Community junior colleges which decide to add an associate degree nursing program to their curriculum must provide a laboratory for the teaching of nursing. The hospital is the primary health agency suited for this purpose. The college initiates cooperative arrangements with selected hospitals, which agree to the use of their facilities as an extension of the college campus. The cooperative agreement is formalized in writing and clearly establishes the responsibility of each institution. The college assumes the responsibility for the education of the students in the nursing curriculum, and the hospital assumes the responsibility for providing the climate and physical setting for learning.
We cannot fully appreciate the opportunity and responsibility community junior college teachers of nursing have when the hospital is used as a nursing laboratory unless we have some knowledge of the early struggles of nursing educators to place collegiate education in nursing on a firm educational base.
The Problem of Control in Collegiate Nursing Education
In the early beginnings of collegiate nursing programs the problem of control, i.e., the selection of students, the appointment of faculty, financial support, curriculum development, and the conduct of the program through the regular lines of authority of the educational institution, was a recurring one as nurse educators struggled to have nursing education become a legitimate curriculum offering of the college or university.
At the 1915 Annual Convention of the National League for Nursing Education, Leonia Powell enumerated seven points which schools under university control should absolutely insist upon. Several of her points related to control. For instance, she said that the head of the school of nurses should be a member of the faculty. She also maintained that students should not be paid a monthly wage, which would make them employees instead of students. She further expressed concern about the number of hours of work students had in the hospital. "These hours," she said, "should be such that time can be had for study and so that all lectures and recitations may be held in the day." i The university-hospital relationship was seen as an "affiliation" between the two, with neither one completely controlling the program.
Subsequently, as a result of requests from universities and schools of nursing, the Committee on Education of the National League of Nursing Education published a preliminary report on university schools of nursing in 1921. 2 The report described what had been done in these schools, outlined some of the aims the schools were trying to realize, and pointed out a few principles which seemed to be essential in building up a sound structure of nursing education within a university or college. Essential elements in the structure were listed. One of these dealt with the available hospital facilities. "No matter how good the university, it would be unwise to offer a university course in nursing unless the hospital facilities were of the highest type." The chief nurse administrator was to serve in a dual position. "Where the university nursing school is connected with a special hospital the director will serve as superintendent of nurses in the hospital." The difficulty of maintaining control when the hospital was a distance from the university was also recognized.
The committee further stated that a university school of nursing was expected to place the educational interests of its students first, and to make certain that whatever supplementary forces necessary for the work of the hospital is supplied without drawing on its student body for unnecessary services. The employment of "competent supervisors who are really educators and not just foremen of a group of workers" was advocated, and the committee recommended that these supervisors be considered part of the university staff. The need for "coordinators as well to go between the university and the hospital and tie up the one constantly with the other" was also recognized.
Approximately ten years after this report the NLNE conducted a questionnaire study to determine the cooperative arrangements between schools of nursing and academic institutions. A study of the returns from 83 questionnaires led to the conclusion that only 12 schools were an integral part of a college or university.3
In 1937 the NLNE, through its Central Curriculum Committee, brought together some of the facts concerning the historical development of degree programs in nursing. 4 The study revealed that as of 1936 there were 70 nursing curriculums in the United States which lead to degrees. Of this number, 58 schools of nursing had organizational relationships with a college or university. Only 15 of the 58 schools were integral parts of their colleges or universities and set up in the same manner as were other departments of these institutions. Seven schools were subdivisions of medical schools. The committee was also interested in the status of the faculty of the school of nursing since it believed that the status of the school would reveal the type of relationship existing between the university and the professional school. In 27 of the 58 schools the director had a faculty title in the college or university with which the school of nursing was connected. Evidently the control of the nursing curriculum remained a matter of confusion and continued to be a cause of concern to nurse educators.
