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Professional Nursing Education - Today and Tomorrow
Pages 333-360

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From page 333...
... Outlines of Nursing History, fifth ea., 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.
From page 334...
... 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.
From page 335...
... 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., 19831. For example, the first generic nursing doctorate (ND)
From page 336...
... , 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 BSNthen presupposes advanced preparation in a specialty area at the master's level.
From page 337...
... 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.
From page 338...
... 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.
From page 339...
... 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 de.
From page 340...
... 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)
From page 341...
... 341 <,, o ~ Cal 04 o C)
From page 342...
... 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, 1994J.
From page 343...
... 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.
From page 344...
... 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.
From page 345...
... 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 .
From page 346...
... 346 NURSING STAFF IN HOSPITALS AND NURSING HOMES TABLE 5 Some of the Paradigm Shifts That Academia Is Experiencing Traditional Expanded Teaching · Emphasis on teaching · Emphasis on learning · "Sage on stage" · "Guide by side" · Obtain and retain facts · Apply knowledge to real problems · Obtain degree · Develop portfolio of competencies · Process oriented · Outcomes oriented · Discipline based · Interdisciplinary · Place bound · "Virtual university" Research · Scholarship narrowly defined · Scholarship broadly defined · Congruent with personal interests · Congruent with institutional mission · Emphasis on refereed publications · Emphasis on dissemination to · Supported largely by federal professionals and public alike government · Supported increasingly by private sector Service · Undervalued and discouraged · Confused with volunteer community activities · Seen as quasi-charity · Emphasis on university and 1- ' 1 · a.lsclpllnary 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.
From page 347...
... 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)
From page 348...
... 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 SO-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.
From page 349...
... 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.
From page 350...
... 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)
From page 351...
... 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
From page 352...
... 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~.
From page 353...
... 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.
From page 354...
... 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.)
From page 355...
... Journal of Professional Nursing 8:7-15, 1992. Annas, G.J.
From page 356...
... Reconsidering Nursing Education: The Report of the Pew Health Professions Commission. Journal of Nursing Education 31 :296-301, 1992.
From page 357...
... Fenton, M.V., and Brykczynski, K.A. Qualitative Distinctions and Similarities in the Practice of Clinical Nurse Specialists and Nurse Practitioners.
From page 358...
... Koerner, J Differentiated Practice: The Evolution of Professional Nursing.
From page 359...
... San Francisco: University of California Center for the Health Professions, 1993. Pew Health Professions Commission.
From page 360...
... Health Professions Education and Relationshipcentered Care. San Francisco: Pew Health Professions Commission, 1994.


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