Needed: Articulation between nursing education programs

and institutions of higher learning

L a u r a C. Dustan, MN, EdD

“A democratic, industrialized so- ciety needs many types and levels of talent and education . . . and rests on the service of citizens whose talents are few or modest together with those whose abilities are many or ex- ceptional.”’

The proposition stated in the above quotation from T. R. McConnell’s book, A General Pattern for Ameri- can Public Higher Education, refers to our overall system of higher edu- cation. However, it can also be ap- plied to subsystems within the gen- eral pattern which prepare the man- power for specific occupations. The

Laura C. Dustan received an MN from Frances Payne Bolton School of Nursing a t Western Re- serve University in Cleveland, and a EdD from

the University of California at Berkeley. She is dean of the College of Nursing at the University of Iowa, Iowa City. She i s also chairman of the Na- tional League for Nursing Council of Baccalaureate and higher degree programs. This article, Copy- right December 1970, The American Journal of Nursing Company, is reprinted from the December

1970 issue of Nursing Outlook.

occupational field of nursing is a case in point. This broad area of essential service to both well and ill human be- ings encompasses a wide variety of activities that range from those re- quiring the commitment of scholars to those well served by vocationally trained nurses’ aides.

Educational programs for the pre- paration of nurses developed outside the higher education system. So- called “schools” of nursing were established by hospitals to provide in- expensive patient care. Students were expected to earn their right to learn. As a result, learning was all too often subservient to earning. This type of education for nursing persisted al- most unchallenged until World War I1 disrupted the hospital system for pa- tient care. When both doctors and nurses were drained away by the de- mands of the Armed Services, medi- cine responded by delegating some of its time-honored functions to nursing and some to other allied health work-

November 1971 49

ers. Nursing, with no sub-group avail- able, adjusted to its manpower short- age by opening the doors to untrained workers who required on-the-job training as well as close supervision. Thus, World War I1 was the catalyst that cracked the monolithic, hospital- controlled nursing education system.

In its search for a way to provide a variety of educational opportunities that would prepare personnel to as- sume nursing’s expanding responsi- bilities, the profession has increas- ingly sought support from the gen- eral education system. Consequently, the programs that have evolved ac- commodate to persons with a wide variety of levels of training and abil- ity, all of whom come under the umbrella of nursing. The total nurs- ing education system encompasses vocational training of aides and order- lies; formal programs sponsored by high schools and community colleges for the preparation of practical nurses; diploma schools of nursing and two-year associate degree pro- grams for the preparation of techni- cians; baccalaureate programs for the preparation of professionals; masters programs for the preparation of teachers, supervisors, and clinical specialists; and doctoral programs.

In spite of the positive aspects of the diversity which nursing educa- tion has developed, some major prob- lems are still unsolved because the system has failed to produce enough college prepared nurses to meet the requirements of the professional com- ponent of nursing practice. Like other service occupations, nursing has found that college and university edu- cation is essential preparation for the more complex aspects of its functions. The need for more nurses prepared at this level was clearly identified in the

1963 report of an expert committee appointed by the Surgeon General of the US. Public Health Service to study the pressing problem of the shortage of nurses:

Most urgent is the need to increase the number of nurses with academic preparation for teaching, supervision, and other leadership positions. We be- lieve that with adequate support the number of nurses prepared a t the bac- calaureate level can reach 13,000 a year (by 1970), and at the masters level 3,000 a year.2

During the decade of the 1960s, the number of students graduating from four-year college and university programs increased but the increment fell short of the identified need. In 1959-1960,4,136 baccalaureate gradu- ates were reported. Six years later (1965-1966) the number of yearly graduates had increased to 5,498. However, between the academic years of 1964-1965 and 1965-1966, the in- crease in the number of graduates was a mere 117.3 From these figures, it seems obvious that the nursing education system is failing rather badly at the baccalaureate level and that, consequently, there is little hope for an increase in the numbers of nurses prepared at the graduate level to assume leadership positions in both educational and service agencies.

The major stumbling block faced by nursing educators, today, and by the students who choose to prepare for a career in nursing, is the lack of direct articulation between the termi- nal preparatory programs for the preparation of vocational and tech- nical workers and the baccalaureate programs which prepare the profes- sional practitioners of nursing. Even at the less-than-baccalaureate level there is an absence of articulation be-

50 AORN Journal

tween the preservice programs that prepare vocational and technical nurses. The student who chooses a practical nursing program enrolls in a terminally designed curriculum which is not the same as that for the first year of a diploma or an associate de- gree program. By the same token, stu- dents who select technical preparation in hospital-conducted or community college-sponsored programs do not re- ceive the equivalent of the lower-di- vision component of a baccalaureate curriculum. In fact, the only natural progression from one educational level to the next that our system pro- vides is that between baccalaureate programs and graduate programs leading to the master’s degree.

