Discussion and expression of concern for registered nurse students in baccalaureate degree programs has assumed major proportions within the profession. This professional issue has individual, educational and practical significance. With 80% of the professional membership prepared below the baccalaureate level, the burden of responsibility falls to that portion of the remaining 20% who are in positions to provide access to educational programs, which can reasonably articulate with diploma and associate degree preparation.
The nursing literature has liberally discussed the problem, has laboriously identified the characteristics and needs of this learning group, and in some instances proposed course modification. But within the literature few articles appear to attack the problem of how to design a program in any comprehensive manner. The need for a generalizable model is apparent.
Two program types exist which prepare registered nurse graduates of diploma and associate degree programs at the baccalaureate level: one exists independent of a generic nursing program; the second, coexists with a generic nursing program. This article proposes to address the latter and provide a description of one school's development of an alternative plan for registered nurse students as well as propose guidelines whereby other schools of nursing can design similar programs.
Identifying Common Needs
There is a certain hopelessness that surrounds attempts to identify a homogenous student body in registered nurse students. They are a diverse student group bringing with them not only a sanctioned approval for practice through state registration but in addition a wealth and variety of experiential learning. The key to designing a program which provides for the learning needs of such a group appears to rely on a certain degree of generalizability in respect to entering competencies. No firm conclusions can be assumed for the entire student body but assumptions based on the group as a whole can serve as a beginning point.
It is unlikely that anyone will argue against the assumption that all basic nursing programs share certain content and ultimate learning outcomes. Students in all programs will assuredly learn care of the hospitalized patient. We could expect all to be reasonably skilled at taking TPRs, blood pressures, giving bed baths and administering medications via the various routes. At the same time, certain characteristics unique to baccalaureate nursing programs can be identified. Research, leadership and management, care of clients in the community, and concern for health maintenance are usually addressed only within baccalaureate degree programs. Between these two areas, i.e., those learnings that can clearly be defined as common to all basic nursing programs versus those unique to baccalaureate programs, exists cause for argument regarding what rightly belongs to one, the other, or both. The development of a taxonomy identifying and clarifying which learnings belong in which program would facilitate articulation. Clarification would require not only consideration of the cognitive, psychomotor and affective domains but also consideration for leveling of desired learning outcomes within the three domains relevant to each program. Such a taxonomy would improve understanding of learning needs and facilitate appropriate program development.
The determination of entering competencies provides a baseline for instructional development. In planning any instruction, a beginning point is the anticipated competencies students bring with them. Adjustment in instruction becomes necessary when the predicted competencies are at variance with the actual competencies. We can predict that a nursing student having completed a fundamentals course will be able to change a dressing, catheterize a patient, or regulate an intravenous. How many times do we find a student or many students who fail to meet our expectations? Conversely, we may begin at lower expectations and find a student or many students who already have the knowledge and skills we were proposing to teach. Whether the competencies are higher or lower, the bottom line requires adjustment in instruction.
With RN students, we can begin by identifying anticipated competencies of this group of learners. The closer we can come to defining these competencies, the less likely that it will be necessary to adjust instruction. When a few students do not meet the anticipated entering competencies, remediation should be available rather than lowering the instructional level for the entire group. Remediation with RN students can be made available through programmed instruction, assigned readings, peer learning, independent study, or individual counseling. Ideally, the student will be able to choose from a variety of remediation options to select one or a combination of routes which best suits his/her learning style.
Curricular modification for RN students within a generic baccalaureate program begins with the examination of the overall philosophy, conceptual framework and objectives of the program to be modified. This examination provides the curriculum designer with an awareness of the desired program outcomes. Further inspection of the array and sequence of courses assists the designer in identifying where and through what experiences and assignments, the overall program meets these broader curricular objectives. Each program includes requirements in basic distribution and general education courses as well as nursing courses. The SUNY/Buffalo program is comprised of 128 credit hours. Sixty-four of these credits are within the lower division and include specific prerequisite courses to the nursing major, courses in the humanities and social sciences and also electives. The upper division consists of 64 credit hours, of which 53 credits are in nursing.
A Student Profile of RNs at SUNY/Buffalo revealed that an average 33 transfer credits are accepted. Registered nurse students can then expect to take some 31 credit hours of courses prior to entering the nursing component. This could reasonably be completed in two semesters of full-time study for students wishing to complete the program quickly. The major goal in developing an alternative program was to provide an appropriate curriculum for RNs within that sequence of courses designated as the nursing major. A faculty committee proceeded to examine the content and objectives of all the nursing courses for purposes of identifying those which were unique to baccalaureate education and represented new learning for RNs versus those that were totally or in part contained within any basic nursing program and therefore repetitious for RN students.
