education is related to the first. When collegiate educators in nursing were approached they regarded us as a “Daniel come to judgment,’ when we advocated the termination of diploma programs. I am afraid that when the corollary of this recommendation was proposed it was more often viewed as “Daniel come for destruction!,’ If the Commission wants a rational system for nursing education, it also demands that it be an articulated system with proper bridging built between the two: and the four-year programs. This recommendation, of course, flies in the face of all the nonsense that has ever been JanuaryFebruary 1974 JOGN Nursing

generated by nursing educators about the differences between the two- and four-year programs. Terms such as “technical” and “professional” have been used to obscure the fact that most nursing curricula are generally alike whether in a two-, three-, or four-year program. In terms of objective results, state licensing board scores, blind studies of beginning practitioners, and other measures, there are at least as many similarities as there are differences among all kinds of educational institutions. How much difference is there between a two-year nursing program and a “generic” baccalaureate program in nursing in which the student takes no nursing courses for the first two years of college and then takes two years of nursing, with other subjects, in the junior and senior years? I submit that most of the “differences” are as easily explained by simple maturation and differences in age as by the “inherent and unique qualities” of the baccalaureate program. What is needed are genuine lower and upper division sequences in nursing, and genuine differences between two- and four-year collegiate programs, as well as ready Bccess from the two-year college into the third year of the baccalaureate program. It can be done. It is being done in institutions in such states as Illinois, Wisconsin, California, Florida, and Arkansas, to name a few. It is also time for the nursing profession to end the continued inarticulation of collegiate nursing-and to do it at once. Unchallenged Cmmnon Beliefs

One of the reasons that the two- and four-year, nursing curricula are not more different lies in the third problem of professional education, which requires an explanation. In philosophy, we speak of “primitive assumptions.” This is a common belief held so uncritically that we don’t realize that it may actually never have been examined. For example, until the time of Christopher Columbus, how many Spaniards, or other western Europeans, had ever questioned that the world was flat. Each of us has his own set of “primitive assumptions” which can cause him trouble. In the case of nursing education, one “primitive assumption” surely has. Because nursing education grew up in the hospital setting, it was taken for granted that nurses should be trained to work in that environment. Even when collegiate nursing began in the early 19oO’s, the clinical curriculum was modeled after that of the hospital school, and student nurses maintained their clinical circumlocution through medical-surgical, pediatrics, ob‘9

stetrics-gynecology, and the standard medical services. It was assumed that the best way to learn nursing was from the patient in a hospital ward. So prevalent was this notion that this educational pattern was called general nursing education. Superimposed on this were such areas as public health nursing. It was John Millis who first called attention to the fact that 88 percent of the health care problems in this country have nothing to do with hospital services. Rather, they are problems of health maintenance, disease prevention, primary care, and nonacute illness. Only 12 percent of the health problems are ones for which the hospital and the hospital nurse are equipped. This is really a set of figures to conjure with because, a t the present time, approximately 89 percent of all full-time nurse practitioners in this country are in hospital or hospital-related activities, while the remaining 11 percent are scattered around in public health, school nursing, occupational and industrial nursing, and other distributive care activities. Worse than this juxtaposition, however, is ”the fact that almost all preparatory programs in nursing, wherever located, are turning out nurses whose clinical instruction is shaped entirely around the episodic environment. What is needed is the development of alternative clinical tracks leading to beginning practitioner skills in both episodic and distributive care with individuals permitted to elect their areas of concentration. This would further mean that the present baccalaureate programs will not only have to add genuine upper division sequences but will also have to increase their alternatives and strengthen specialization in clinical nursing roles. The early development\-of episodic and distributive tracks in both ADN and baccalaureate programs has already been seen, and more will be seen in the coming months. It is time, now, for nurses to insist that nursing education prepare practitioners across the entire range of consumer needs, including the ability to care for the well and the sick. Separation of Education md Practice In all candor, the reason that nurse educators don’t teach expanded role functioning and extended clinical practice is related to the fourth problem in professional education-the separation of education and practice. Most nurse educators are simply not capable of serving in an expert role for tbe edification of their students. And perhaps one reason that we continue to teach fundamentals of nursing to third-year college students is that the faculty is much more secure teach20