In 1938 Elizabeth S. Soule of the University of Washington presented evidence that the "weak connection with the hospitals" she had previously referred to had been considerably strengthened.5,6 A clear definition of policy between the University and the Hospital regarding responsibilities in relation to the school of nursing had been agreed upon at the University of Washington. Policy had been developed from the principle that the University should finance the administration and the teaching load in the school of nursing, and the hospital should carry the responsibility and expense for the nursing care of patients. One of Soule's recommendations was that a college or university and a hospital which cooperated in a nursing education program appoint a committee to work out the details of a plan. She saw the responsibility of the university in relation to the matter of control as including the appointment of a qualified faculty, the creation of a school or department of equal rating with other similar types of work, and the directing of the professional education in the hospital by appointing a faculty member of appropriate rank to administer the professional curriculum in the hospital. She also recommended that the university share with the hospital the salaries of the clinical instructors and teaching supervisors.
The responsibilities of the hospital were identified as ( 1 ) working with the university in the selection of students and faculty, (2) working with the university in building a sound curriculum, and (3) planning for the care of the sick in such a way that clinical material would be available to students, rotation of services as outlined by the university would not be interrupted, and the number of hours of work would be limited. Soule further recommended that the administration of the school be in the hands of the university and the administration of nursing service in the hands of the hospital. It is apparent that there was increasing clarification on the problem of control of nursing education in the college and/ or university setting.
In 1943 the American Journal of Nursing published an article which invited the evaluation and criticism of the nursing profession. 7 Eugenia K. Spalding, the Senior Nursing Education Consultant of the United States Public Health Service, had developed guides which were modified from the standards of the Association of Collegiate Schools of Nursing and other sources. Spalding believed that if the university had to secure clinical facilities from outside sources, organizational and contracture! arrangements should be carefully considered and formulated in order to give each of the cooperating institutions or agencies freedom to carry out its own purposes. Dual responsibility for education and service was advocated.
Spalding followed this article with "Contractural Agreements," in which she attempted to clarify some of the problems relating to control. 8 After clearly defining an agreement, she offered suggestions which she believed should be considered when the agreement was drawn up. The agreement, she believed, should indicate in broad terms the distribution of authority and the responsibilities of participating institutions and agencies. The "jurisdiction must be defined sufficiently to indicate plans of administration and responsibility of adniinistrative, supervisory and instructional personnel in each hospital or other agency."
Spalding also recommended that the question of salaries be settled when the agreement is being developed. This would involve, she said, discussions on how salaries would be shared by hospitals and other agencies concerned, and would require a statement on the apportionment of time of instructional personnel who hold teaching positions in clinical units in relation to time spent in instruction and in nursing service.
The implications for control of the educational program were becoming clearer, and provocative questions, which brought the issues into sharper focus, were being asked.
The nursing needs of World War II increased the pressures on nurse educators to solve some of the problems facing collegiate nursing programs. In recognition of this pressure a series of regional conferences was sponsored by the Committee on Educational Problems in Wartime and the Association of Collegiate Schools of Nursing, with the active cooperation of the American Council on Education, in an effort to determine the problems of collegiate schools of nursing. The need for careful contractural agreements between colleges and cooperating hospitals was recognized.
The following items were listed among the general provisions which should be included in the agreement: (1) general responsibility for students while they are in the practice field, (2) responsibility for planning and administering curriculum while students are in the affiliating agency, (3) appointment and approval of personnel who participate in the instruction given in the affiliating agency, and (4) financial responsibility of the participating institutions for payment of salary to those holding dual positions. 9 Apparently the participants of the conferences recognized the areas where control was needed. However, they did not reach a decision on which party should control the educational enterprise. The result of this indecision continued to be a shared and poorly defined control of the collegiate nursing programs.
The NLNE assumed the initiative in clarifying the characteristics of collegiate nursing education and defined collegiate school of nursing as "a complete structural and functional unit for the conduct of a program of nursing education as an integral part of a college or university". 10 Further clarification was achieved by describing the meaning of "integral part" as financial support and full control of the school of nursing by the university with the control operating through the regular lines of authority.
In 1948 an important report from the Committee on the Functions of Nursing was published. " This Committee had been appointed in the fall of 1947 by the Division of Nursing Education of Teachers College, Columbia University, and was composed of experts in the various fields of medicine and social sciences. The report identified the major factors which appeared responsible for the shortage of nursing personnel and factors which, in the opinion of the Committee, would intensify the shortage of nurses during the next decade.