Given the diversity of sponsorship of the various types of preparatory programs - high schools, hospitals, junior and community colleges, and four-year colleges and universities- this disarticulation is understandable -but it defies easy remedy. Propo- nents of a ladder concept for profes- sional education seemingly fail to take into account that curriculums de- signed as terminal require only those foundational courses which contribute directly to the objectives of the spe- cific program. More specifically, for the nursing education system as a whole, no basic set of requirements in general education and the be- havorial and biological sciences which would undergird the study of nursing for all of the various types of prepara- tory programs has been devised.

The nursing content of a practical nursing curriculum is built on a high- school education base. Associate de- gree and hospital-conducted diploma programs do include some general education and selected science con- tent, but their primary focus is on

the early and somewhat limited study of nursing. Baccalaureate programs require that at least half the total credit hours required for the bache- lor’s degree must be from general liberal studies and from those sciences deemed essential for a comprehensive understanding of nursing theory. In the main, most of this course work is considered foundational and, there- fore, prerequisite to the courses which comprise the nursing major. As a re- sult, students who enter the system by the practical nursing route have not acquired the educational base deemed essential for any of the other three types of programs. By the same token, the student who graduates from a diploma or associate degree program lacks essential general edu- cation and science content to use as a foundation for an upper-division ma- jor offered by a four-year college or a university.

Graduates of practical, diploma, or associate degree p r o g r a m s who change their educational and career goals must backtrack to pick up the required foundational courses before they are ready to undertake the upper-division major in a baccalau- reate program. Because their pro- grams have included only a limited amount of general studies and science content, a certain amount of repeti- tion is inevitable when a student moves up in the system. In terms of time, money, and frustration, this repetition is costly-to the student, to nursing faculties, and to society.

The problem is most acute for di- ploma program graduates who decide that they wish baccalaureate prep- aration. Because the sponsoring insti- tution (the hospital) is a service agency, it is outside the credit system that is used by institutions of higher

November 1971 51

education to assure course equival- ency. If the hospital school has con- tracted for general education and science courses to be taught at a local accredited college or university, these courses will transfer. But no such measures of equivalency exist for the nursing content and, therefore, no direct transfer of credit is possible. Thus, a diploma school graduate, having completed up to three years of post-high school study, may have earned no credits which are directly transferable to a college or university. Some four-year institutions provide methods whereby students may “chal- lenge for eredit” but, even by such methods, little more than a year of academic credit can be earned, This means that a scholastically able, di- ploma school graduate who changes to career goals which require bacca- laureate preparation must spend two and one-half to three years in study at a university. This, added to the three years spent in a diploma school, makes baccalaureate education al- most prohibitive-both as to time and cost.

The problems presented by the lack of articulation between the compo- nents of the nursing education system would be less acute for students and for the leadership needs of the pro- fession if ways could be found to match students with programs before they enter the system. Studies of stu- dents enrolled in the various types of programs and of practicing nurses’ interest in occupational advancement have further identified the dilemma which the nursing profession faces in providing sufficient leadership per- sonnel.

One of these studies examined the “fit” between the scholastic aptitude, interests, and career expectations of

students and the type of nursing edu- cation programs they had selected. Students in one baccalaureate pro- gram, two diploma programs, and one associate degree program (all in San Jose, California) were the subjects. Long-range career expectations of many of the students in diploma and associate degree programs were found to be inconsistent with the objectives of schools they had chosen to enter; in other words, they looked forward to positions for which preparations at the baccalaureate level is the mini- mum education prerequisite-posi- tions in public health nursing, nursing service administration, and teaching in schools of nursing. The lack of “fit” between program objectives and students’ scholastic aptitude, values, interests, and long-range career plans was particularly marked for the stu- dents in the associate degree pro- gram :

It would appear that there was either a serious discrepancy between what they (associate degree students) wanted to do and the educational preparation they had chosen to un- dertake, or that they had failed to in- vestigate the implications of a ter- minal, technical curriculum. In either case, this mismatching between stu- dents and program objectives has serious implications for the system of nursing education which has the re- sponsibility for preparing nurses for all levels of practice. If large numbers of students with interest in, and ability for, college-level work select associate degree programs as their initial entry point into nursing, there will be an indefinite perpetuation of the “patchwork” programs which the senior colleges have faced in their attempts to absorb diploma school graduates into the structure of bac-

52 AORN Journal

calaureate education. On no basis can this be considered a desirable or eco- nomical way to meet the need for nurses with the educational prepara- tion which is essential for teachers, nursing service administrators, and research workers upon whom the pro- fession depends for its present prac- tice and its future development."