ing fundamentals than they are instructing students in advanced clinical specialties. The day we begin to “push” clinical instruction “down” into the lower division, develop true upper division courses in nursing science and practice, and insist that the nurse faculty be able to practice what they preach, we will have solved our problem of separation between education and service. It will no longer be possible for nursing education and nursing service to exist in splendid isolation with the students orbiting in a limbo by themselves. If nhrsing is to remain relevant, nurse educators must return to practice and establish themselves as models of excellence. Over the past six years, I probably have talked with more nursing students than any other individual in this land. One general conclusion that can be taken from their comments is: “We are sick and tired of educators telling us to do something one way and service people telling us to do it differently. Why don’t they for once get together and show us-not tell us. Just once, we would like to look over their shoulders and see how care should be provided.” Their point is a very real one. If nursing is to be truly a full profession, it must be ueated as an applied clinical science without a false division between education and practice. Nursing can profitably take one lesson from medicine. If any member of our medical school faculty were to be asked what he “does,” his first answer would be couched in terms of his practice specialty. “I am a neurologist.” “I am a surgeon.” “I work in pediatrics.” If you ask the question a second time, the physician is likely to add, “Oh, yes, I’m an assistant professor of pediatrics, here on the faculty.” Just as medicine allows no false dichotomy between teaching and practice, so nursing must reassert the fundamental unity of its own professional field. A real effort in this direction is being made at the University of Rochester. The Dean of the School of Nursing is also Director of Nursing Service in the university health center. Every nurse educator flow hired on the faculty must have a commitment to personal practice and to clinical excellence so that there will be outstanding role models in every field of specialty care. The development of these teacher-practitioners was watched with initial skepticism by the medical disciplines because it was such a new departure in nursing education. Today, I think it can be said that it has been accepted with enthusiasm, and that there is a beginning in the development of true physician-nurse practitioner teams based on mutual respect and professional competency in practice. It seems almost ludicrous to point out that teaching January/February 1974JOGN Nursing

and practice are but opposite sides of the same coin in a clinical profession, but for a long, long time nursing education has behaved as if teaching and practice were mutually exclusive, and occasionally belligerent, rivals. Not every faculty group can change overnight, however. Some proportion of nurse educators are not only incapable of excellence in practice but are likely to be downright dangerous. Nursing service and nprsing education, however, must start working together and striving for excellence in clinical teaching and continuing excellence in care provision that will be mutually supportive. This effort should begin a t once. Lnck of Contimiing Edzicntion

The fifth problem in nursing education that directly affects specialty nursing care is an over concern for preparatory education to the detriment of well planned, continuing clinical education. There is a rising tide of legislation aimed at mandating continuing education for relicensure in nursing and, in some cases, in medicine as well. This effort to require continuous learning has served to highlight more than anything else how little there is to offer nurses who really are committed to the extensio9 of their clinical skills. Throughout the country, &re is a paucity of continuing education offerings. Most of the “courses” that are available do not embody participative elements in practice skills. While a course in “Pre-Civil War Nursing in America” may have great esthetic appeal and provide worthwhile information, clinical rounds in neonatology taught by physician-nurse teams of practitioners would also find a great number of registrants. In part, the lack of continuing education in clinical nursing is the result of separation between educators and service people. It is also due to organizational separatism between nurse educators who belong predominantly to the American Nurses’ Association and to the Aational League for Nursing, and to nurse ptactitioners who belong to the specialty practice groups which have, in the past, been viewed by the traditional organizations as “splinter groups.” One outcome that should emerge from the new Federation of nursing organizations is a clearer dialogue between educators and practitioners concernhg the needs for continued clinical teaching and how this may be provided. N o profession can be true to itself unless there is a deep-felt commitment to increasing knowledge, expanding services, and maintaining excellence. For the individual practitioner this involves lifelong learning with or without legislative mandates. For the educational system of the profession, there is January/Februaxy 1974 JOGN Nursing

an obligation to provide relevant, timely, and authoritative clinical updating. Nursing must face squarely the problems now extant in continuing education for clinical excellence. Edztcationnl Isolation