As we examined the content and objectives of these courses, six courses were identified which contained content and objectives common to all basic programs in nursing. These were: Introduction to the Nursing Process, Nursing Process Applied to the Surgical Client, Contemporary Perspectives in Childbearing - Childrearing Family, Concepts of Restorative Nursing, Care of the Acutely 111 Client, and Care of the Chronically 111. The composition of these courses did not favor deletion of any one course. A fundamentals course, for example, clearly suggests basic nursing common to all programs. Within our program, however, physical assessment was placed within this first course. A decision to separate these two components into two courses was made. Generic students take both; RN students, only the physical assessment course.
New learning was identified in all courses. Some of this new learning was at the level of application rather than basic knowledge. The nursing process, for example, was identified as a thread in all courses. Application of the nursing process at different phases of the healthillness continuum was a differentiating feature.
As the committee examined the different courses, certain content and objectives which represented new learning were identified and extracted. It was determined that this learning could be arranged into two courses for RN students only, and would be taken in lieu of the six basic nursing courses previously identified. These courses are entitled: Concepts of Professional Nursing Practice 1 and II. Each course contains six credit hours; three of theory, and three of practicum. Within the first course, there are five units. These are: 1. Professional Interactions as They Influence Client Care, 2. The Nursing Process Applied at Various Stages of the Health- Illness Continuum, 3. Stress in Health and Illness, 4. Family Assessment and Nursing Intervention, and 5. Discharge Planning.
The second course contains three units: 1. Group Process and Its Influence on Health Care Delivery, 2. The Role of the Nurse in Meeting Health Teaching Needs of Clients and Their Families, and 3. Nursing Intervention in Community Health Settings. Each course requires three hours of theory weekly as well as clinically related activities involving approximately nine hours per week. Assignments which are clinically related include independent student activities which allow application of the theory. Within the first unit, students use process recordings to gain insight into their skills in professional interactions and through seminars arranged within the weekly classes participate in discussion with faculty and students. Their ability to interact with patients and co-workers in effective therapeutic ways is examined and students are guided in improvement of techniques.
Each unit contains clinically related activities. Students when employed are encouraged to utilize the work setting in meeting this requirement. Caution is taken to avoid confusion of work and school activities. The student secures permission from the employing agency and wears a name tag identifying her as a student at the University when undertaking school related activities within the agency. Such arrangements allow the student to complete her clinical requirements at her own convenience.
These two courses as well as an additional eight courses constitute 38 credits in nursing compared to 53 credits in the generic program. Courses that both generic and RN students take are: Health Assessment; Concepts and Skills; Professional Issues in Nursing; Health in Communities; Management Process in Nursing; Professional Seminar; Advanced Clinical Nursing; Applied Scientific Inquiry in Nursing; and Nursing Perspectives of Groups at Risk.
Although the RNs take these eight courses, two of the eight contain modified clinical components. Management Process in nursing contains theory unique to baccalaureate degree programs. The clinical component in our school offers the basic student an opportunity to increase her patient load, function as a team member, function as a team leader and when possible assume the duties of charge nurse for one or two days. This ten-day clinical assignment fails to offer a challenging learning experience for RN students. In the alternative program, RN students instead of clinical placement are assigned a weekly topical focus whereby they examine various aspects and levels of administration within a health agency in respect to its influence on the health care delivery system. Additional assignments include: preparation and presentation of an inservice program, evaluation of a staff member and preparation and implementation of change. Registered nurse students are required to keep a log of their clinically related assignments and participate in weekly seminars to discuss the management experiences with faculty and fellow students.
The second modified course is the Advanced Clinical Nursing course. This course is modeled after a course at Boston University as described by Scipien and Pasternak (1977). The course assists basic students undergo role change from student to graduate through a culminating four- week block of the program. Within this course, the basic student selects an area and locale of interest. A preceptorship experience is arranged by a faculty member. The student develops objectives and proceeds to engage in clinical practice under the supervision of a preceptor. This experience promotes realism as the student spends eight-hour days, four days a week in a clinical setting.