Another study identified the re- cruitment of nurses for administra- tive positions as one of the most pressing problems facing the nursing profession, and investigated some of the factors that contribute toward or mitigate against nurses developing an interest in occupational advancement. The sample studied consisted of public health nurses employed in agencies located in the Greater Bay area around San Francisco. The principal factors investigated were social class origins and situational realities in- herent in the woman's role which seemed most pertinent to her occu- pational pursuits. The findings in re- lation to social class origins showed that proportionately as many nurses from the lowest social class back- ground registered interest in becom- ing supervisors and administrators as from the highest social class. On the other hand, nurses who fell into the middle class grouping were less in- terested in positions of leadership. Also, those nurses whose first en- counter with nursing education cul- minated in a baccalaureate degree showed more interest in occupational advancement than those nurses who graduated first from a diploma pro- gram:

The findings suggest intensified and aggressive recruitment of student nurses from the highest and lowest social classes as a possible medium for developing more nurse leaders. The

lowest class group has the least fi- nancial opportunity for higher educa- tion. . . . If they have had the good fortune to have had higher education they appear, in this study sample, to be a highly motivated group. Meth- ods for reaching this group, influenc- ing them, and assisting them finan- cially to obtain higher education need to be developed. Also girls and their parents from the highest social class should be informed that nursing is changing and that the nursing role is no longer akin to that of a domestic servant so that more of their mem- bers might be attracted to the pro- fession.5

The findings in both of these studies support the proposition that there is a need for the development of transfer curriculums in community colleges as a means of expanding op- portunities for baccalaureate educa- tion for nursing. The fact that these two-year institutions may be more financially and geographically acces- sible to students might attract more applicants from the less affluent seg- ment of our society. The report of the second study indicated that the ex- istence of transfer curriculums in the private college sector of our general education system might attract indi- viduals from the more affluent seg- ment of the po~ulation.~J

In addition to the needs of society for more nurses prepared in the col- lege setting, the needs and desires of individual students for a college edu- cation must be recognized, supported, and made possible. Baccalaureate pro- grams have long held a three-fold ob- jective to prepare the individual to function in the role of a beginning professional, a self-fulfilled person, and a citizen. Ours is a college-bound age, and students interested in nurs-

November 1971 53

ing as a career have a right to expect that this profession, as well as a mul- titude of others, can be studied in the

major in nursing offered by the Col- lege of Nursing a t the University of Iowa.

college and university setting. This constitutes another compelling, but less frequently cited, reason for ex- panding baccalaureate nursing edu- cational opportunities.

A solution to the problem of the slow and inadequate increase in the number of graduates from baccalau- reate programs must be sought and found if the nursing education system is to produce a balanced output from its various types of preparatory pro- grams. The best approach to this so- lution would appear to be the develop- ment of a method by which nursing could better utilize the tremendous system of higher education which the public supports through universal taxation and private giving. Such a method should involve both the pub- licly and privately supported sectors, as well as the two- and four-year com- ponents of the system. If a new way can be found to markedly increase the number of graduates with baccalau- reate preparation, it should follow that an expansion will occur in oppor- tunities for graduate education. This, in turn, may finally resolve nursing’s pressing problem of acute shortages in “the number of nurses with aca- demic preparation for teaching, su- pervision, and other leadership po- si tions. ’ ’ 8

A pilot project based on the propo- sition stated in the foregoing para- graph has been undertaken in the state of Iowa. The specific objectives of the project are to:

1. Develop “feeder” or lower di- vision transfer curriculums in se- lected two- and four-year higher edu- cation institutions which will articu- late directly with the upper-division

2. Markedly expand enrollments in a baccalaureate nursing program by providing locations all across the state where students can begin the lower-division component of the cur- riculum.

3. Recruit students from all social classes by utilizing both publicly and privately supported two- and four- year institutions of higher education.

4. Provide students with a number of options in the lower-division years in order to accommodate to individual financial ability, choice of location, and size and type of institution in which to begin college preparation.

Iowa presents a rather unusual set- ting in which to test this type of ap- proach to planned articulation. Out of 52 institutions of higher education in the state, only four 4-year institu- tions have assumed the responsibility for baccalaureate nursing education and, to date, only a few community colleges have associate degree nursing programs. Many educational oppor- tunities are available to students pre- paring for many types of careers, but preparation for nursing has received little attenion from either the publicly or privately supported sectors of the higher education system.