The problems were clearly stated by this interdisciplinary committee. The time had come for nurse educators in collegiate settings to finally clarify who should control the education of the student.
Two educators described their beliefs about a university controlled nursing education program in an article entitled "A Laboratory in Clinical Experience." 12 They identified one problem associated with the development of university programs in basic nursing experience. They said that if this problem is viewed from the vantage point of the educator, nursing practice represents the laboratory portion of the curriculum, whether it is placed in the hospital ward or in the outpatient department, in homes, or in the schools of the community.
The authors acknowledged that even after the acceptance of the principle that nursing practice must be planned as a laboratory course, it would be difficult to establish the educational process, because it did not fit into the old scheme of things. They identified further problems, and believed that a direct approach was hindered not only by the economic issues involved but because it had been impossible to determine how many hours were required to learn nursing.
The Hospital Becomes a Laboratory
In The Education of Nursing Technicians Mildred Montag proposed a new type of education for nurses under the control of the community junior college. Montag proposed that the courses in nursing arts be carried on by class work, demonstration and discussion, laboratory practice, and experience in the actual situation of the hospital, clinic, and home, and that institutions offering this kind of program should have complete control of the entire curriculum, including the clinical experience.
Seven colleges used cooperating hospitals as laboratories for teaching nursing during a cooperative research project which was reported in another book by Montag, Community College Education for Nursing. 14 The results indicated that control of the educational program by the college made it possible to select learning experiences regardless of where they were provided.
The cooperative nature of the working relationship within the terms of the agreement was explained as the "determination of how long the student would be in the agency, and for what purpose" by the instructor.
The close cooperation necessary between college instructors and hospital personnel was also explained by Montag, who pointed out that although the head nurse or supervisor shared in the process of selection, it was the instructor who was responsible for the student's learning experience. "This relationship does not come about spontaneously. It must be developed."
In the fourteen years since the first associate degree programs in nursing were established, we have learned much about the hospital as a laboratory for the teaching of nursing. First of all we recognize how important it is to survey the available hospital resources in the community before the college makes a decision about offering an associate degree nursing program. The survey of hospitals seeks to determine (1) adequacy in size and variety of patients, (2) suitability for participation in the teaching of nursing, (3) attitude of the controlling board toward the participation of the hospital in the teaching of nursing, and (4) attitude of the nursing department toward the hospital's cooperation with the college.
This comprehensive survey not only helps the college administration decide whether or not to establish a nursing program, but in the process serves as a means of educating hospital personnel to the needs of the program. The groundwork for future communication and cooperation between the two institutions is also established.
Secondly, the written agreement the college initiates with the hospital is of immense importance. It is important that this agreement clearly establish the general outline of the working relationship between the two institutions. Persons who should be involved in formulating the agreement include the chief administrative officer of the college, the college nurse administrator, the hospital administrator, and the director of nursing service. In some situations appropriate legal counsel for both institutions will be involved.
The college must assume the responsibility for knowing what must be in this agreement. The terms of the agreement should assure the faculty freedom to teach, and the students opportunity to learn within the framework of the hospital's policies and in recognition of the need for the safety of patients.
After the formal agreement has been made the college nurse faculty needs to become familiar with its contents since this is the framework within which they will teach in the hospital. Conversely the key nursing service personnel must also be familiar with the terms of the agreement so that they also will know what is expected of them.
The terms of any agreement are only as good as the people who implement them. It has been our experience that those involved in this type of nursing education program are willing to implement the college-hospital agreement if they know it has been developed within the philosophy and objectives of the educational program and has full administrative support.
The third important lesson we have learned is that orienting hospital personnel to the philosophy, objectives, and teaching methods of the associate degree nursing program is an important and never-ending process. There may be the best of intentions among top administrators when the written agreement is developed and formalized, but it is at the working level that the agreement is implemented. This means that the college nurse teacher and the head nurse must develop an understanding and respect for each other's role and responsibility. Unless the hospital nursing service staff is willing to assume its responsibility for enhancing the climate of learning for the students the college teacher has a very difficult task.