As structured, this course appears inappropriate for RN students who are well accustomed to the realities of practice. A rethinking of how this course might realistically support RNs in role transition led to restructuring the course over one semester rather than a four-week final block. The same number of contact hours are prescribed, and the student with faculty guidance participates in a preceptorship position. This experience is determined by the interest of the student, and the focus is on a professional interest area which requires the baccalaureate degree.
Through the alternate program, the RN can reasonably complete the nursing component in one and onehalf semesters. An accelerated schema has been proposed which may allow students to complete the nursing component in two full-time semesters at a slight overload. Plans for the accelerated program have not been finalized.
The alternative program for RN students assumes a difference in entering competencies between basic baccalaureate nursing students and RN students, and with this assumption proposes to achieve the same learning outcomes through different instructional methods.
In order to assure that 1. the entering competencies are different and 2. that the two programs assure the same terminal behaviors, a comparative evaluation was undertaken. This evaluation consisted of pre and post testing the junior class of 1980. All generic and RN students were included. Test items were generated from four junior level courses that were identified as containing learnings common to all basic nursing programs. Pretest was conducted the first week in September 1980 and post test scheduled for the last week in April 1981.
Advanced Placement Through Challenge Opportunities
Challenge opportunities within this alternative program are not currently available. Although popular as a means of increasing credits, they are more problematic than they would appear. Standardized examinations do not parallel any one course and thus can not be accepted in an even exchange. Course specific challenges usually imply a clinical challenge which is costly to the school. Within both of these challenge procedures, the primary goal, i.e., to allow the RN student to move through the program more quickly, is defeated by the very fact that challenges of any variety require considerable study and preparation. No student is about to approach a series of examinations that comprise the entire junior year within a two-week or even one-semester block. If indeed she did accomplish this in one semester through hard work, her net gain is one semester. Challenges then might spare the student classroom time but does little to save time in the long run or the effort involved in laboring over the same basic materials she has learned previously. The answer is therefore not in a challenge process but in the examination of the nursing component in order to identify the entering competencies and needs of a specific group of learners.
Guidelines for Developing an Alternative Program
The following guidelines are proposed whereby faculty committees in baccalaureate nursing programs can develop similar alternative programs for RN students.
* Become familiar with the program structure already in place.
* Examine this in respect to commonalities in all basic nursing programs.
* Proceed to extract courses which clearly represent new learning.
* Identify courses which have as their major content repetitious learning and extract only new learning.
* Prepare supplemental courses addressing these areas of need.
* Propose an alternative plan for RN students whereby the same overall program objectives can be met through a combination of courses, some within and some aside from the generic program.
It is a need of our times to improve the quality of baccalaureate programs for RN students. Professional pressures to secure the degree must be accompanied by the availability of appropriate programs. The yardstick of measure should not differ between generic or RN student. Care should be taken to assure that the competencies commensurate with a baccalaureate degree are attained by any graduate. It is inappropriate to extend the learning requirements for RNs beyond the basic degree requirements. In developing an alternative program for RNs, care should be taken to provide a program congruent with the philosophy, conceptual framework and objectives of the parallel program. Since the entering competencies of RNs differ from those of the basic student, curricular alternatives and course modification should address only that portion of knowledge that is unique. Clinical experiences should be planned to facilitate skill development in those areas that are needed. Registered nurse students should not be placed in clinical sections which fail to foster new skill development.
Hopefully, as schools develop more appropriate BS(N) educational programs we will enjoy the success of assisting in the learning process and find the graduates not merely pleased by the degree obtained as a route to better employment opportunities but pleased with the knowledge and skills they have obtained by way of the degree.
- Scipien, G.M., & Pasternak, S.B. Creating more confident baccalaureate graduates. American Journal of Nursing.May 1977, pp. 818-820.
- Garvey, J. Individualization of Instruction for RN Students Articulating into BS(N) Degree Programs. Dissertation, Ann Arbor, Michigan: University Microfilms International, 1979.
- Hase, G. Curriculum Planning: A New Approach (ed. 3). Boston: Allyn and Bacon, Inc., 1980.
- Pratt, D. Curriculum Design and Development. New York: Harcourt, Brace and Jovanovich, Inc., 1980.
- Saylor, J. G., & Alexander, W. M. Planning Curriculum for Schools. New York: Holt, Rinehart and Winston, Inc., 1974.
- Bullough, B. The entry into practice resolutions. Pediatric Nursing, September/October 1979, pp. 25-28.
- Muzio, LG., & Ohashi, J. The RN student- Unique characteristics, unique needs. Nursing Outlook, August 1979, pp. 528-532.