The sixth, and final, problem is the parochial separation of our educational patterns throughout the health professions. While this is a problem not exclusive to nursing, it is certainly one which affects the quality of clinical nursing care. It is not possible to educate student nurses and student physicians apart from each other, and then have them function as members of a health team. This educational isolation has been endowed with a sanctity that was never intended. Health historians point out that a t the turn of the century, up to 1905, there was less difference than one might think between educational patterns experienced by the “trained nurse” and those of the medical student who attended the then current didactic schools of medicine. With the implementation of the Flexner report after 1910, however, medicine moved rapidly into the educational mainstream and nursing remained in the hospital schools. Medical research rapidly expanded the parameters of that profession and the resultant psychologic distance was codified into educational patterns that still remain. The fresh stirrings in American nursing, however, suggest that it is time for reexamination of joint nursephysician learning at both preparatory, advanced, and continuing levels. The repositioning of nursing education into the collegiate mainstream, the new emphasis on clinical excellence and teacher-practitioner roles, and the establishment of lengthened career perspectives in professional nursing all support a new relationship between the, two primary practitioner groups -medicine and nursing. It was no accident that the Board of Trustees of the American Medical Association endorsed the central thrust of the recommendations of the National Commission for the Study of Nursing and Nursing Education. It was no accident that the AMA and ANA worked together to establish the National Joint Practice Commission between medicine and nursing. And it was certainly no accident when that body designated, as one of its initial task forces, a committee to explore educational patterns to foster and enhance the joint provision of care by nurses and physicians. There is a “blowin’ in the wind” that presages a new relationship between medicine and nursing. It is essential that educators and practitioners in nursing foster and en-

courage these trends toward change, and do it now. Conclusion

These, then, are educational problems that can and must be solved. Nursing is not granted any luxury in time to set about the work of repatterning and reconstruction. There has been a great deal of talk over the past 50 years; now is the time for concerted and decisive action. Not all the problems of specialty nursing care, of course, can be attributed to educational difficulties. It wasn’t an educator that created utilization patterns for hospital nursing which move nurses inevitably farther and farther away from patient care and more and more closely into administrative systems and paper management. It wasn’t an educator who fostered the practice patterns that permit (as in the Yale-New Haven Study) 60 percent of patient care to be provided by untrained aides, attendants, and volunteers while nurses stand atop a pyramidal structure and provide “care through others.” These are matters which nurse practitioners must correct. T o start, the responsibility for excellence in practice which cannot be divested must be reclaimed by the nursing profession and the oath each nurse took as she entered this profession must still be maintained. Education and practice must join hands to ensure that nursing becomes a full profession. A rational pattern of education, fully articulated, clinically excellent, with opportunity for specialty choice, and continuing,

interdisciplinary learning must be ensured. All false and illogical barriers by which nurse educators have become isolated and weakened must be eliminated. Client care must become the standard of measurement for the profession and education and research established as the means to that end, not treated as independent entities. It must be demonstrated to the American public and to congruent health practitioners that nursing is capable of facing up to the facts and of taking vital corrective action, no matter what the weight of tradition or the inertia of the status quo. Esther Lucile Brown, in 1948, said that nursing could only truly become a profession when a sufficient number of individual nurses developed strong self-images as worthy contributors to the solution of this Nation’s health problems. Today, first and foremost, we need nurse practitioners, and nurse clinicians, by their example of competence and dedication, to assert the true worth of the profession. In the past six years, there has been a great strengthening of such purpose and resolve. As a result, we have seen great strides toward the development of a new, unambiguous profession of nursing. With education and practice working together, the profession can now solve its basic paradoxes and dilemmas. And it is to this final solution of its unfinished agenda that nursing must make its commitment toward change-and do it today! Address reprint requests to Dr. Jerome P. Lysayght, 17 Bretton Woods Drive, Rochester, N Y 1M18.

T h e author has bee72 affiliated with T h e University o f Rochester, Rochester, N e w Y o r k , since 1963. H e received his doctorate there in 1964 and is currently Professor of Education at the College of Education and Professor of Medical Education at tbe School of Medicine and Dentistry. Dr. Lysaught is also Director of the National Connnirsion for the Study o f Nursing and Nursing Education and the Coordinator of the Rochester Clearinghouse o n Self-Instructional Materials for Health Care Facilities. H i s AB and M A (political science) degrees were taken at the University of Kansas. Dr. Lysaught has received several professionnl awards and holds ( o r has held) numerous advisory positions and professional board mzd organization memberships. These include the Association of American Medical Colleges, the Harvard University School o f Public Health and the National Society for Programmed Instruction. H e has also written or edited 12 books, 25 chapters in anthologies, and 71 articles and has been the editor of six periodicals. Having served for t w o periods in the U. S. Marine Corps, the second time i n the Korean W a r , Dr. Lysaught resigned in 1952 with the rank of Captain. H e is married and has four childreiz. 22

January/February 1974 JOGN Nursing