Community junior college teachers have evolved various ways of orienting hospital nursing service staffs. It has become accepted practice to hire new nurse faculty several months before their teaching responsibilities begin. This offers the teacher an opportunity to spend time in the hospital in which she will be teaching for the purpose of nursing patients in order to become familiar with personnel, with nursing practices and procedures, and with the physical setup of the hospital. In the course of her practice and observation the teacher is also afforded an excellent opportunity to answer questions and to interpret the college nursing program.
More formal orientation programs are also developed jointly by the director of nursing service and the nurse administrator of the college nursing program. The nurse administrator is also invited to meet with all levels of nursing service personnel to interpret the program. This is extremely important because students will have contact not only with head nurses but also with general staff nurses, practical nurses, nurses' aides, etc Each of these groups needs some understanding of why the students will be coming to the hospital, what they will be doing, and who will be responsible for their teaching. Unless these groups receive this orientation they may resent the fact that students are not carrying a proportionate share of the nursing service load.
Continuing orientation and interpretation has been assured in many situations through a joint committee composed of the members of the college department of nursing and representatives of hospital nursing service. This simply structured committee provides the means for placing troublesome items on an agenda for objective discussion and decision. The minutes of the meetings provide orientation for future faculty members and new nursing service personnel.
The variety of learning experiences we have used within the setting of the cooperating hospitals has grown with experience. In the early years of these programs it was difficult for some teachers to make full use of the hospital setting in developing learning experienees for students. The teachers needed time and help in breaking away from traditional approaches and methods. They also needed opportunity to try out new learning experiences and to evaluate the results. This process continues and should never end. As new approaches to teaching emerge they often present new problems to the nursing service personnel in the cooperating hospitals. Only by working together can the college and hospital develop a laboratory for the teaching of nursing which will support the learner and at the same time safeguard the patient.
- 1. Leonia Powell, "Existing Affiliations Between Universities and Nursing Schools," Proceedings of the Twenty-First Annual Convention of the National League of Nursing Education, Baltimore, Williams and Wilkins Co., Annual, 1915.
- 2. Committee on Education of National League of Nursing Education, "Preliminary Report on University Schools of Nursing," American Journal of Nursing, 21: 620-629, June, 1921.
- 3. Mabel F. Huntley, "Report of a League Study of Cooperative Arrangements Between Schools of Nursing and Academic Institutions," Proceedings of the Thirtyseventh Annual Convention of the National League of Nursing Education, New York, The. League, 1931, pp. 129-146.
- 4. Lucile Petry, "Basic Professional Curricula in Nursing Leading to Degrees," American Journal of Nursing, 37: 287-297, March, 1937.
- 5. National League of Nursing Education, Proceedings of Conference on Nursing Schools Connected with Colleges and Universities, New York, The League, 1928.
- 6. Elizabeth S. Soule, "Building the University School," American Journal of Nursing, 38: 580-586, May, 1938.
- 7. Eugenia K. Spalding, "The College and Centralization of Nursing Instruction," American Journal of Nursing, 43:195-201, February, 1943.
- 8. Eugenia K. Spalding, "Contractural Agreements," American Jo urnal of Nursing, 44:385-387, April, 1944.
- 9. National League of Nursing Education, Committee on Educational Problems on Wartime, Problems of Collegiate Schools of Nursing Offering Basic Professional Programs, New York, The League, 1945.
- 10. National League of Nursing Education, National Nursing Council for War Service and Association of Collegiate Schools of Nursing, 1 942, A Guide for the Organization of Collegiate Schools of Nursing, New York, The League, revised, 1946.
- 11. Committee on Functions of Nursing, A Program for the Nursing Profession, New York, The Macmillan Co., 1948.
- 12. John J. Hereford and Lulu K Wolf, "A Laboratory in Clinical Experience," American Journal of Nursing, 49:799-800, December, 1949.
- 13. Mildred L. Montag, The Education of Nursing Technicians, New York, G.P. Putnam's Sons, 1951.
- 14. Mildred L. Montag, Community College Education for Nursing, New York, McGraw-Hill Book Company, 1959.