Education: Fitting In or Standing Out: What Will Change in Nursing Education Over the Next Five Years?
When I graduated from my nursing program in 1981 I was one of a rare breed: a "basic" baccalaureate graduate nurse. I recall being told then that only 20 per cent of nurses in Canada graduated with an undergraduate nursing degree. In some rather unusual ways, I had to fight my way into practice. My nursing colleagues, all of whom held a diploma in nursing, had a hard time understanding what it meant to have graduated from a degree program. The assumption was that I had probably read a lot of books and had thought about practice, but likely had never actually practised and would not want to engage in "hands-on" practice. Indeed, seeking an initial position in nursing during the summer prior to my final year in university, I made inquiries at a small rural hospital. I had bought into the rhetoric that, as a "university" nurse, I would need a great deal more experience than I had obtained in my nursing program before I could succeed as a nurse. I was desperate to fit in. When I inquired into the availability of nursing positions, I was met by a Director of Nursing who, looking at me suspiciously, asked me if I was after her job!
Twenty-one years later, the government of British Columbia approved a budget for the Ministry of Advanced Education that would enable all students entering nursing programs in that province to complete a baccalaureate degree in nursing by 2005. We were not the first province to make this policy decision. We have followed Ontario, Saskatchewan and the Atlantic provinces. We are ever watchful that what happened in Manitoba (achieving entry-to-practice only to lose it again) does not happen here. This is a precarious existence indeed. Precarious - but powerful. It is my view that this policy decision could, if we support it, change nursing radically.
The entry-to-practice "debate" has been with us as long as I have been involved in nursing education. As I was making decisions about where to enroll in a nursing program, I recall being told that a degree would soon be required for entry into the profession. Up to that point, my planning had always involved thoughts of the local hospital nursing program. I was unaware in the mid-1970s that university education for nurses was even a possibility. Someone must have directed me to university. I remember meeting some very impressive women at the University of Calgary - nursing faculty who took time from their busy academic lives to talk with young women and men interested in engaging in nursing as an academic endeavour. It has taken me a very long time to appreciate what that means. I certainly didn't understand it when I entered my undergraduate program, and I'm not sure I understood it when I left. It was my doctoral education that moved me to a place from which I can now point to choices I made and opportunities I've been presented with in each of those educational and practice settings: specifically, the links between the generation of disciplinary knowledge and engagement in professional practice.
It was and continues to be troubling to me that the question of whether nurses should have academic training for entry into the profession is still current. Debate is always valuable; it provides opportunities for members of a discipline to share their views. But when the debate occurs only within nursing, we experience nursing as fractured: divided by complex arguments about "worthiness." Perhaps more important would be an ongoing debate between nursing and other health professions on this question of appropriate educational qualifications - and then, a debate not just about credentials but what credentials denote. Baccalaureate education is about the ability to think critically. What might this qualification mean when, instead of having 20% of the nursing population educated with a degree, 100% of nursing graduates hold it?
If we get the best out of university education, a baccalaureate degree means a vast number of different things. Each teacher that a student meets during his or her education will have a position on what it is to think critically and what to think critically about. The implication is that each nurse will enter practice with different thinking processes. These differences should not be mistaken for a lack of rigour - in education or in conceptual activity. I fear there is an enduring and deep value in nursing for sameness: a hope for similarities among practitioners, that one nurse can replace another in any circumstance, that they will "fit in." Such a value suggests a discomfort with and rejection of difference. Such a value system - a hope for sameness and a rejection of difference - has led us to employment practices in which we have unprecedented levels of casualization of the nursing workforce and a crisis of retention of new nurses entering the profession (Armstrong and Armstrong 2003; McIntyre and Ceci 2003).
Education provides students with conceptual tools with which to recognize and analyze situations. The best education ensures that students know about choices among conceptual tools they have available to them to engage in this analytic work. It also ensures that students recognize that such choices are tightly linked to values they hold about the practice of nursing and the goals of that practice. And it is at this juncture - the juncture between thinking, practice and values - that baccalaureate education for nurses will make a difference for client care over the years ahead.
We all have a responsibility to participate in facilitating this difference. Nurses with good academic training will want to think independently. They will want to distinguish themselves from their peers. They will want to "stand out." They will want to make decisions, and they will demand respect for their decisions. They will want to analyze how nursing practice is conducted, and they will want to make suggestions for improving that practice. Not all these suggestions will be achievable. But they will come from a conceptual framework enabling particular analyses of what effective practice might be. These analyses can, and must, be made explicit so that they can be debated openly within and across disciplinary lines. These nurses are going to seek out nurse leaders who can help them realize their goals for practice. That demand will require of leaders an engagement with nursing practice that acknowledges autonomous practice within an organizational context of multidisciplinary contributions to the care of people who are sick and vulnerable - and in desperate need of nurses who think, who act on the basis of their knowledge and who are valued for their independence of professional action.
About the Author(s)
M.E. Purkis, RN, PhD
Associate Professor and Director, School of Nursing
University of Victoria, British Columbia
Armstrong, P. and H. Armstrong. 2003. Wasting Away: The Undermining of Canadian Health Care. (2nd ed.). Toronto: Oxford University Press.
McIntyre, M. and C. Ceci. 2003. "The Nursing Shortage: Historical Links and Current Understandings." In M. McIntyre & E. Thomlinson, eds., Realities of Canadian Nursing: Professional, Practice, and Power Issues. Philadelphia: Lippincott.
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