Traditionally, Iowa has relied on hospitals, supported by the sick seg- ment of the population, and on stu- dent services and fees, to provide and finance schools of nursing, As service agencies, hospitals never were logical settings for educational programs. Now that rising costs are forcing a more careful assessment of the way the patient’s dollar is being spent,

54 AORN Journal

hospital-supported schools b e c o m e less and less viable and justifiable. Therefore, Iowa, still dependent on hospitals for the preparation of the majority of its nursing practitioners, is an ideal place to test new ap- proaches to the absorption of prep- aratory nursing education programs by the higher education system.

year curriculum that meets the re- quirements for a biology major. Stu- dents interested in this approach transfer a t the end of three years to the College of Nursing for the upper- division course work in nursing. At the successful completion of the five- year program, they will simultane- ously be awarded a B.A. from Luther

colleges. Each pilot school is develop- ing a lower-division transfer sequence that is designed to meet the general education (arts, sciences, and human- ities) requirements of the nursing major offered at the University of Iowa. Under this plan, a student who chooses baccalaureate nursing edu- cation can start the program in one of 12 different locations scattered across the state. At the end of the first two years, all students who have success- fully completed the lower-division se- quence will transfer to the College of Nursing for the upper-division courses in the nursing major.

While the Iowa plan is designed as a two-year sequence of general edu- cation and science courses plus a sum- mer session and two upper-division years for the nursing major, a vari- ation has been worked out with one private liberal arts college which has a long tradition of preparing students for entry into medicine, dentistry, and many other professional and scientific occupations. The Luther College transfer sequence consists of a three-

This particular approach to bac- calaureate education for nursing has a number of broad implications for nursing, for higher education, and for students. If successful, it will: (1) in- crease the involvement of Iowa insti- tutions of higher education in college education for nursing; (2) increase opportunities for students to enter a baccalaureate p r o g r a m first by making the lower-division transfer sequence available all across the state; (3) spread the responsibility for the general education base (arts, science, humanities) required for the nursing major across a broader seg- ment of higher education institutions; and (4) provide a way for the rapidly expanding community college system to tie in with the upper-division nurs- ing major offered by a senior college.

The fourth outcome may have the most far-reaching implications for the future of baccalaureate education for nursing because it can serve to weld together the two- and four-year com- ponents of the higher education sys-

November 1971 55

tem. Community colleges are a natural setting for technical nursing programs. If they can also provide a transfer sequence which feeds directly into a baccalaureate program in a senior college, prospective students can be guided into the type of pro- gram best suited to the individual's scholastic ability, interest, and long- range career goals. Benefits will ac- crue to students, to nursing's leader- ship corps, and to society-the con- sumer of that portion of health care services which is the responsibility of nursing practice.

To quote McConnell again, ". . . the system (of American public higher education) must be flexible enough to enable each student to reach the high- est level for which his aptitude and performance qualify him."9 Hope- fully, the Iowa project will point the way to the development of a rational nursing education system with the flexibility it needs to meet that speci- fication.

REFERENCE

I . McConnell, T. R. A General Pattern for Amer-

ican Public Higher Education. New York, McGraw-

H i l l Book Co., 1962.

2. US. Public Health Service. Toward Quality in

Nursing; Needs and Goals. Report of the Surgeon

General's Consultant Group on Nursing. (Publica-

t ion No. 992) Washington, DC, U S Government

63. pp 22-23.

3. American Nurses' Association. Facts About

Nursing: a Statistical Summary. New York, The As- sociation, 1967, p. 96.

4. Dustan. Laura C. Characteristics of Students in

Three Types of Nursing Education Programs. Berk-

eley, Ca l i f , University of California a t Berkeley,

1963, p 195. (Unpublished doctoral dissertation)

5. Knudson, Eleanor Gray. Public health nurses'

interest in occupational advancemwt. Nurs Res

17:335, July-Aug. 1968.

6. Dustan, op cit , p 2 10.

7. Knudson, op c i f , p 333.

8. U.S. Public Health Service, op cit , p 23.

9. McConnell, op cit , p 190.

While asleep and dreaming A proiect that could lead to the development of a new measure of central nervous system activi ty during sleep has been announced by HEW'S National Institute of Mental Health, Health Services and Mental Health Administration.

Scientists at the University of Texas, Austin, are monitoring the activi ty of the tongue and laryngeal muscles during sleep to determine i f "silent speech"-known scientifically as subvocal motor activity--accompanies dreams.

I f it i s found that "silent speech" does occur, the phenomenon could be used as a measure of dream content and sleep talking.

Peter F. MacNeilage, MD, director of the University's Linguistics Laboratory, says that if "silent speech" is found to occur " i t may be a useful index of neurological organization during (various stages o f ) sleep, and a useful manifestation of dream content."

Since rapid eye movement was found to accompany most dreams, it has been used widely as an overt measure of sleep and dream activity. Its use has aided sleep research immeasurably.

The proposed method i s t o make recordings during sleep from representative points in the laryngeal and upper articulatory musculature to determine the frequency and patterning of subvocal muscle activity. Col lege student volunteers w i l l be selected on the basis of a sleep questionnaire which includes questions about dream recall and sleep talking.

56 AORN Journal